Tracking US Health Care Spending by Health Condition and County

Abstract

Importance: Understanding health conditions with the most spending and variation across locations and over time is important for identifying trends, highlighting inequalities, and developing strategies for lowering health spending.

Objective: To estimate US health care spending for each of 3110 US counties, across 4 payers (Medicare, Medicaid, private insurance, and out-of-pocket payments), and according to 148 health conditions, 38 age/sex groups, and 7 types of care from 2010 to 2019.

Design, setting, and participants: Observational analysis using more than 40 billion insurance claims and nearly 1 billion facility records.

Exposures: Ambulatory care, dental care, emergency department care, home health care, hospital inpatient care, nursing facility care, and purchase of prescribed retail pharmaceuticals.

Main outcomes and measures: Health care spending and utilization (eg, number of visits, admissions, or prescriptions) estimates from 2010 through 2019.

Results: Between 2010 and 2019, 76.6% of personal health care spending was captured by this study. More spending was on type 2 diabetes ($143.9 billion [95% CI, $140 billion-$147.2 billion]) than on any other health condition, followed by other musculoskeletal disorders, which includes joint pain and osteoporosis ($108.6 billion [95% CI, $106.4 billion-$110.3 billion]), oral disorders ($93 billion [95% CI, $92.7 billion-$93.3 billion]), and ischemic heart disease ($80.7 billion [95% CI, $79 billion-$82.4 billion]). Of total spending, 42.2% (95% CI, 42.2%-42.2%) was on ambulatory care, while 23.8% (95% CI, 23.8%-23.8%) was on hospital inpatient care and 13.7% (95% CI, 13.7%-13.7%) was on prescribed retail pharmaceuticals. At the county level, age-standardized spending per capita ranged from $3410 (95% CI, $3281-$3529) in Clark County, Idaho, to $13 332 (95% CI, $13 177-$13 489) in Nassau County, New York. Across counties, the greatest variation was in age-standardized out-of-pocket spending, followed by private insurance spending. Cross-county variation was driven more by variation in utilization rates than variation in price and intensity of care, although both types of variation were substantial for all payers but Medicare.

Conclusions and relevance: Broad variation in health care spending was observed across US counties. Understanding this variation by health condition, sex, age, type of care, and payer is valuable for identifying outliers, highlighting inequalities, and assessing health care gaps.

Figure 1.. Estimated Health Care Spending and Spending per Capita by Age, Sex, Type of Care, and Payer Category in 2019

A, Study captured $2.4 trillion in spending in 2019, measured in 2019 US dollars. Medicare is inclusive of Medicare Advantage. B, National average spending per capita in 2019 was $7374, measured in 2019 dollars.

Figure 2.. Estimated Age- and Sex-Standardized Health Care Spending per Capita and per Beneficiary by US County in 2019

Spending in each panel has been split by septiles (panel A) or quintiles (panels B, C, D, and E). Dark gray counties have estimates masked because the relative uncertainty for the estimates is greater than 1. Refer to eFigure 7.3 in Supplement 1 for maps of the upper and lower uncertainty intervals for spending per capita. Study captured $2.4 trillion in spending in 2019. Measured in 2019 US dollars. For panel A, spending is inclusive of all personal health care spending, excluding spending on durable medical equipment and over-the-counter drugs, and from Veterans Affairs, Department of Defense, and Indian Health Services. Medicare is inclusive of Medicare Advantage. This map is a US National Atlas Equal Area projection.