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Cited by 1,313Healthcare Policy and ManagementGlobal Health Care IssuesHealthcare Systems and Reforms

US Health Care Spending by Payer and Health Condition, 1996-2016

Open access
Dieleman, Joseph L., Cao, Jackie, Chapin, Abby, Chen, Carina, Li, Zhiyin, Liu, Angela, Horst, Cody, Kaldjian, Alexander +14 more·2020·JAMA
DOI 10.1001/jama.2020.0734PMC PMC7054840
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Abstract

Importance: US health care spending has continued to increase and now accounts for 18% of the US economy, although little is known about how spending on each health condition varies by payer, and how these amounts have changed over time. Objective: To estimate US spending on health care according to 3 types of payers (public insurance [including Medicare, Medicaid, and other government programs], private insurance, or out-of-pocket payments) and by health condition, age group, sex, and type of care for 1996 through 2016. Design and Setting: Government budgets, insurance claims, facility records, household surveys, and official US records from 1996 through 2016 were collected to estimate spending for 154 health conditions. Spending growth rates (standardized by population size and age group) were calculated for each type of payer and health condition. Exposures: Ambulatory care, inpatient care, nursing care facility stay, emergency department care, dental care, and purchase of prescribed pharmaceuticals in a retail setting. Main Outcomes and Measures: National spending estimates stratified by health condition, age group, sex, type of care, and type of payer and modeled for each year from 1996 through 2016. Results: Total health care spending increased from an estimated $1.4 trillion in 1996 (13.3% of gross domestic product [GDP]; $5259 per person) to an estimated $3.1 trillion in 2016 (17.9% of GDP; $9655 per person); 85.2% of that spending was included in this study. In 2016, an estimated 48.0% (95% CI, 48.0%-48.0%) of health care spending was paid by private insurance, 42.6% (95% CI, 42.5%-42.6%) by public insurance, and 9.4% (95% CI, 9.4%-9.4%) by out-of-pocket payments. In 2016, among the 154 conditions, low back and neck pain had the highest amount of health care spending with an estimated $134.5 billion (95% CI, $122.4-$146.9 billion) in spending, of which 57.2% (95% CI, 52.2%-61.2%) was paid by private insurance, 33.7% (95% CI, 30.0%-38.4%) by public insurance, and 9.2% (95% CI, 8.3%-10.4%) by out-of-pocket payments. Other musculoskeletal disorders accounted for the second highest amount of health care spending (estimated at $129.8 billion [95% CI, $116.3-$149.7 billion]) and most had private insurance (56.4% [95% CI, 52.6%-59.3%]). Diabetes accounted for the third highest amount of the health care spending (estimated at $111.2 billion [95% CI, $105.7-$115.9 billion]) and most had public insurance (49.8% [95% CI, 44.4%-56.0%]). Other conditions estimated to have substantial health care spending in 2016 were ischemic heart disease ($89.3 billion [95% CI, $81.1-$95.5 billion]), falls ($87.4 billion [95% CI, $75.0-$100.1 billion]), urinary diseases ($86.0 billion [95% CI, $76.3-$95.9 billion]), skin and subcutaneous diseases ($85.0 billion [95% CI, $80.5-$90.2 billion]), osteoarthritis ($80.0 billion [95% CI, $72.2-$86.1 billion]), dementias ($79.2 billion [95% CI, $67.6-$90.8 billion]), and hypertension ($79.0 billion [95% CI, $72.6-$86.8 billion]). The conditions with the highest spending varied by type of payer, age, sex, type of care, and year. After adjusting for changes in inflation, population size, and age groups, public insurance spending was estimated to have increased at an annualized rate of 2.9% (95% CI, 2.9%-2.9%); private insurance, 2.6% (95% CI, 2.6%-2.6%); and out-of-pocket payments, 1.1% (95% CI, 1.0%-1.1%). Conclusions and Relevance: Estimates of US spending on health care showed substantial increases from 1996 through 2016, with the highest increases in population-adjusted spending by public insurance. Although spending on low back and neck pain, other musculoskeletal disorders, and diabetes accounted for the highest amounts of spending, the payers and the rates of change in annual spending growth rates varied considerably.

Integrity signals

Registry

Crossref · 10.1001/jama.2020.0734

Cites

18 of 18 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

1 of 9 cited sources checked · 0 supported · 0 flagged · accuracy not yet measured

  • Findingown data

    In 2016, 33.7% of low back and neck pain spending was paid by public insurance.

    “33.7% (95% CI, 30.0%-38.4%) by public insurance”
    • Also stated in: § Health Care Spending by Payer and Health Condition in 2016 · plain
      “33.7% (95% CI, 30.0%-38.4%)paid by public insurance”
    Quote in the paperNot a substantial claim
  • Findingown data

    In 2016, urinary diseases had estimated health care spending of $86.0 billion.

    “urinary diseases ($86.0 billion [95% CI, $76.3-$95.9billion])”
    • Also stated in: § Health Care Spending by Payer and Health Condition in 2016 · hedged
      “urinary diseases at $86.0 billion (95% CI, $76.3 billion-$95.9billion)”
    Quote in the paperNot a substantial claim
  • Findingown data

    After adjusting for inflation, population size, and age groups, out-of-pocket payments increased at an annualized rate of 1.1% from 1996 to 2016.

    “and out-of-pocket payments, 1.1% (95% CI, 1.0%-1.1%)”
    Quote in the paperSubstantial claim
  • Findingown data

    In 2016, an estimated 9.4% of health care spending was paid by out-of-pocket payments.

    “9.4% (95% CI, 9.4%-9.4%)by out-of-pocket payments”
    • Also stated in: § Health Care Spending by Payer, Age, and Aggregated Health Condition in 2016 · hedged
      “an estimated $255.2 billion (95% CI, $255.0 billion-$255.2billion) or 9.4% (95% CI, 9.4%-9.4%)by out-of-pocket payments”
    Quote in the paperNot a substantial claim
  • Findingown data

    In 2016, diabetes had the third highest health care spending, estimated at $111.2 billion.

    “Diabetes accounted for the third highest amount of the health care spending (estimated at $111.2 billion [95% CI, $105.7-$115.9billion])”
    • Also stated in: § Health Care Spending by Payer and Health Condition in 2016 · hedged
      “diabetes at $111.2 billion (95% CI, $105.7 billion-$115.9billion)”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 21
  • May combine two claims. 13

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Subsidies for employer-sponsored private insurance accounted for $146 billion of health care costs in 2017.

    “Recent studies suggest that these subsidies accounted for $146 billion of health care costs in 2017.32”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [32] 32. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053): 1545-1602. doi:10.1016/S0140-6736(16)31678-6 source

      The Methods (Data sources; page unavailable) describe insurance claims used to estimate disease prevalence, not the cost of employer-sponsored insurance subsidies. Searches for “$146 billion,” “2017,” and employer-sponsored insurance subsidies found no passage addressing the claimed amount. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    The conditions with the highest spending varied by type of payer, age, sex, type of care, and year.

    “The conditions with the highest spending varied by type of payer, age, sex, type of care, and year.”
    • Also stated in: § Health Care Spending by Payer and Health Condition in 2016 · plain
      “Spending varied based on type of care, age, and payer.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Spending on diabetes occurs later in life than low back and neck pain and other musculoskeletal disorders and is generally financed by public insurance.

    “Figure 3C shows that spending on diabetes occurs later in life than low back and neck pain and other musculoskeletal disorders and is generally financed by public insurance.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    There was higher spending for ischemic heart disease among men at younger ages than among women, and higher spending among women at older ages than among men.

    “However, there was higher spending for ischemic heart disease among men at younger ages than among women, and higher spending among women at older ages than among men.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For urinary diseases, spending was higher among men at older ages, with a major increase at age 55 years.

    “there was higher spending among men at older ages with a major increase at aged 55 years”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Private insurance funded most of the modeled health care spending for low back and neck pain, whereas public insurance played a substantive role for the population aged 65 years or older, and out-of-pocket payments were relatively constant across age groups.

    “Figure 3A shows that private insurance funded most of the modeled health care spending for low back and neck pain, whereas public insurance played a substantive role for the population aged 65 years or older, and out-of-pocket payments were relatively constant across age groups (when measured as a fraction of the total amount of low back and neck pain spending).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In 2016, out-of-pocket payments varied much less across age and sex than public and private insurance, with the highest spending among individuals older than 85 years.

    “Out-of-pocket payments varied much less across age and sex than across public and private insurance, with the highest spending found among individuals older than aged 85 years.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The study estimated health care spending in 2016 for the 100 most expensive health conditions of the 154 analyzed.

    “Health Care Estimated Spending in 2016 for the 100 Most Expensive Health Conditions of the 154 Health Conditions Analyzed”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The study estimated health care spending in 2016 for the 54 least expensive health conditions of the 154 analyzed.

    “Health Care Estimated Spending in 2016 for the 54 Least Expensive of the 154 Health Conditions Analyzed”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The study analyzed 154 health conditions.

    “154 Health Conditions Analyzed”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Bootstrapping methods only capture a subset of uncertainty and do not reflect the uncertainty associated with some modeling decisions and processes.

    “Moreover, bootstrapping methods only capture a subset of uncertainty and do not reflect the uncertainty associated with some modeling decisions and processes.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: Bootstrapping methods assume that the empirical distribution of the errors in the sample data approximates the population's distribution.

  • May combine two claims.

    Interpretationown data

    Estimates of US spending on health care showed substantial increases from 1996 through 2016, with the highest increases in population-adjusted spending by public insurance.

    “Estimates of US spending on health care showed substantial increases from 1996 through 2016, with the highest increases in population-adjusted spending by public insurance.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Although spending on low back and neck pain, other musculoskeletal disorders, and diabetes accounted for the highest amounts of spending, the payers and the rates of change in annual spending growth rates varied considerably.

    “Although spending on low back and neck pain, other musculoskeletal disorders, and diabetes accounted for the highest amounts of spending, the payers and the rates of change in annual spending growth rates varied considerably.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductreasoning

    The 95% CIs should be used as a relative indication of when the measurements are the most precise rather than as exact 95% CIs.

    “Due to these limitations, the 95% CIs should be used as a relative indication of when the measurements are the most precise rather than as exact 95% CIs.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: Bootstrapping methods assume that the empirical distribution of the errors in the sample data approximates the population's distribution.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The study excluded home health care (2.6% of total health care spending between 1996 and 2016), durable medical equipment and nondurable medical products (3.7%), government public health activities (2.9%), and research and infrastructure investment (5.6%).

    “Excluded from this study were home health care (2.6% of total health care spending between 1996 and 2016); durable medical equipment and nondurable medical products, which include over-the-counter medicines (3.7%); government public health activities (2.9%); and research and infrastructure investment (5.6%).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] 3. Emergency department care F 0 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 Mean spending for 1996-2016, % Public insurance, 48.8 Private insurance, 47.0

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The health burden of low back and neck pain, measured using disability-adjusted healthyears, increased by 1.3% annually.

    “the health burden (measured using disability-adjusted healthyears) increased by only 1.3% annually.25”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] 25. Substance Abuse and Mental Health Services Administration. Results from the 2016 national survey on drug use and health: detailed tables. http://www.samhsa.gov/data/report/results-2016- national-survey-drug-use-and-health-detailed- tables. Published September 7, 2017. Accessed January 23, 2020.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The point estimate of a percentile interval bootstrap is not based on the observed data but is instead based on the mean of the bootstrap draws and can be skewed in some cases.

    “In addition, the point estimate (ie, the reported value) of a percentile interval bootstrap is not based on the observed data but is instead based on the mean of the bootstrap draws and can be skewed in some cases.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: Bootstrapping methods assume that the empirical distribution of the errors in the sample data approximates the population's distribution.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    At the time of publication, these estimates are 3 years out of date.

    “these estimates are, at the time of publication, 3 years out of date.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductreasoning

    The many statistical adjustments and modeling necessary to complete this study are only as strong as the underlying data.

    “the many statistical adjustments and modeling necessary to complete this study are only as strong as the underlying data.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Health care spending differs from actual health system costs.

    “This study assessed health care spending, which for many reasons differs from actual health system costs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    It is unclear if the health condition, age group, and sex distribution for this spending actually reflects regular health care spending paid by public insurance.

    “However, it is unclear if the health condition, age group, and sex distribution for this spending actually reflects regular health care spending paid by public insurance.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Specialty drugs contributed to 43% of net pharmaceutical spending across all health conditions despite being only 2% of the volume in 2016.

    “it is estimated that specialty drugs contributed to 43% of net pharmaceutical spending across all health conditions despite only being 2% of the volume in 2016.29”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] 29. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The data used in this study are imperfect.

    “First, the data used in this study are imperfect.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The study cannot make any claims regarding the efficiency and effectiveness of these spending amounts and whether the trends are best suited in meeting national objectives to optimize the value of health care spending overall.

    “this study cannot make any claims regarding the efficiency and effectiveness of these spending amounts and whether the trends are best suited in meeting national objectives to optimize the value of health care spending overall.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Study design and conductnone given

    This classification aligns with US government accounting in the National Health Expenditure Accounts.

    “This classification aligns with US government accounting in the National Health Expenditure Accounts”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The estimates extend 3 additional years through 2016 compared to prior estimates.

    “the estimates extend 3 additional years through 2016”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study did not provide granular and potentially distinct spending trends associated with Medicare and Medicaid separately.

    “the study did not provide granular and potentially distinct spending trends associated with the 2 major government insurance programs, Medicare and Medicaid”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    MEPS and other data sources exclude active military personnel, incarcerated individuals, and homeless individuals.

    “the MEPS and other data sources exclude active military personnel, incarcerated individuals, and homeless individuals.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Payers with the highest spending for each health condition may have been underrepresented in the survey data due to the infrequency in which these cases occur.

    “the payers with the highest spending for each health condition may have been underrepresented in the survey data due to the infrequency in which these cases occur.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    These subsidies are indirect contributions from the government and explain why these estimates do not account for the health care system's entire effect on the government.

    “These subsidies are indirect contributions from the government and provide further explanation as to why these estimates do not account for the health care system's entire effect on the government.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Spending was attributed to the entity that managed the spending rather than the originating source of the resources.

    “In the current study, spending was attributed to the entity that managed the spending rather than the originating source of the resources.”
    Quote in the paperSubstantial claim
31 of 31

  • The paper relies on this without support.

    Little is known about how spending by each type of payer is divided across health conditions.

    “Although the Centers for Medicare & Medicaid Services provides annual estimates of total health care spending for each of these programs, little is known about how spending by each type of payer is divided across health conditions.”

  • The authors state this as an assumption.

    Bootstrapping methods assume that the empirical distribution of the errors in the sample data approximates the population's distribution.

    “Bootstrapping methods assume that the empirical distribution of the errors in the sample data approximates the population's distribution.”

  • The paper relies on this without support.

    Women live longer than men on average.

    “on average, women live longer than men”

  • The paper relies on this without support.

    Women are less likely to have an in-home informal caregiver (eg, a spouse) than men.

    “are less likely to have an in-home informal caregiver (eg, a spouse)”

  • The paper relies on this without support.

    Baby boomers will age into the years most affected by dementia.

    “as baby boomers age into the years most affected by the disease”

  • The paper relies on this without support.

    Out-of-pocket payments are not distributed evenly or according to individuals' ability to pay.

    “the 9.4% (95% CI, 9.4%-9.4%)that is financed by out-of-pocket payments (in 2016) is not distributed evenly or in accordance to individuals' ability to pay.”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Study coverage is reported as both 85.2% and 86.8%

    Minor

    The paper gives two different percentages for the share of health care spending included in the study over 1996-2016.

1 of 1

Cites

Flagged first, then by citations

1 of the 19 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. Morrisey, Health Insurance, 1
  2. CurrieJ, HoK, KellyBR, KuziemkoI. Who will be our moral conscience now? a tribute to Uwe Reinhardt. https://www.healthaffairs.org/do/10.1377/hblog20190805.922868/full/. Accessed February 4, 2020. · DOI

Cited by

Sorted by citations

Related

Authors
Dieleman, J. L., Cao, J., Chapin, A., Chen, C., Li, Z., Liu, A., Horst, C., Kaldjian, A., Matyasz, T., Scott, K. W., Bui, A. L., Campbell, M., Duber, H. C., Dunn, A. C., Flaxman, A. D., Fitzmaurice, C., Naghavi, M., Sadat, N., Shieh, P., Squires, E., Yeung, K., & Murray, C. J. L.
Affiliations
  • Institute for Health Metrics and Evaluation (US)
  • Harvard University (US)
  • Seattle Children's Hospital (US)
  • Meta (United States) (US)
  • University of Washington (US)
  • Bureau of Economic Analysis (US)
  • Microsoft (United States) (US)
  • The Improve Group, St Paul, Minnesota
  • Kaiser Permanente Washington Health Research Institute (US)
Corresponding author
Dieleman, Joseph L.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2020-03-03
Volume
323
Issue
9
Pages
863
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2020.0734
PMC
PMC7054840
OpenAlex
W3010268726
Cited by
1,313
References
19
Citations by year
2026: 171 · 2025: 269 · 2024: 284 · 2023: 221 · 2022: 160 · 2021: 139 · 2020: 69
FWCI
125.10
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
National Institute on Aging (P30AG047845)
Topics
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
  • Health Sciences › Health Professions › General Health Professions › Global Health Care Issues
  • Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
Keywords
health care spending, public insurance, private insurance, out-of-pocket costs, Medicare, Medicaid, health conditions, outpatient care, inpatient care, nursing facilities, emergency department care, dental care, prescription drug spending, health care costs
MeSH terms
Adolescent, Adult, Aged, Aged, 80 and over, Child, Child, Preschool, Disease, Health Expenditures, Female, Health Status, Humans, Infant, Insurance, Health, Male, Middle Aged, United States, Age Distribution, Sex Distribution, Young Adult

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