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  • Trends in U.S. Health Care Spending Leading Up to Health Reform

    ACA Implementation—Monitoring and Tracking

    Fredric Blavin, Linda J. Blumberg, Timothy Waidmann,

    and Lokendra Phadera The Urban Institute

    September 2012

  • Trends in U.S. Health Care Spending Leading Up to Health Reform 2

    InTRodUCTIon The fast pace of health care spending growth is a central concern in ensuring access to necessary medical care, playing a prominent role in all discussions related to health care reform and implementation of the Affordable Care Act (ACA). Health care spending has increased faster than has income over the last decade (Holahan, Blumberg et al. 2011), at the same time that the share of the population with health insurance declined. Such a dynamic forces trade-offs both in the public sector (i.e., spending on health programs may decrease spending in other sectors of government if additional revenues are not raised) and in the private sector (i.e., families that spend increasing shares of their income on health insurance have less to spend on other goods and services). While additional per capita spending on medical care, even without expansions in the share of the population insured, can increase value for those receiving additional services or greater intensity of care (Hadley et al. 2011), it does not always translate into additional value. At a minimum, the implicit trade-offs inherent in increased spending must be recognized and evaluated from both a societal and individual perspective. Quantifying the trends in health care spending is also a critical in effectively measuring the effect of key ACA provisions on health expenditures. Not doing so would mean that changes that would have likely occurred absent any reform could be wrongly attributed to the law.

    The ACA’s expansion of coverage, both public and private, and the consequent reduction in the uninsured should increase health care expenditures for those who sought less care due to lack of insurance coverage. Changes to typical cost-sharing responsibilities could also affect use of services and resulting costs. In addition, cost-containment initiatives introduced under the law could reduce health care spending relative to prior trends. Other components of the law that could affect spending include increased insurance market competition,

    increased payments to primary care providers under Medicaid, increased emphasis on preventive services and wellness programs, increased use of comparative effectiveness research, and changes in public and private payment strategies, including bundling provider payments or pay-for-performance programs.

    Using the 2001 to 2009 Medical Expenditure Panel Survey–Household Component (MEPS-HC), this research analyzes trends in per capita health expenditures among the nonelderly by service category. We examine the composition of spending and how it has changed over the decade, and assess how spending growth has changed in the latter half of the period relative to the first. We also decompose the changes by service type into changes in the share of individuals using services, the average number of services used, and expenditures per unit of service.

    This study addresses the following key questions:

    • What was the overall trend in per capita health care spending over the decade? Did the average per capita spending growth rate in the first part of the decade differ from the growth rate in the latter part?

    • What is the distribution of per capita health care spending across service categories? Has this distribution changed over the decade?

    • Which key factors—growth in spending per unit of service, share of the population using services, the average number of services used—contributed to per capita spending growth over the decade? Were changes in per capita spending driven by compositional changes in demographic characteristics, changes in the distribution of insurance coverage, the prevalence of chronic conditions, or some combination?

    • How do these findings affect predictions about the impacts of the Affordable Care Act?

    LITeRaTURe RevIew A recent analysis of the National Health Expenditure Accounts (NHEA) finds that total spending in the last three years has grown at a near-historic low, largely due to the recession, but that spending has slowed each year since 2001. This analysis also finds that hospital spending was responsible for 40 percent of the increase in per capita health spending between 2006 and 2010,

    whereas spending on physician and clinical services, home health, and long-term care accounted for 35 percent of the increase (National Institute for Health Care Management 2012).1

    Several other studies have examined broad national trends in health care spending. NHEA data from 2000 to 2009

  • Trends in U.S. Health Care Spending Leading Up to Health Reform 3

    show that health expenditures increased at an average rate of 6.8 percent while GDP grew at 4.0 percent annually. Spending growth also varied across payer type: Medicare spending increased at an average rate of 9.4 percent (8.3% after removing the effect of prescription drug payments shifting from Medicare to Medicaid), Medicaid spending for all enrollees increased at an average rate of at 8.1 percent, and total private health insurance spending increased at an average rate of 6.4 percent (Holahan, Blumberg et al. 2011). Martin et al. (2011) conclude that the deceleration of spending in 2009 was primarily driven by the slowdown in private health insurance spending to 1.3 percent (because many consumers lost employer-based private health insurance coverage), a 0.6 percent decline in spending on health care investment, and slower growth (0.4%) in out- of-pocket spending. As a counteracting force, Medicaid spending increased by 9 percent in 2009 due to rapid increases in enrollment. Martin et al. also find that in 2009, hospital spending increased by 5.1 percent, about the same growth rate as in 2008, but slower than the trend between 1999 and 2007. Physician and clinical service spending slowed to 4.0 percent, down from 5.2 percent in 2008, and retail prescription expenditures grew by 5.3 percent, up from 3.1 percent in 2008.

    Similarly, researchers at the Agency for Healthcare Research and Quality release annual snapshots of health care expenses using the Medical Expenditure Panel Survey (MEPS). Kashihara and Carper (2010) provide 2008 point estimates of health care spending by type of service and payer, but do not analyze how spending changes over time. In contrast, Machlin and Kress (2009a, b) compare the distribution of expenses in 1996 with the distribution in 2006 among different adult age groups. They find that the proportion of adults 45 to 65 with non zero expenses remained relatively constant between 1996 and 2006, whereas the proportion of adults 18 to 44 with

    non zero expenses decreased by nearly 4 percentage points. Average expenses among those using health care services in all age groups substantially increased during this period. They also find that prescribed medicines were a substantially higher proportion of total expenses among adults, while hospital inpatient care was a markedly lower share in 2006 than in 1996.

    A recent review of the literature highlights four reasons health care costs grow at a faster rate than the economy as a whole (Holahan, Blumberg et al. 2011). One of the most commonly cited sources of spending growth is the development and dispersion of medical technology, which directly and indirectly increases medical spending (e.g., new technologies increase an individual’s lifespan and thereby lead to the use of other medical services). Second, other researchers find that the increased prevalence of chronic diseases and spending per treated case determine most of the growth in private health care spending. Third is the growing consolidation and lack of competition in both insurer and provider markets. Finally, high health care spending growth could be attributed to consumers being overinsured and shielded from the true cost of their care through the federal tax exemption of employer-sponsored insurance contributions.

    Our analysis contributes to the literature in three ways. First, this study provides the most up-to-date look at spending trends by incorporating results from the 2009 MEPS. Similarly, none of the prior studies provide a comprehensive trend of health care expenses over the entire past decade. Third, this is the first study to isolate the drivers of health care spending factors on the MEPS (e.g., comparing utilization-pattern changes versus expenditure per use changes), using a multivariate regression approach to decompose variation in spending patterns.

    daTa We rely on the full-year consolidated data files from the MEPS-HC as the core dataset for this study. The MEPS- HC is a nationally representative survey of individual household members drawn from the pool of the prior year’s National Health Interview Survey respondents. Given the large sampling variation in the MEPS-HC from 1998 to 2000, we analyze trends between 2001 and 2009, the most recent years of data available.

    The MEPS-HC full-year consolidated data files provide detailed information on spending by public and private programs as well as out-of-pocket spending on various

    health care services used during the year. Panels for the

    survey are designed for two calendar years, featuring

    five rounds of interviews.2 The survey also collects

    monthly information on each individual’s health insurance

    status. Based on