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  • 1. An Overview of the U.S. Health Care System Chart Book Centers for Medicare and Medicaid Services And Office of the Assistant Secretary for Planning and Evaluation January 31, 2007 1 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 2. Table of Contents - Section 1 Section 1: Overview of the U.S. Health Care System 8 Table 1.1 National Health Expenditures and their share of GDP, 1980-2015 9 Table 1.2 National Health Expenditures per Capita, 1980-2015 10 Table 1.3 Personal Health Expenditures by Source of Funds, 1960-2004 11 Table 1.4 Health Insurance Coverage for the Under 65 Population, 1980-2004 12 Table 1.5 Personal Health Care Expenditures by Service, 1960-2003 13 Table 1.6 Annual Percent Change in Personal Health Care Expenditures for Medicare, Medicaid, and Total, 1971-2015 14 Table 1.7 Average Annual Growth in Medicare & Private Health Insurance Benefits Per Enrollee, Selected Periods 15 Table 1.8 Concentration of Health Spending, 1987-2002 16 Table 1.9 Factors Accounting for Growth in Prescription Drug Spending per Capita, 1980-2011 17 Table 1.10 Prescription Drug Expenditures by Source of Funds, 1965-2004 18 Table 1.11 Sources of Payment for Nursing Home and Home Health Care, 2004 19 Table 1.12 Number of People Employed in Health Care, 1990-2005 20 Table 1.13 Health Care Employment by Occupation, 1983-2005 21 Table 1.14 Health Care Employment Growth Projections, 2000-2010 22 Table 1.15 Average Annual Salaries of Selected Groups of Workers, 2005 23 Table 1.16 HMO Enrollment by Ownership Status, 1981-2004 24 Table 1.17 Concentration of Managed Care Enrollment, 1988-2003 25 Table 1.18 Managed Care Enrollment by Type of Plan, 1984-2004 26 Table 1.19 Health Care as a Percent of Income by Age, 2004 27 Table 1.20 Annual Growth Rates in the Overall CPI and MCPI, 1993-2005 28 2 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 3. Table of Contents - Section 2 Section 2: International Comparisons 29 Table 2.1 Percent of GDP Spent on Health Care by OECD Country, 1960-2004 30 Table 2.2 Per Capita Spending on Medical Services by OECD Country, 1980-2004 31 Table 2.3 Average Annual Growth in Per Capita Spending by Decade by OECD Country, 1960-2003 32 Table 2.4 Per Capita Health Spending by Type of Service by OECD Country, 2003 33 Table 2.5 Share of Total Health Spending on Outpatient care by OECD Country, 1970-2003 34 Table 2.6 National Health Spending by Source of Funds by OECD Country, 2003 35 Table 2.7 Per Capita Spending on Drugs and other Non-durables by OECD Country, 1970-2003 36 Table 2.8 Drug Spending as a Percentage of Total Health Spending, 1980-2003 37 Table 2.9 Infant Mortality Rates per 1,000 Live Births by OECD Country, 1970-2004 38 Table 2.10 Male and Female Life Expectancy at Birth by OECD Country, 1960-2004 39 Table 2.11 Male and Female Life Expectancy at Age 65 by OECD Country, 1960-2004 40 Table 2.12 Number of Inpatient Discharges and Total Beds per 1,000 persons, by OECD Country, 2004 41 Table 2.13 Average Length of Hosptial Stay for Selected OECD Countries, 2004 42 Table 2.14 Medical Technology and Use of High Technology Medical Procedures by OECD Country, 2004 43 Table 2.15 Selected Indicators of Mobidity by OECD Country, Selected Years 44 Table 2.16 Selected Indicators of Mortality by OECD Country, 2004 45 3 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 4. Table of Contents - Section 3 Section 3: Providers 46 Table 3.1 Number of Hospitals by Type, 1980-2004 47 Table 3.2 Number of Hospital Beds and Occupancy Rates by Hospital Type, 1980-2004 48 Table 3.3 Number of Hospital Beds per 1,000 Persons by State, 2004 49 Table 3.4 Number of Nursing Home Beds & Residents, 1985-2003 50 Table 3.5 Number of Physicians per 100,000 Persons by State, 2004 51 Table 3.6 Distribution of Active Physicians:1950-1998 52 Table 3.7 Percentage of Physicians in Differing Practice Arrangements, 1987-2001 53 Table 3.8 Physician Revenue by Payer, 1986-2004 54 Table 3.9 Physician Participation in Managed Care, 1988-2001 55 Table 3.10 Physician Managed Care Payment Arrangements, 2001 56 Table 3.11 Hospital Participation in HMOs and PPOs, 1987-2004 57 Table 3.12 Hospital Managed Care Payment Arrangements, 2001 58 Table 3.13 Hospital Profit Margins for All Payers and Medicare, 1997-2004 59 Table 3.14 Hospital Payment to Cost Ratios for Medicare, Medicaid, and Private Payers, 1985-2002 60 Table 3.15 Change in Nursing Home Institutionalization Rate for Elderly, 1985-1999 61 Table 3.16 Nursing Home Resident Rate by State, 2003 62 Table 3.17 Number of Hospital Discharges and Average Length of Stay, 1980-2004 63 Table 3.18 Number of Physician Visits per 1,000 Persons, 1990-2000 64 4 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 5. Table of Contents – Section 4, Tables 4.1 to 4.20 Section 4: Public Programs 65 Table 4.1 Public Payers’ Share of National Health Spending, 1980-2010 66 Table 4.2 Personal Health Care Expenditures by Type of Service and Percent Medicare Paid, 2004 67 Table 4.3 Personal Health Care Expenditures by Type of Service and Percent Medicare Paid, 1980 68 Table 4.4 Where the Medicare Dollar Went, 1980 and 2005 69 Table 4.5 Medicare Trustees Report: Part A Income and Expenses, 1970-2015 70 Table 4.6 Number of Medicare Beneficiaries, 1970-2040 71 Table 4.7 Medicare Beneficiaries as a Share of the US Population, 1970-2030 72 Table 4.8 Medicare Spending for Fee-For-Service Beneficiaries by Income, 2003 73 Table 4.9 Living Arrangements of Medicare Beneficiaries, 2003 74 Table 4.10 Age and Gender of the Medicare Population, 2003 75 Table 4.11 Total Health Care Spending for Medicare Beneficiaries, 2003 76 Table 4.12 Sources of Payment for Medicare Beneficiaries’ Medical Services, 2003 77 Table 4.13 Sources of Payment for Medicare Beneficiaries by Type of Service, 2003 78 Table 4.14 Types of Supplemental Health Insurance held by Fee-for-Service Medicare Beneficiaries, 2003 79 Table 4.15 Medicare Beneficiary Out-Of-Pocket Spending, 2003 80 Table 4.16 Per Capita Out-Of-Pocket Expenses for Medicare Beneficiaries by Type of Insurance Coverage, 1993 and 2003 81 Table 4.17 Distribution of Medicare Enrollees by Functional Status, 2003 82 Table 4.18 Beneficiaries with Poor Health or Functional Limitations by Insurance Status, 2003 83 Table 4.19 Medicare Managed Care Enrollment, 1990-2005 84 Table 4.20 Medicare Beneficiaries with Prescription Drug Coverage,1992-2003 85 5 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 6. Table of Contents – Section 4, Tables 4.21 to 4.40 Section 4: Public Programs 65 Table 4.21 Total Spending for Prescription Drugs for all Medicare Beneficiaries, 1996-2003 86 Table 4.22 Medicare Beneficiaries with Drug Coverage by Primary Source of Supplemental Coverage, 1995 and 2003 87 Table 4.23 Personal Health Expenditures by Type of Service and Percent Medicaid Paid, 2004 88 Table 4.24 Personal Health Expenditures by Type of Service and Percent Medicaid Paid, 1980 89 Table 4.25 Medicaid Enrollment by Eligibility Group, 2003 90 Table 4.26 Average Medicaid Payments Per Person Served by Eligibility Group, 1985-2003 91 Table 4.27 Medicaid Enrollees by Eligibility Group, 1975-2003 92 Table 4.28 Total Medicaid Expenditures by Type of Service, FY 2005 93 Table 4.29 Total State Spending and Federal Funds Provided to States, 2004 94 Table 4.30 Medicaid Spending for Long-Term Care, 1999-2003 95 Table 4.31 Births Financed by Medicaid as Percent of Total Births by State, 2005 96 Table 4.32 Medicaid Enrollment by Age, Sex, and Ethnicity, 2003 97 Table 4.33 Medicaid Managed Care Enrollment, 1996-2004 98 Table 4.34 Health Insurance Coverage of Children, 1988-2005 99 Table 4.35 State Children’s Health Insurance Program Spending and Enrollment, 1998-2004 100 Table 4.36 State Children’s Health Insurance Program Plan By State, 2006 101 Table 4.37 State Health Spending as a Percent of Gross State Product, 2004 102 Table 4.38 Share of State Health Spending Financed by Medicare and Medicaid, 2004 103 Table 4.39 Share of State Health Spending Financed by Medicare, 2004 104 Table 4.40 Share of State Health Spending Financed by Medicaid, 2004 105 6 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 7. Table of Contents – Sections 5 and 6 Section 5: Private Health Insurance 106 Table 5.1 Health Spending From Out-of-Pocket and Private Health Insurance, 1980-2010 107 Table 5.2 Changes in Employer Health Insurance Premiums, Overall Inflation, and Workers' Earnings, 1989-2005 108 Table 5.3 Change in Health Insurance Premiums by Firm Size, 1988-2005 109 Table 5.4 Employee Contributions to Health Insurance Premiums, 1988-2005 110 Table 5.5 Average Annual Premium Costs by Plan Type, 2005 111 Table 5.6 Changes in Employee Benefit Packages, 1980-2004 112 Table 5.7 Firms Offering Health Insurance Coverage by Firm Size, 1996-2005 113 Table 5.8 Number of Health Plans Offered by Firm Size, 2005 114 Table 5.9 Private Health Insurance Enrollment by Plan Type, 1988-2005 115 Table 5.10 Employees With a Choice of Health Plans, 1988-2005 116 Table 5.11 Covered Employees in Firms that Offer Health Benefits, 2005 117 Section 6: Uninsured 118 Table 6.1 Out of Pocket Spending by the Under 65 Population by Insurance Status by Income, 2001 and 2003 119 Table 6.2 Out of Pocket Spending by the Under 65 Population by Insurance Status by Type of Service, 2001 and 2003 120 Table 6.3 Percent Uninsured within Age Categories, 1987-2005 121 Table 6.4 Percent Uninsured within Income Categories, 1987-2005 122 Table 6.5 Percent Uninsured by Ethnicity, 1987-2005 123 Table 6.6 The Uninsured by Age, 1987-2005 124 Table 6.7 The Uninsured by Income, 1987-2005 125 Table 6.8 The Uninsured by Ethnicity, 1987-2005 126 Table 6.9 The Uninsured by State, 2005 127 Table 6.10 Impact on Non-Elderly Adults of Being Uninsured, 2006 128 7 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 8. Section 1 Overview of the U.S. Health Care System 8 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 9. Table 1.1 National Health Expenditures and Their Share of Gross Domestic Product (GDP), 1980-2015 National health spending is projected to continue to increase as a share of GDP over the next decade. NHE Projected NHE GDP Share Projected GDP Share $4,500 25% Projected Actual $4,000 20% $3,500 $3,000 15% GDP Share Billions $2,500 $2,000 10% $1,500 $1,000 5% $500 $0 0% 1980 1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Calendar Year Source: CMS, Office of the Actuary, National Health Statistics Group. 9 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 10. Table 1.2 National Health Expenditures Per Capita, 1980-2015 National health spending per capita is projected to increase rapidly over the next decade. $13,000 $12,000 $ 12, 357 Actual Projected $11,000 $10,000 $ 10, 339 $9,000 $8,000 $ 8, 636 $7,000 $ 7, 129 $6,000 $ 6, 280 $5,000 $ 5, 879 $ 5, 485 $4,000 $ 4, 471 $3,000 $2,000 $1,000 $ 1, 067 $0 1980 1998 2000 2002 2004 2006 2009 2012 2015 Calendar Year Source: CMS, Office of the Actuary, National Health Statistics Group. 10 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 11. Table 1.3 Personal Health Care Expenditures by Source of Funds: Selected Years 1960-2004 Over the last several decades, both the public and private sector share of health spending has increased, while the share from out-of-pocket spending has declined. Dollars in Billions $23.3 $63.1 $214.5 $609.3 $1,553 $1,877.6 100 14% 13% 23% 27% 5% 7% 55% 40% 80 5% 4% 35% 3% 35% 60 Percent 33% 28% 2% 22% 40 12% 13% 21% 12% 10% 16% 17% 17% 20 17% 18% 12% 21% 16% 16% 8% 12% 11% 0 1960 1970 1980 1990 2002 2004 Calendar Year Other Public Out-of-Pocket Total Total Medicare Other Private Public Private Total Medicaid, SCHIP expansion and SCHIP Private Health Insurance Source: CMS, Office of the Actuary, National Health Statistics Group. 11 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 12. Table 1.4 Health Insurance Coverage for the Under 65 Population, 1980-2004 Over the last two decades, private coverage has declined, public coverage (mostly Medicaid) has increased a small amount, and the uninsured have grown. 90 83% 80 Any Private 74% 70 69% ESI 63% 60 50 40 30 18% Uninsured 20 Any Government 15 18% 10% 10 13 8% Medicaid 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Notes: ESI - Employer Sponsored Insurance. Any Private includes ESI and individually purchased insurance. Any government includes Medicare for the disabled population. Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments. 12 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 13. Table 1.5 Personal Health Care Expenditures by Type of Service, 1960-2003 The share of health spending on prescription drugs has grown since 1980. Physician share has stayed about the same while the hospital share grew and then declined. 47.3% 50 41.7% 39.3% 40 35.8% 36.5% 30 25.9% 25.7% Percent 25.3% 22.9% 22.5% 21.9% Service 20 16.4% 15.8% 15.6% 15.2% 12.4% 11.4% 10.8% 10 8.2% 8.6% 8.2% 7.7% 6.6% 5.6% 3.6% 2.9% 2.8% 2.1% 1.1% 0.2% 0 Hospital Physician Home Health Prescription Nursing Home Other Drugs Percent 1960 1980 1990 2000 2003 Source: CMS, Office of the Actuary, National Health Statistics Group. 13 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 14. Table 1.6 Annual Percent Change in Personal Health Care Expenditures for Medicare, Medicaid and Total: 1971-2015 While the actual percent changes vary, overall spending for Medicare and Medicaid tend to rise and fall together. PHCE Medicare Medicaid Projected PHCE Projected Medicare Projected Medicaid 40 Actual Projected Medicaid Taxes 35 & Donations Medicare Extended to (1991) Medicare Disabled & ESRD Catastrophic 30 (1973) Coverage Medicaid Act of 1988 Percent 25 Balanced Budget 20 Refinement Act (1999) Medicaid 15 Medicare Medicare (projected) (projected) PHCE 10 5 PHCE Medicare Prospective Balanced Budget Act (projected) Payment System (1983) (1997) 0 1971 1975 1979 1983 1987 1991 1995 1999 2003 2007 2011 2015 Calendar Year Source: CMS, Office of the Actuary, National Health Statistics Group. 14 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 15. Table 1.7 Average Annual Growth in Medicare and Private Health Insurance Benefits Per Enrollee : Selected Periods Except for 1993-1997, Medicare has grown slightly more slowly than private health insurance. Medicare Private Health Insurance 16 Entire Period Selected Calendar Year Periods 14 12.8 12 10.9 10.9 9.5 10 9.2 7.6 Percent 8 6.4 5.9 6 4.3 4 2 0 4 93 97 -0.2 999 04 00 19 19 20 -2 1 0- 3- 7- 9- 70 -2 97 99 99 99 19 1 1 1 1 Calendar Years Source: CMS, Office of the Actuary, National Health Statistics Group. 15 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 16. Table 1.8 Concentration of Health Spending, 1987-2002 Health spending remains highly concentrated on a small percentage of people. The top 1% of people account about a quarter of all health spending, 97% 97%97% Percentage of Expenditures 70% 69% 1987 64% 1996 56% 56% 49% 2002 28% 28% 22% Top 1% Top 5% Top 10% Top 50% Population Ranked By Expenditures Source: Yu, William W. & Trena M.Ezzati-Rice, Medical Expenditure Panel Survey Statistical Brief #81, AHRQ, May 2005. 16 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 17. Table 1.9 Factors Accounting for Growth in Prescription Drug Spending per Capita, 1980-2011 Drug Prices and Utilization significantly affect prescription drug spending per capita. Drug Utilization (Number of Prescriptions per Capita) Drug Prices (Consumer Price Index - Drugs) 14 12.3% Average Annual Percent Change 12 10.7% 10 2.7 8.3% 8.2% 8.1% 8.0% 7.7% 8.3 8 4.5 6 4.4 4.9 4.5 6.2 8 4 2 4 3.8 3.7 3.5 3.3 * 1.5 0 1988-1993 1993-2003 2003-2004 2004-2005 2005-2006 2006-2010 2010-2015 Calendar Years Note: Utilization also includes the effects of intensity and population growth. Per capita drug spending in 1990 was $252 * Without the effect of Part D, overall growth would be 8.1% (price: 3.8%, Utilization 4.3%) Source: CMS, Office of the Actuary, Health Affairs Web Exclusive, Exhibit 6, pp. W70 17 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 18. Table 1.10 Prescription Drugs Expenditures by Source of Funds, 1965-2004 The share of drug spending covered by public and private sources has grown significantly. 100% 4% 4% 14% 90% 22% 27% 80% 24% 70% 60% 46% 50% 48% 93% 40% 63% 30% 20% 32% 25% 10% 0% 1965 1985 2000 2004 Out-of-Pocket Private Health Insurance Public Note: Percentages may not sum to 100 due to rounding. Drug spending grew from $3.7 billion in 1965 to $188.5 billion in 2004 Source: CMS, Office of the Actuary, National Health Statistics Group. 18 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 19. Table 1.11 Sources of Payment for Nursing Home and Home Health Care, 2004 Most such care is paid for by Medicare and Medicaid. Nursing Home Home Care Out-of-Pocket Medicare 12.3% 14.8% Out-of-Pocket 29.6% Private LTC Ins. 12.9% Medicare 40.8% Private Medicaid LTC Ins. 47.3% 8.4% Medicaid 34% Total nursing home and home health care spending in 2004 is $148 Billion Source: CMS, Office of the Actuary, National Health Statistics Group. 19 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 20. Table 1.12 Number of People Employed in Health Care, 1990-2005 Number of people employed in health is growing. 14 Health Services 12.1 12.3 Employment as a % 11.8 11.2 11.5 12 10.9 of Non-Farm Private 10.4 10.5 10.7 9.8 10.1 Sector Employment Employment in Millions 9.5 10 9.3 9 7.5% 1990 8.6 8.2 8.0% 1991 8.2% 1992 8 8.3% 1993 8.3% 1994 8.4% 1995 6 8.4% 1996 8.4% 1997 8.4% 1998 4 8.3% 1999 8.2% 2000 8.5% 2001 2 8.8% 2002 9.1% 2003 9.2% 2004 0 9.2% 2005 p 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 Note: Not seasonally adjusted. Health Care Employment includes those who work in ambulatory health care services, hospitals, and nursing and residential care facilities. Source: Kaiser Family Foundation, Trends and Indicators in the Changing Health Care Marketplace, 2006 Chartbook. 20 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 21. Table 1.13 Health Care Employment by Occupation, 1983-2005 Health care employment growth varies by occupation. Percent Change 1990-05 Radiologic Technicians 72.3% . . . . . . . . . . . . . . . . . . . . . . . . . . Health Record Technologists & Technicians -67.4% . . . . . . . Dental Hygienists 139.4% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Laboratory Technologists & Technicians 0.8% . . 1990 2000 2005 Physicians' Assistants 11.8% . . . . . . . . . . . . . . . . . . . . . . . . . -23.5% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Speech Therapists 150.9% . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Therapists 151.9% . . . . . . . . . . . . . . . . . . . . . . . . Occupational Therapists 26.1% . . . . . . . . . . . . . . . . . . . . . . . . . Respiratory Therapists Dietitians -23.9% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -24.1% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pharm acists 46.2% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Registered Nurses 33.6% . . . . . . . . . . . . . . . . . . . . . . . .Licensed Practial Nurses 80.8% . . . . . . . . . . . . . . . . . . Health Diagnosing Practitioners -9.5% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Optom etrists -24.6% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dentists -17.1% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physicians -57.1% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Scientists 485.7% . . . . . . . . . . . . . . . . . . . Managers, Medicine & Health 0 200 400 600 800 1000 1200 1400 1600 1800 2000 2200 Em ploym ent (Thousands) Source: Dept. of Labor, Bureau of Labor Statistics. Occupational Employment Statistics. 21 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 22. Table 1.14 Health Care Employment Growth Projections, 2000-2010 Over the next decade, health care employment is expected to grow at a rapid rate. General Health Care Fastest Growing* Specific 100% Occupations Health Care Occupations 90% 2000-2010 Employment Growth 80% 70% 62% 57% 60% 53% 47% 50% 40% 33% 26% 30% 25% 19% 20% 15% 10% 3% 0% T o tal S e rv ic e M a nuf a c t uring H e a lt h C a re H e a lt h C a re P e rs o na l & M e dic a l P hys ic ia n H o m e H e a lt h R .N .s E m plo ym e nt Secto r Secto r P ra c t it io ne rs S uppo rt H o m e C a re A s s is t a nt s A s s is t a nt s A ide s G ro wt h & T e c hnic a l O c c upa t io ns A ide s O c c upa t io ns *Note: Five of the nation’s top 10 fastest growing occupations are in health care. Source: Dept. of Labor, Bureau of Labor Statistics. Monthly Labor Review. November 2001. 22 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 23. Table 1.15 Average Annual Salaries for Selected Groups of Workers, 2005 Health professionals earn higher than average incomes. $150,000 $133,717 $125,000 $99,547 $93,515 $100,000 $75,000 $58,843 $57,282 $55,760 $50,000 $39,629 $25,000 $0 All Professional, Physical RNs Dentists Pharmacists Physicians Workers Technical, Therapists Health Professionals Specialty Workers Source: National Compensation Survey: Occupational Wages in the US, June 2005 . US Department of Labor, July 2006. 23 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 24. Table 1.16 HMO Enrollment by Ownership Status, 1981-2004 The proportion of HMO enrollees in not-for-profit plans stabilized in 1997. % Non-Profit % For-Profit 100% 12.0% 26.0% 80% 46.2% 52.2% 59.7% 62.7% 61.7% 62.6% 63.3% 63.5% 63.7% 64.0% 60% 88.0% 40% 74.0% 53.8% 47.8% 20% 40.3% 37.3% 38.3% 37.4% 36.7% 36.5% 36.3% 36.0% 0% 1981 1985 1989 1993 1997 1998 1999 2000 2001 2002 2003 2004 Total HMO enrollment in 2004 = 66.1 Million Note: HMO enrollment includes enrollees in both traditional HMOs and point-of-service (POS) plans through: group/commercial plans, Medicare, Medicaid, the Federal Employees Health Benefits Program, direct pay plans, supplemental Medicare plans, and unidentified HMO products. Source: Kaiser Family Foundation. Trends & Indicators in the Changing Health Care Marketplace, 2006 Chartbook. 24 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 25. Table 1.17 Concentration of Managed Care Enrollment, 1988-2003 Half of managed care enrollees are enrolled in the nation’s 10 largest managed care firms. 80 70 66.5 65.0 65.2 Percent Enrolled in 10 Largest Firms 64.1 66.0 60 56.2 54.6 50 48.0 45.8 48.0 40 30 20 10 0 * 1988 1991 1994 1997 1998 1999 2000 2001 2002 2003 *Note: The decrease in concentration does not represent a decline, but rather a change in the methodology. Note: The largest national managed care firms include Kaiser Foundation Health Plans, UnitedHealth Group, WellPoint Health Networks, Aetna, and Health HMO enrollment includes enrollees in both traditional HMOs and point of service plans. Source: Kaiser Family Foundation. Trends & Indicators in the Changing Health Care Marketplace, 2005 – Chartbook. 25 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 26. Table 1.18 Managed Care Enrollment by Type of Plan, 1984-2004 Mixed model HMO plans grew rapidly before 2000 and declined less rapidly after 2000. 78.9 74.2 80 Staff Group Network IPA Mixed 66.1 63.3 70 32.1 60 Enrollees (in millions) 28.5 23.1 28.9 50 38.8 40 31.4 6.7 33.5 29.9 30 27.5 21.5 13.5 16.2 15.1 20 5.6 3.9 2.9 8.3 8.3 3.3 7.1 3.5 10 8 9.7 6.6 8.7 7 7.4 7.2 4.3 2.4 2.1 0.8 0.4 0.2 0.2 0 1984 1988 1992 1996 2000 2002 2004 Mixed NA NA 17.3% 36.4% 40.0% 38.4% 43.7% IPA 19.5% 43.0% 41.7% 43.4% 41.9% 40.2% 32.6% Network 23.3% 18.0% 10.0% 5.3% 8.9% 11.2% 12.5% Group 43.6% 25.4% 24.8% 13.7% 8.8% 9.9% 11% Staff 13.6% 13.6% 6.2% 1.2% 0.4% 0.2% 0.3% Note: Plans analyzed are comprehensive HMO plans. Traditional HMOs and point of service plans are included, managed care carveouts for selected services such as behavioral health are not included. Enrollment includes group and commercial plans, Medicare, Medicaid, Federal Employee group health program, and others. Source: Kaiser Family Foundation, Trends & Indicators in the Changing Health Care Marketplace, 2006 Chartbook. 26 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 27. Table 1.19 Health Care as a Percent of Income by Age, 2004 Those over 65 and those with incomes under $20,000 spend a higher percentage of their income on health than other groups. By Age Group By Income Level P ercen t of In com e S p en t on H ealth 16 15% 16 P ercen t o f In co m e S p en t o n Health 14 14 11.4% 12 12 10 10 6.9% 8 8 5.6% 5.0% 6 6 3.8% 3.2% 2.9% 4 4 2 2 0 0 Under 35 35 to 54 55 to 64 65 and Less than $20,000 to $50,000 to $70,000 over $20,000 $49,999 $69,999 and above Age Group Income Level Source: Dept. of Labor, Bureau of Labor Statistics, Consumer Expenditure Survey. 27 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 28. Table 1.20 Annual Growth Rates in the Overall Consumer Price Index (CPI) and Medical-Specific Consumer Price Index (MCPI), 1993-2005 Medical prices have risen faster than overall consumer prices. 7.0% 6.0% 5.0% MCPI 4.0% CPI 3.0% 2.0% 1.0% 0.0% 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 CPI MCPI Source: Dept. of Labor, the Bureau of Labor Statistics. 28 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 29. Section 2 International Comparisons 29 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 30. Table 2.1 Percent of GDP Spent on Health Care by OECD Country, 1960-2004 The U.S. has had a higher share of GDP spent on health than the OECD median for the past four decades. 16.00 15.3 14.00 11.9 12.00 10.6 9.9 10.00 9 8.8 8.7 8.5 8.1 Percent 8 8.00 7.1 7 7 6.4 6.2 6 5.9 6.00 5.6 5.4 5.1 4.5 4.5 3.9 4.00 3 2.00 0.00 Canada United Kingdom Japan** Germ any* United States 1960 1970 1980 1990 2004 Median: 3.9% 5.1% 6.8% 7.5% 9.6 % *For 1960, no data was available. **2003 data was used because 2004 were not available. Note: The data is arrayed by spending growth from 1990 to 2004. The medians include all OECD countries. Source: OECD Health Data 2006. 30 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 31. Table 2.2 Per Capita Spending on Medical Services by OECD Country, 1980-2004 US spending is growing rapidly compared with other OECD countries. 5000 $ 4,451 4500 4000 $ 3,408 3500 3000 2500 $ 2,308 $ 2,153 $ 2,027 $ 1 $1,984 $ 2,132 ,951 2000 $1,639 $1,423 ,445 $ 1,406 $1 1500 $1,348 $1,365 1000 $ 783 $ 675 $ 827 $ 617 500 0 Canada France Germany Japan United States 1980 1990 2000 2004 * 2003 Data Used for Germany and Japan Source: OECD Health Data, 2006 31 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 32. Table 2.3 Average Annual Growth in Per Capita Spending by Decade by OECD Country, 1960-2003 Health spending growth over the last decade is lower in OECD countries than in prior decades. 20 18.0 18 16 14.1 14 13.5 13.0 12 11.6 11.1 11.1 10.3 Percent 9.9 9.9 10 9.5 8.8 8.9 8.3 8.0 7.5 7.6 8 6.8 6.3 6.5 6.2 6.0 5.7 6 5.6 5.1 4.2 4.4 4.3 3.9 3.7 4 2 0 Canada France United States Germ any Japan^ United Kingdom ^ 1960-1969 1970-1979 1980-1989 1990-1999 2000-2003 ^ Average annual change calculated from 2000-2002 Note: Each bar represents the average annual nominal growth over the decade. The data is arrayed by spending growth from 1990 to 1999. The medians include all OECD countries. Source: OECD Health Data 2005. 32 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 33. Table 2.4 Per Capita Health Spending by Type of Service by OECD Country, 2003 Per capita outpatient spending in the US is almost double inpatient spending. In other OECD countries per capita inpatient spending is greater than outpatient spending. $6,000 $380 $5,000 $709 $131 $4,000 $3,000 $2,473 $256 $89 $70 $467 $247 $509 $581 $167 $2,000 $12 $202 $454 $13 $113 $51 $162 $843 $670 $666 $675 $1,000 $1,551 $1,114 $1,053 $1,056 $766 * $0 United States Japan Germany France Canada Inpatient Outpatient Ancillary Home Health Drugs Nursing Home Source: OECD Health Data 2006. 33 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 34. Table 2.5 Share of Total Health Spending on Out-Patient Care by OECD Country, 1970-2003 In 2003, the U.S. spent the highest percent of total healthcare spending on out- patient care; In 1970 Japan spent an even higher percent of total health care spending on outpatient care 60% 50% 48.4% 44.6% 43.3% 43.5% 43.9% 39.6% 40% 33.4% 31.3% 31.9% 32.3% 31.6% 30.4% 31.2% 30% 25.1% 26.1% 25.3% 25.3% 22.6% 20.8% 20.9% 20% 10% 0% Japan Canada Germany United States 1970 1980 1990 2000 2003 Source: OECD Health Data 2006 34 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 35. Table 2.6 National Health Spending by Source of Funds by OECD Country, 2003 Source of funding varies significantly by country. For instance, out-of-pocket spending ranges from 8% to 18% of health spending, with the U.S. at about the median. 100% 8% 10% 14% 15% 1% 18% Out-of-Pocket 90% 4% Payments 12% 1% 4% 0.9% 9% 80% 13% Percent of Total Health Expenditure All Other Private 2% 70% Funds 37% 60% Private Insurance 50% 68% 75% 40% 13% 69% Social Security 30% Schemes 20% 32% General 10% 17% Government, Excl. 9% 4% Social Security 0% France Germany United States Canada Japan Source: OECD Health Data 2006 35 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 36. Table 2.7 Per Capita Spending on Pharmaceuticals and Other Non-Durables by OECD Country, 1970-2003 Variation across countries is increasing. Recent growth in North America is most rapid. 1970 1980 1990 2000 2003 $709 $700 $572 $600 $539 $514 $498 * $500 $438 $425 $398 $367 $400 $363 $300 $258 $252 $248 $239 $202 $200 $128 $123 $112 $96 $100 $67 $49 $43 $43 $34 $0 Japan Germany Canada France United States Expenditures in U.S. dollars using purchasing power parity rates. Note: Data is arrayed by spending levels for 2003. Japan not available for 1970. Source: OECD Health Data 2006. 36 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 37. Table 2.8 Drug Spending as a Percentage of Total Health Spending by OECD Country, 1980-2003 Although, recent drug spending in the United States on this measure has grown, it is still low compared to other OECD countries 21.4 21.2 20.3 18.7 18.8 18.4 17 16.9 15.9 16 14.6 14.3 13.6 12.4 13.4 11.7 9 9.1 8.00 9 Canada France Germany Japan* United States 1980 1990 2000 2003 *2003 data for Japan is not available; 2002 was used Source: OECD Health data, 2006. 37 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 38. Table 2.9 Infant Mortality Rates per 1,000 Live Births by OECD Country, 1970-2004 OECD country infant mortality rates have declined since 1970. 25 United States 20 Median Canada France 15 Japan 10 United States Canada 5 Median France Japan 0 1970 1980 1990 2004 Note: The median includes all OECD countries. The decrease from 1960-2004 is in percentage points. 2003 data used for Canada and the United States as the latest available. Source: OECD Health Data 2006. 38 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 39. Table 2.10 Male and Female Life Expectancy at Birth by OECD Country, 1960-2004 Japan has the highest life expectancy at birth for both males and females. Male Female 85.6 78.6 Japan 78.8 Japan 73.4 70.2 65.3 82.7 78.4 Sweden 78.9 Sweden 72.8 74.9 71.2 83 78.1 Australia 78.1 Australia 71 73.9 67.9 83.8 76.7 France 78.4 France 70.2 73.6 67 79.9 75.2 Denmark 77.3 * Denmark 71.2 74.4 70.4 80.1 74.8 United States* 77.4 United States* 70 73.1 66.6 77.6 72.7 Mexico 70 Mexico 64.1 59.5 55.8 79 72.6 Czech Republic 73.9 Czech republic 66.8 73.4 67.9 76.9 68.6 Hungary 72.7 Hungary 65.5 70.1 65.9 0 30 60 90 0 30 60 90 Year Year 1960 1980 2004 1960 1980 2004 Median = 67.2 70.0 76.4 Median = 72.5 76.6 81.4 *2003 data was used because 2004 was not available. Note: Data are arrayed by male life expectancy; countries are kept together. The medians include all OECD countries. Source: OECD Health Data 2006 39 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 40. Table 2.11 Male and Female Life Expectancy at Age 65 by OECD Country, 1960-2004 Japan has the highest male and female life expectancy Female Male 23.3 17.7 Japan 18.2 14.1 14.6 Japan 11.6 21.1 17.8 Australia 17.9 Australia 13.7 15.6 12.5 21.3 17.1 18.2 France** 13.6 France** 15.6 12.5 18.6 17.1 Mexico 17 Mexico 15.4 14.6 14.2 16.8 19.8 14.1 United States* 18.3 United States* 12.8 15.8 15.5 18.6 Denmark* 13.6 Denmark* 17.6 13.7 15.3 13.9 Czech 17.3 11.2 Czech Repuiblic* 12.5 14.3 Republic* 14.5 13.1 Hungary 11.6 16.9 12.3 Hungary 14.6 13.8 0 10 20 Year 0 10 20 30 1960 1980 2004 Year 1960 1980 2004 Note: Data are arrayed by male life expectancy; countries are kept together * 2003 data **Data are 2001 for females and 2002 for males. Source: OECD Health Data 2006. 40 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 41. Table 2.12 Number of In-Patient Discharges and Total Beds per 1,000 Persons by OECD Country, 2004 Discharge rates generally track bed supply. Austria 7.7 Austria 311 7.8 Hungary 263 Hungary Germany 8.6 Germany* 201 France 7.5 France* 269 Czech Republic 8.7 Czech Republic 229 4.2 Italy* 140 Italy* Australia* 3.8 Australia* 157 United Kingdom 4.1 United Kingdom 235 Ireland 4.2 Ireland 104 United States 3.3 United States* 119 Portugal 3.7 Portugal 90.4 Spain* 3.4 Spain* 109 Canada* 3.4 Canada* 88 Turkey 2.6 Turkey 84 Mexico 1.9 Mexico* 42 0 2 4 6 8 10 0 50 100 150 200 250 300 350 Number of Discharges/1000 beds/1000 Source: OECD Health Data 2006 * 2004 data not available, used 2003. 41 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 42. Table 2.13 Average Length of Hospital Stay For Selected OECD Countries, 2004 The length of stay for specific procedures varies differently from total length of stay Average Length of Stay- In-Patient Acute Average Length of Stay- Appendicitis* United States* 3.3 United States 6.5 United Kingdom 4.1 United kingdom 7.2 Turkey 4.1 Turkey 5.7 Switerland 5.6 Switzerland 11.9 Spain* 4.8 Spain* 8.7 Slovak Republic 4.6 Slovak Republic 8.6 Portugal 4.2 Portugal 8.9 Norway 3.3 Norway 8.2 Mexico* 3.6 Mexico* 4.1 Korea** 6.3 Korea* 13.5 Japan*** Japan 36.3 Iitaly* 4.6 Italy* 7.7 Ireland 4.5 Ireland 7.5 Hungary 5.8 Hungary 8.2 Germany* 6.1 Germany 10.4 France 4.7 France 13.4 Finland 3.1 Finland 10 Denmark* 3.5 Denmark 5.2 Czech Republic 5.7 Czech Republic 10.7 Austria 6.1 Austria* 7.8 Australia* 3.2 Australia* 16.7 0 2 4 6 8 0 5 10 15 20 25 30 35 40 *2003 Data.; **2002 data ***no data available Countries are listed alphabetically. Data Expressed in Days Source: OECD Health Data 2006. 42 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 43. Table 2.14 Medical Technology and Use of High-Technology Medical Procedures by OECD Country, 2004 Different countries spend health dollars in different ways: Japan has the highest rate of diagnostic high-tech procedures, the U.S. has the highest rate of heart procedures. Coronary Bypass Coronary Angioplasty Patients Undergoing Bone Marrow MRIs per CT Scanners per Procedures per Procedures per Dialysis per Transplants per Million People 100,000 People 100,000 People Million People 100,000 People 100,000 People Australia 3.7 20.8***** 77.9* 153.0* 39.5 5.6* Austria 14.9 28.5 54.6* 174.8**** 43.7 4.6 Canada 4.9 10.3 97.6* 167.4*** 56.4 3.9*** Denmark 10.2 14.5 60.0* 156.9* 45.1 0.7***** France 3.2 7.5 40.8*** 155.9**** 26.2***** 6.9 Germany 6.6 15.4 86.5 301.6 73.9 4.8 Greece 2.3** 17.1** 59.6***** 122.9** 75.4 1.9 Hungary 2.6 6.8 135.5 235.8 49.6 2.8 Italy 10.2 20.6 46.5* 92.4* 34.4***** 7.1* Japan 35.3** 92.6** _ _ 194.3 0.9 Mexico 1.7 3.1 2.3 1.5 37.2 0.1 Netherlands 3.9***** 9***** 58.2 92.6* 28.2***** 3.6 Poland 1* 6.3* 8***** 19***** …… 2.1* Spain 7.7 13.3 29.9* 58.5* 49.3 4.6 Sweden 7.9***** 14.2***** 75.1* 144.0* 25.5***** 2.0*** Switzerland 14.3 17.9 32.6 85.6 26.5***** 1.7 United Kingdom 5.0 7.0 55.5 113.4 41.6 4.2 United States ….. ….. 160.7* 426.4* 159.5* 5.1* Median 6.0* 14.0* 60.0* 158.5* 45.1* 2.9* *2003 data,**2002 data, ***2001 data, ****2000 data, *****earlier data. Medians reflect all OECD countries Source: OCED Health Data 2006 43 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 44. Table 2.15 Selected Indicators of Morbidity by OECD Country, Selected Years Risky behaviors vary significantly by country: the U.S. has higher rates of obesity and HIV; Western Europe has higher rates of smoking and in some countries, surgery. 2002 Incidence of 2004 Cancer 2004 2004 2004 2004 Percentage of (All Types of Incidence of Total Surgeries on an In-patient Basis, Percentage of Percentage of Total Live Births Malignant AIDS per 1,000 Population That is Population That That are Low- Neoplasms) in Population, Obese (BMI >30) are Daily birthweight per 100,000 per 1,000,000 Smokers Births Australia 312.0 12.0 50.2* 21.7***** 17.7 6.3* Austria 275.5 8.2 133.6* 9.1***** 36.3***** 6.8 Canada 299.9 9.4 44.8* 122.4 15.0 5.8* Denmark 281.4 9.9 97.4 9.5**** 26.0 5.3 France 289.5 23.4* _ 9.5 23.0 6.8 Germany 283.3 6.0* 79.4 12.9* 24.3* 6.9 Greece 203.0 6.8 _ 21.9* 38.6 8.6 Hungary 318.8 2.3 228.6 18.8* 30.1* 8.3 Italy 276.5 29.2 52.7* 8.0* 24.2* 6.7* Japan 214.5 3.0 _ 3.2* 29.4 9.4 Mexico 147.3 45.3* 31.3 24.2**** 26.4** 9.1 Netherlands 283.0 12.1 39.8 10.9 30.0 5.4** Poland 256.1 4.9 _ _ 27.6**** 5.1 Spain 243.4 43.0 51.9* 13.1* 28.1* 7.1 Sweden 264.7 7.5 54.6** 9.8 16.2 4.2 Switzerland 284.6 4.8 103.9 7.7** 26.8** 6.5 United Kingdom 273.6 14.1 63.3 23.0* 25.0 7.6* United States 357.7 149.0 89.9 30.6** 17.0 8.1 Median 266.2 9.9 52.7* 12.9* 26.5 5.1 *2003, **2002, ***2001, ****2000, *1999 or earlier Median includes all OECD countries. Source: OECD Health Data 2006. 44 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 45. Table 2.16 Selected Indicators of Mortality by OECD Country, 2004 Causes of mortality differ: the U.S. and Mexico have high homicide rates, Japan and Europe have high suicide rates. HIV Mortality Rates for Suicide Rates for Homicide Rates for Homicide Rates for Total Population Due to Cancer Mortality Rates, Total Population, Total Population, Males, HIV Infection, per 100,000 per 100,000 per 100,000 per 100,000 per 100,000 Australia 161.0 11.1** 1.4** 1.9*** 0.5** Austria 161.4 14.5 0.7 0.7 0.5 Canada 173.2** 10.6** 1.5** 2.0** 1.0** Denmark 212.5**** 11.3*** .8*** 1.1*** 0.5*** France 172.7** 15.1*** 0.8** .9** 1.4** Germany 161.2 10.3 0.6 0.7 0.5 Greece 152.4* 2.9* 1.0* 1.5* 0.2* Hungary 244.8* 22.6* 1.8* 2.2* 0.1* Italy 167.3** 5.6** 0.9** 1.3** 0.0** Japan 146.5** 20.3* 0.15* 0.6* 0.4* Mexico 114.2**** _ 20.1**** 37.8**** _ Netherlands 182.2 7.9 1.1 1.6 0.4 Poland 202* 13.6* 1.4 2.0* 0.3* Spain 158.* 6.7* 0.9* 1.4* 3.2* Sweden 148.8** 11.4** 1.1** 1.1** 0.3** Switzerland 144.1** 15.3** 0.9** 0.8** 1.1** United Kingdom 181.8** 6.3** 1.2** 1.2** 0.3** United States 166.3** 10.2** 6.2** 9.7** 4.2** Median 166.0** 11.5** 1.2** 1.5** 0.35** Median includes all OECD countries. *2003 data;**2002data;***2001data,****earlier data Source: OECD Health Data 2006. 45 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 46. Section 3 Providers 46 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 47. Table 3.1 Number of Hospitals by Type, 1980-2004 The number of hospitals has declined with the exception of rehabilitation hospitals. All Hospitals Specialty Hospitals 7,000 800 6,965 ric 750 at hi 700 yc 6,053 Ps 650 6,000 5,759 600 550 529 Number of Hospitals 500 N u m b e r o f H o s p ita ls 450 443 5,000 General 400 4,776 Fed General 350 335 300 250 227 4,000 Total 200 193 Other 183 * 150 128 123 Pediatric n ilitatio 100 114 Rehab 62 50 Fed Psych 24 10 3,000 0 1980 1985 1990 1995 2000 2004 1980 1985 1990 1995 2000 2004 *Includes specialty hospitals such as TB, Ob-Gyn; eye, ear, nose and throat; orthopedic and chronic disease. Source: American Hospital Association, personal communication, 2006. 47 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 48. Table 3.2 Number of Hospital Beds and Occupancy Rates by Hospital Type, 1980-2004 The decline in the percentage of general hospital beds is greater than the percentage decline in occupancy rates in general hospitals. Beds Occupancy Rate 100% 1,500,000 1,400,000 1,364,516 To 1,300,000 90% All Hospitals tal Ot ric 85% hiat 1,200,000 85% Psyc he r* 82% Re 1,066,836 1,100,000 Percent Occupancy 81% ha Number of Beds 80% bi 78% lit a tio 76% 1,000,000 n 73% 955,768 General 74% 73% 900,000 70% ric t Pedia 67% 800,000 815,589 General 700,000 60% 600,000 500,000 50% 1980 1985 1990 1995 2000 2004 1980 1985 1990 1995 2000 2004 *Includes specialty hospitals such as TB, Ob-Gyn; eye, ear, nose and throat; orthopedic and chronic disease. Source: American Hospital Association, personal communication, 2006. 48 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 49. Table 3.3 Number of Hospital Beds per 1,000 Persons by State, 2004 The number of hospital beds varies by state, with the lowest concentration in the Western U.S. WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS TX LA FL AK Low (1.8-2.5) HI Medium (2.6-3.9) High (4.0 - 6.5) National average is 3 Note: Per 1,000 population. Source: 2004 AHA Annual Survey. Kaiser Family Foundation State Health Facts Online. 49 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 50. Table 3.4 Number of Nursing Home Beds and Total Residents, 1985-2003 From 1985 to 1999 beds grew slightly more rapidly than residents, after 1999, resident counts fell more rapidly than the bed count. 2,000,000 Number of Beds & Residents 1,800,000 1,600,000 1,400,000 1,200,000 1,000,000 1985 1995 1997 1999 2003 Year Beds Current Residents Source: Health, United States, 2005, National Center for Health Statistics. 50 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 51. Table 3.5 Number of Physicians per 100,000 Persons by State, 2004 Availability of Physicians varies substantially by state, with the highest concentration in the Northeast. WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS TX LA FL AK Low (175-240) HI Medium (241 - 290) High (291 - 752) National average is 281 Note: Includes non-federal physicians only. Source: Physician Characteristics and Distribution in the U.S. 2004. American Medical Association. Kaiser Family Foundation State Health Facts Online. 51 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 52. Table 3.6 Distribution of Active Physicians, 1950-1998 Since 1950, urban areas have seen much more rapid growth in physicians than rural areas. 350 308 Physicians per 100,000 Persons 300 271 * 268 247 250 234 234 204 197 200 185 175 172 157151 156 149 150 141 140 132 124 124 113 108 110 99 85 84 84 92 100 78 75 77 72 61 57 62 52 50 0 Rural (no city of Rural (city Rural (city Small Metro Large Metro Active Physicians 10,000); adjacent >10,000; not adj. >10,000; adj. to (<1,000,000) (>1,000,000) per 100,000 and not adj. To to metro area) metro area) Persons (national metro area) average) 1950 1960 1970 1980 1990 1998 *Projection for 2000. Note: Includes all active physicians. Source: AMA data from the Bureau of Health Professions and Health, United States, 1993. 52 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 53. Table 3.7 Percentage of Physicians in Differing Practice Arrangements, 1987-2001 Declines in solo practice physicians are offset by increases in salaried physicians and group practices. 21.3% 26.1% 31.3% 30.1% 5.3% 9.8% 8.2% 9.2% 33.1% 32.1% 38.4% 33.8% 40.4% 32.0% 25.7% 23.3% 1987 1993 1999 2001 Self Employed in Solo Practice Owner of Group Practice Employee in Group Practice Other Employee Source: AMA Socioeconomic Monitoring System and 2001 Patient Care Physician Surveys, American Medical Association 53 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 54. Table 3.8 Physician Revenue by Payer, 1986-2004 The share of physician and clinical services revenue paid by patients out-of-pocket has declined substantially since 1986. Private health insurance continues as the largest source of physician and clinical services revenue. $99.5 billion $157.5 billion $220.5 billion $286.4 billion $399.9 billion 100 10% 11.6% 11.9% 19.3% 27.4% 6.9% 7.5% 8.0% 80 7.2% 8.2% 60 Percent 48.5% 47.7% 48.6% 43.0% 35.9% 40 6.9% 5.6% 5.9% 7.0% 6.4% 20 20.4% 20.8% 18.9 19.1 19.4% 7.2% 6.7% 6.8% 4.0% 4.5% 0 1986 1990 1995 2000 2004 Calendar Year Other Public Out-of-Pocket Total Total Medicare Other Private Public Private Total Medicaid, SCHIP expansion and SCHIP Private Health Insurance Source: CMS, Office of the Actuary, National Health Statistics Group. 54 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 55. Table 3.9 Physician Participation in Managed Care, 1988-2001 Most physician practices have managed care contracts and receive a significant share of revenue from them. 100 92% 91% 88 % 90 80 70 61% 60 49% 50 44% 41% 40 30 23% 20 10 0 % of Physicians in a Practice With at Average Share of Total Practice Least One Managed Care Contract Revenue Derived from Managed Care 1988 1997 1999 2001 Note: Managed care contracts include HMOs, IPA, and PPOs. Data from the American Medical Association. Source: Trends and Indicators in the Changing Health Care Marketplace, 2005, Kaiser Family Foundation. 55 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 56. Table 3.10 Physician Managed Care Payment Arrangements, 2001 Fee-for-Service is the predominant payment arrangement for physicians. 90 84% 74% 80 70 63% 60 Percent 50 42% 40 30 25% 23% 20 10 6% 3% 0 Primary Care Physicians Specialty Care Physicians Relative Value Scale Fee-for-Service Salary Capitation Note: Physicians may receive payment in multiple ways, so the payment methods do not add to 100%. Source: Trends and Indicators in the Changing Health Care Marketplace, 2005, Kaiser Family Foundation. 56 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 57. Table 3.11 Hospital Participation in HMOs and PPOs, 1987-2004 A steady rise in the number of hospitals participating in both Health Maintenance and Preferred Provider Organizations has leveled off in recent years. 4000 Number of Community Hospitals 3173 3000 2681 2488 2290 2000 1000 0 1987 1990 1995 2000 2004 HMO PPO Source: American Hospital Association, personal communication. 57 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 58. Table 3.12 Hospital Managed Care Payment Arrangements, 2001 Most hospitals receive per diem and fee-for-service payments, a much smaller number also receive capitated payments. 100% 89% 90% 80% 71% 70% 62% 60% 50% 40% 30% 19% 20% 10% 0% Per Diem Rate Fee-for-Service Diagnosis Related Capitation Groups Source: Trends and Indicators in the Changing Health Care Marketplace, 2005, Kaiser Family Foundation. 58 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 59. Table 3.13 Hospital Profit Margins for All Payers and Medicare, 1997-2004 For both rural and urban hospitals, overall and Medicare inpatient hospital profit margins have declined. Total margins remain positive. 20 1997 2000 2004 18 16.9% 16% 16 14 12.3% 12 10.9% 9.6% 10 8 6.2% 5.9% 5.9% 5.3% 6 4.4% 4.3% 4.1% 3.7% 3.6% 4 2.4% 2 0 -0.7% -0.9% -2 -2.2% -4 All Hospitals Urban Rural All Hospitals Urban Rural Total Margins Medicare Inpatient Margins Source: CMS, Office of the Actuary. Medicare cost report data. 59 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 60. Table 3.14 Hospital Payment to Cost Ratios for Medicare, Medicaid, and Private Payers, 1985-2002 Private Payers continue to pay a larger share of hospital costs than Medicare and Medicaid but less so than in the late eighties and early nineties.. 140% 130% Private Payment-Cost Ratio Payers 120% 119% 110% Medicare 97.9% 100% Medicaid 90% 96.1% 80% 70% 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 Year Medicare Medicaid Private Payers Source: American Hospital Association Annual Survey. Chapter 4. Trends in Hospital Financing 60 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 61. Table 3.15 Change in Nursing Home Institutionalization Rate for the Elderly, 1985-1999 While the absolute number of elderly in nursing homes continues to rise, the number of residents per 1,000 elderly has declined. Total Number of Rate of Elderly in Elderly in Nursing Nursing Homes per Homes 1,000 Elderly 1,600,000 160 140 1.46 m illion 1.42 m illion 120 1,400,000 100 1.31 m illion 80 54 60 45.9 1,200,000 43.3 40 20 1,000,000 0 1985 1995 1999 1985 1995 1999 Source: Health, United States, 2005, National Center for Health Statistics. 61 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 62. Table 3.16 Nursing Home Resident Rate by State, 2003 The Western U.S. houses the smallest share of nursing home residents. WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS TX LA FL AK Low (131 - 299) HI Medium (300 - 400) High (400+) National average is 308 Note: Number of nursing homes residents (all ages) per 1,000 resident population 85 years of age and over. Source: Health, United States, 2005. Table 116. 62 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 63. Table 3.17 Number of Hospital Discharges and Average Length of Stay, 1980-2004 Hospital discharges and length of stay have generally declined over the last two decades. 8 175 170 7 165 Discharges per 1,000 Population 160 6 Average Lenth of Stay 155 5 150 145 4 140 135 3 130 2 125 120 1 115 0 110 1980 1985 1990 1996 2001 2004 Average Length of Stay Discharges Note: Non-Federal short-stay hospitals. Source: Center for Disease Control and Prevention, National Center for Health Statistics. 63 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 64. Table 3.18 Number of Physician Visits per 1,000 Persons, 1990-2000 While there was a drop in the overall number of physician visits during the early nineties, by 1996-97, visits steadily increased. 3100 3004 3000 2925 2931 2900 Visits per 1,000 People 2865 2777 2800 2700 2643 2600 2500 2400 1990-91 1992-93 1994-95 1996-97 1998-99 2000 Source: Center for Disease Control and Prevention, National Center for Health Statistics. 64 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 65. Section 4 Public Programs 65 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 66. Table 4.1 Public Payers’ Share of National Health Spending, 1980-2010 The share of national spending by public payers has increased slightly over the last two decades, driven by faster growth in Medicare and Medicaid spending. Total Public Medicare Medicaid Other State & Local 50 46.3 45.2 45.1 42.7 45 40.6 40 35 30 Percent 25 18.6 20 17.3 16.415.6 15.8 15.6 15.6 15.2 13.6 13.5 12.9 15 10.6 10.6 10 6.8 6.2 5 0 1980 1990 2000 2004 2010* Note: Total public includes Medicare, Medicaid, other federal (not shown) and state and local spending. *2010 is a projection. Source: CMS, Office of the Actuary, National Health Statistics Group. 66 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 67. Table 4.2 Personal Health Care Expenditures by Type of Service and Percent Medicare Paid, 2004 Total personal health care spending in 2004 was $1.56 trillion; Medicare accounted for over 19%. $570.8 Billion Hospital Care Medicare pays 28.6% $399.9 Billion Physician and Clinical Services Medicare pays 20.5% 1 $188.5 Billion Prescription Drugs Medicare pays 1.8% $115.2 Billion Nursing Home Medicare pays 13.9% $81.5 Billion Dental Services Medicare pays 0.1% $52.7 Billion Other Professionals Medicare pays 19.2% Medicare Spending Other Payers $53.3 Billion Other Personal Health Care Medicare pays 0% $43.2 Billion Home Health Medicare pays 37.9% $32.3 Billion Other Medical Nondurables Medicare pays 5.9% $23 Billion Medical Durables Medicare pays 28.3% 0 50 100 150 200 250 300 350 400 450 500 Personal Health Spending (Billions of Dollars) 1Medicare payments are mostly from managed care plans, since fee-for-service Medicare did not generally cover outpatient prescription drugs in 2004. Source: CMS, Office of the Actuary, National Health Statistics Group. 67 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 68. Table 4.3 Personal Health Care Expenditures by Type of Service and Percent Medicare Paid, 1980 Total personal health spending in 1980 was $214.6 billion; Medicare accounted for 17% $101 Billion Hospital Care Medicare pays 26% $47 Billion Physician and Clinical Services Medicare pays 17% $12 Billion Prescription Drugs Medicare pays 0% $17 Billion Nursing Home Medicare pays 2% $13 Billion Dental Services Medicare pays 0% $3 Billion Other Professionals Medicare pays 8% $3 Billion Other Personal Health Care Medicare pays 0% $2 Billion Home Health Medicare pays 27% Medicare Spending Other Payers $9 Billion Other Medical Nondurables Medicare pays 0% $3 Billion Medical Durables Medicare pays 8% 0 10 20 30 40 50 60 70 80 90 100 110 Personal Health Spending (Billions of Dollars) Source: CMS, Office of the Actuary, National Health Statistics Group. 68 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 69. Table 4.4 Where the Medicare Dollar Went: 1980 and 2005 Medicare spending has moved from inpatient hospital services to all other settings. Managed care has grown while the physician share declined. 1980 2005 Administrative HHA Outpatient Hospital 2% Expenses 2% 5% and Other 14% Outpatient Facility1 Physician Other Inpatient 24% Hospital 43% 14% Managed Care SNF 1% Inpatient Hospital 17% 68% Physician 4% 6% Home SNF Health Care Total = $37 Billion Total = $336 Billion 1Other services include other professional services and ambulance services. Note: Data do not sum due to rounding. Spending includes benefit dollars only. Source: CMS, Office of the Actuary, Trustees Report 2006 69 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 70. Table 4.5 Medicare Trustee’s Report: Part A Income and Expenses, 1970-2015 Projected Expenditures First Exceed Projected Income in 2011 Actual Income Actual Expenditures Projected Income Projected Expenditures $400 $375 Actual Projected $350 $325 $300 Dollars in Billions $275 $250 $225 $200 $175 $150 $125 $100 $75 $50 $25 $0 1970 1980 1990 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 Calendar Year . Source: CMS, Office of the Actuary.Trustees Report, 2006. 70 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 71. Table 4.6 Number of Medicare Beneficiaries, 1970-2040 Enrollment in the Medicare Program is projected to nearly double in the next 30 years. 100 Actual Projected 90 86.4 Enrollment (millions) 80 78.6 70 61.6 60 50 46.5 39.7 42.5 40 34.2 30 28.4 20.4 20 10 0 1970 1980 1990 2000 2005 2010 2020 2030 2040 Year . Source: Medicare Trustees Report 2006 71 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 72. Table 4.7 Medicare Beneficiaries as a Share of the U.S. Population, 1970-2030 The U.S. population will age rapidly through 2030, when 22 percent of the population will be eligible for Medicare. 25 65 & Over Disabled 22.0% 2.4 20 18.5% Percent of Population 2.7 15.0% 15 13.9% 13.1% 2.4 12.1% 1.9 1.2 1.3 9.5% 10 9.5 10.8 11.9 12.0 12.6 15.8 19.5 5 0 1970 1980 1990 2000 2010 2020 2030 Total Number of 20.4 28.4 34.3 39.6 46.5 61.6 78.6 Medicare Beneficiaries: (millions) Source: Social Security Administration, Office of the Actuary. 72 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 73. Table 4.8 Medicare Spending for Fee-for-Service Beneficiaries by Income, 2003 About seventy percent of Medicare expenditures are on behalf of individuals with annual incomes of $25,000 or less. $5,000 or Less $40,001 or More 4% 14% $5,001 - $10,000 25% $25,001 - $40,000 16% $10,001 - $15,000 17% $15,001 - $25,000 24% Note: Data may not sum due to rounding. Source: CMS, Office of Research, Development, and Information: Data From the Medicare Current Beneficiary Survey (MCBS) 2003 Access to Care File. 73 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 74. Table 4.9 Living Arrangements of Medicare Beneficiaries, 2003 Among the nearly 30 percent of beneficiaries living alone, a large proportion are women and have low incomes. Live in LTC Live Alone Facility 29% 5% 52% have $ an income Live with <$15,000 Children/Others 17% 70% are women 16% are over 85+ the age of 85 Live with Spouse 49% Source: CMS, Office of Research, Development, and Information: Data from the Medicare Current Beneficiary Survey (MCBS) 2003 Access to Care File. 74 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 75. Table 4.10 Age and Gender of the Medicare Population, 2003 The proportion of women increases among those 85 and older. 20000 Females 18.2 million 18000 Males 16000 Enrollees (millions) 14000 54% 13.1 million 12000 10000 58% 8000 6.1 million 6000 4.9 million 47% 46% 4000 46% 69% 42% 41% 2000 56%53% 29% 31% 0 Under 65 65-74 75-84 85+ Note: Fifty-three percent (23.7 million) of all Medicare beneficiaries are female; 44% (18.6 million) are males. Data reflect Medicare beneficiaries ever enrolled in the program during the year. Source: CMS, Office of Research, Development, and Information: data from the Medicare Current Beneficiary Survey (MCBS) 2003 Access to Care File. 75 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 76. Table 4.11 Total Health Care Expenditures for Medicare Beneficiaries, 2003 Total Health Care Expenditures = $491 Billion Dental 2.4% Rx Drugs ($12.0 B) 13.6% Medical Provider ($66.7 B) 25.3% ($124.3 B) Home Health 2.7% ($13.4 B) LTC 15.6% ($76.6 B) SNF Hospital 3.6% 35.4% ($17.8 B) ($173.7 B) Hospice 1.2% ($6.0 B) Note: Premium payments are excluded. LTC is long-term care. SNF is skilled nursing facility. Source: CMS, Office of Research, Development, and Information: Data from the Medicare Current Beneficiary Survey (MCBS) 2003 Cost and Use File. 76 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 77. Table 4.12 Sources of Payment for Medicare Beneficiaries’ Medical Services, 2003 Medicare pays a little more than half of the total cost of beneficiaries’ medical care. Medicaid 11% ($1,321) Medicare Private 52% Insurance ($6,553) 13% ($1,600) Direct Out-of-Pocket* 18% ($2,350) Other Sources 6% ($688) Overall Medical Expenses per Medicare Beneficiary = $12,512 *Beneficiary out-of-pocket spending does not include their payments for Medicare Part B premiums, private insurance premiums, or HMO premiums. Note: Data are for all beneficiaries, both fee-for-service and Medicare+Choice enrollees. Source: CMS, Office of Research, Development, and Information: Data From the Medicare Current Beneficiary Survey (MCBS) 2003 Cost and Use File. 77 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 78. Table 4.13 Sources of Payment for Medicare Beneficiaries by Type of Service, 2003 Medicare pays a large proportion of the total expenses of services it covers. 100 1 Percent of Covered Expenditure by Payer 5.0 7.7 8.8 7.7 10.7 10.9 9.2 Percent of Expenditure by Payer 6.1 80 11.2 11.2 1.2 31.6 1.8 1 37.7 0.8 40.5 3.1 OOP 20.6 3.1 24.6 2.1 60 2.8 0.6 Other 11.0 9.0 4.7 50.0 40 84.6 83.3 Medicaid 0.4 78.0 78.0 66.3 61.9 50.0 46.7 Medicare 20 0.2 14.8 0.50 3.6 0 0 Inpatient Home Independent Skilled Medical Outpatient Other Prescribed Long-Term 2 Hospital Health Labs Nursing Provider Hospital Medical Medicines Care Facility 1 OOP is out-of-pocket. 2 Other Medical includes things such as hospice and durable medical equipment. Note: Medicare did not generally cover outpatient prescription drugs in 2003. Source: CMS, Office of Research, Development, and Information: Data from the Medicare Current Beneficiary Survey (MCBS), 2003 Cost and Use File. 78 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 79. Table 4.14 Types of Supplemental Health Insurance held by Fee-for-Service Medicare Beneficiaries, 2003 Most beneficiaries using fee-for-service Medicare have private, supplemental health plans. No Supplemental Medicaid Insurance 18% 16% Other 2% 13.5% Individual Medigap Employer- 26% Sponsored 33% Medigap & Employer-Sponsored Insurance 5% Note: Medicaid (shown above) includes both Qualified Medicare Beneficiaries (QMBs) and Specified Low-Income Medicare Beneficiaries (SLMBs). Source: CMS, Office of Research, Development, and Information: Data From the Medicare Current Beneficiary Survey (MCBS) 2003 Access to Care File. 79 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 80. Table 4.15 Medicare Beneficiary Out-of-Pocket Spending, 2003 The majority of beneficiary out-of-pocket spending is for Medicare cost-sharing and payment for non-covered services. Physician/Supplier Medicare 23% Cost- Outpatient Services Sharing Private Health Insurance 5% 35% Premium 23% Inpatient Hospital/SNF 7% Direct Out-of-Pocket Long Term Care 62% 31% Outside Prescription Drugs Medicare 22% Benefit Dental Package 63% 9% Medicare Part B Home Health* Premium 1% 15% Total Out-of-Pocket Expenses Direct Out-of-Pocket $159 billion $99 billion *These are for home health services not covered by Medicare. Note: 1) Data are for all beneficiaries, both fee-for-service and Medicare+Choice enrollees. 2) Total per capita direct out-of-pocket spending is $3,765 Source: CMS Office of Research, Development and Information, Medicare Current Beneficiary Survey (MCBS) 2003 Cost and Use file 80 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 81. Table 4.16 Per Capita Out-of-Pocket Expenses for Medicare Beneficiaries by Type of Insurance Coverage, 1993 and 2003 Beneficiaries without supplemental insurance and those with Medigap coverage have higher out-of-pocket spending than other groups. 1993 2003 $5,000 $4,673 $4,324 $4,500 $3,950 $3,957 $4,000 Per Capita Dollars $3,500 $2,977 $2,862 $2,776 $3,000 $2,691 $2,406 $2,268 $2,500 $1,922 $2,000 $1,433 $1,500 $1,000 $500 $0 Medicare FFS Medigap Other Employer Medicaid Medicare Risk Only Sponsored HMO Plan Percent Change, 1993 to 2003 63.3% 79.7% 46.8% 74.5% 44.4% 107.7% Note: Premium payments are included. Source: CMS, Office of Research, Development, and Information: Data from the Medicare Current Beneficiary Survey (MCBS), 1993 and 2003 Cost and Use Files. 81 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 82. Table 4.17 Distribution of Medicare Enrollees by Functional Status, 2003 More than one-third of the Medicare population needs assistance with at least one “activity of daily living.” 60% 54% 50% No ADL or IADL Limitations 50% IADLs Only 1-2 ADLs Percent of Population 40% 3-6 ADLs 30% 30% 21 %25 % 22 % 20 % 19 % 20% 15% 14 % 13 % 13 % 10% 0% All Elderly Disabled Note: ADLs are activities of daily living (e.g., eating, bathing); IADLs are instrumental activities of daily living (e.g., shopping, use of phone, cleaning). Source: CMS, Office of Research, Development, and Information: Data from Medicare Current Beneficiary Survey (MCBS) 2003 Cost and Use File. 82 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 83. Table 4.18 Beneficiaries with Poor Health and Functional Limitations by Insurance Status, 2003 Medicare beneficiaries in poor health or with functional limitations are more likely to receive Medicaid or to have no supplemental insurance. 80% 74% 70% Percent of Beneficiaries 60% 51% 50% 43% 42% 40% 30% 21% 20% 12% 6% 6% 10% 0% Medicaid Medicare FFS HMO Private only Supplemental insurance Poor Health Functional Limitations Source: CMS, Office of Research, Development, and Information: Data from the Medicare Current Beneficiary Survey (MCBS) 2003 Access to Care File. 83 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 84. Table 4.19 Medicare Managed Care Enrollment, 1990-2005 Managed care enrollment grew through 2000, then declined, and is now on the upswing. 8 6.9 6.8 6.4 6.2 5.8 6 5.5 5.4 5.4 5.3 Enrollment in Millions 4.4 4 3.5 2.8 2.5 2.25 2.0 1.82 2 0 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 Source: CMS, Office of the Actuary. 84 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 85. Table 4.20 Percent of Medicare Beneficiaries with Prescription Drug Coverage, 1992-2003 About three-quarters of Medicare beneficiaries had prescription drug coverage at some point in 2003. 90% 78% 78% Percent of Beneficiaries With Coverage 77% 76% 76% 80% 73% 73% 69% 70% 65% 62% 61% 57% 60% 50% 40% 30% 20% 10% 0% 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Note: This includes beneficiaries who had some type of drug coverage at any point during the year. Does not include beneficiaries in facility care. Source: CMS, Office of Research, Development, and Information: Data from the Medicare Current Beneficiary Survey (MCBS) 1992- 2003 Cost and Use Files. 85 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 86. Table 4.21 Total Spending for Prescription Drugs for All Medicare Beneficiaries, 1996-2003 Total spending for drugs was higher for beneficiaries with drug coverage than without; however, non-covered beneficiaries pay substantially more out-of-pocket costs. Out-of-Pocket Other Payer $2,500 $2,000 Dollars $1,500 $1,592 $1,429 $1,146 $1,000 $942 $779 $674 $601 $516 $500 $894 $822 $763 $732 $690 $617 $548 $546 $542 $463 $448 $395 $352 $325 $276 $253 $0 ed ed ed ed ed ed ed ed ed ed ed ed ed ed ed ed er er er er er er er er er er er er er er er er ov ov ov ov ov ov ov ov ov ov ov ov ov ov ov ov -C -C -C -C -C -C -C -C C C C C C C C C on on on on on on on on N N N N N N N N 1996 1997 1998 1999 2000 2001 2002 2003 Note: Does not include beneficiaries in facility care. Does not adjust for underreporting of prescription drugs. Source: CMS, Office of Research, Development, and Information: Data from the Medicare Current Beneficiary Survey (MCBS) 1996- 2003 Cost and Use Files. 86 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 87. Table 4.22 Medicare Beneficiaries With Drug Coverage by Primary Source of Supplemental Coverage, 1995 and 2003 Employer-sponsored retiree coverage is the largest source of coverage for drug spending. * 100% * 78% of Medicare Percent of Total Medicare Beneficiaries Beneficiaries Have 65% of Medicare Drug Coverage 80% Beneficiaries Have 9% Medicare + Drug Coverage Choice Plans 14% 8% 60% Medicaid 12% 40% 32% Employer- 30% Sponsored 20% 12% Individually 11% Purchased 11% Other 4% 0% 1995 2003 Note: Data are based on the non-institutionalized beneficiaries. Percentages shown in bars are Medicare beneficiaries with drug coverage as a percent of total Medicare beneficiaries. Beneficiaries do not necessarily get drug coverage from their primary sources of supplemental insurance. Source: CMS/Office of Research, Development and Information. Data are from the Medicare Current Beneficiary Survey. 87 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 88. Table 4.23 Personal Health Expenditures by Type of Service and Percent Medicaid Paid, 2004 Total personal health spending in 2004 was $1,560,241,000,000; Medicaid accounted for 17% $570.7 Billion Hospital Care Medicaid pays 17% Physician and Clinical Services $399.9 Billion Medicaid pays 7% $188.5 Billion Prescription Drugs Medicaid pays 19% $115.2 Billion Nursing Home Medicaid pays 44% $81.5 Billion Dental Services Medicaid pays 5% $52.7 Billion Other Professionals Medicaid pays 6% $53.2 Billion Other Personal Health Care Medicaid pays 69% $43.1 Billion Home Health Medicaid pays 32% Medicaid Spending Other Payers $32.3 Billion Other Medical Nondurables Medicaid pays 0% $22.9 Billion Medical Durables Medicaid pays 15% 0 100 200 300 400 500 600 Personal Health Spending (Billions of Dollars) Source: CMS, Office of the Actuary, National Health Statistics Group. 88 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 89. Table 4.24 Personal Health Expenditures by Type of Service and Percent Medicaid Paid, 1980 Total personal health spending in 1980 was $214.6 billion; Medicaid accounted for 12%. $101 Billion Hospital Care Medicaid pays 10% $47 Billion Physician and Clinical Services Medicaid pays 5% $12 Billion Prescription Drugs Medicaid pays 12% $17 Billion Nursing Home Medicaid pays 50% $13 Billion Dental Services Medicaid pays 4% $3 Billion Other Professionals Medicaid pays 5% $3 Billion Other Personal Health Care Medicaid pays 13% $2 Billion Home Health Medicaid pays 12% Medicaid Spending Other Payers $9 Billion Other Medical Nondurables Medicaid pays 0% $3 Billion Medical Durables Medicaid pays 0% 0 10 20 30 40 50 60 70 80 90 100 110 Personal Health Spending (Billions of Dollars) Source: CMS, Office of the Actuary, National Health Statistics Group. 89 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 90. Table 4.25 Medicaid Enrollment by Eligibility Group, 2003 Payments for the elderly, blind and disabled account for 69 percent of total payments. Total Total Enrollees = Expenditures 52.4 million = $235 billion Elderly 9% Elderly 26% Blind & Disabled 16% Adults Blind & 27% Disabled 43% Children Adults 12% 48% Children 19% Note: Expenditure distribution based on Congressional Budget Office data that includes only federal spending on services and excludes DSH payments, supplemental provider payments, vaccines for children, administration, and the temporary Federal Medicaid Assistance Percentage Increase.. Source: Kaiser Family Foundation, Trends and Indicators in the Changing Health Care Marketplace Chartbook 2004. 90 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 91. Table 4.26 Average Medicaid Payments per Person Served by Eligibility Group, 1985-2003 Per capita payments for the elderly, blind and individuals with disabilities continue to be significantly higher than payments for other groups. $15,000 Aged 65 and Older $13,677 Blind & Disabled $13,303 Children Under 21 $13,000 Adults Real Per Capita Payments $11,000 $9,000 $7,000 $5,000 $2,292 $3,000 $1,606 $1,000 1985 1988 1990 1995 1998 2003 -$1,000 Fiscal Year Source: CMS, CMSO, HCFA-2802 reports; Medicaid Statistical Information System. 91 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 92. Table 4.27 Medicaid Enrollees and Beneficiaries by Eligibility Group, 1975-2003 Children historically represent the largest group of Medicaid enrollees. 2003 Total =55.2 million Enrollees 50 Adults 14.3 million enrollees Persons Served (in millions) 11.7 m beneficiaries 40 Children Under 21 30 27.3 million enrollees Other** 24.8 million beneficiaries 20 Blind & Disabled 8.4 million enrollees 7.7 million beneficiaries 10 Age 65 & Older 5.2 million enrollees 0 4 million beneficiaries 1975 1980 1985 1990 1995 1999 2000 2001 2003 Fiscal Year Medicaid “enrollees” are those who are enrolled in Medicaid at any time during the fiscal period. “Beneficiaries” are those for whom services have been reimbursed during the fiscal period. *Note: (1) In 1998, a large increase occurred in the number of persons served which is mainly the result of a new reporting methodology of classifying payments to managed care organizations; FY 1998 was the first year capitation payments were counted as a service for purposes of the HCFA 2082 reporting, and thus all managed care enrollees were counted as individuals receiving services; this new methodology probably has the greatest effect on the reported number of children; (2) the term “adults” as used above refers to non-elderly, non-disabled adults; (3) disabled children are included in the blind & disabled category shown above. **The Other category was dropped in 1999. Source: CMS, CMSO, Medicaid Statistical Information System. 92 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 93. Table 4.28 Total Medicaid Expenditures by Type of Service, FY 2005 Total Medicaid Expenditures in FY 2005 were $300.7 billion EPSDT $1.1 Expenditure (In Billions) 3% Lab & Radiology $1.3 Medicare Premiums $8 Clinic Services $9.1 8% Outpatient $23.9 Physician Services $12.4 5% Other $15 1% Targeted Case Management $3 16% Capitation Payments $50.6 Intermediate Care Facility-MR $12.5 32% Long Term Care $95.3 Nursing Homes $46.4 Community Based Long Term Care $36.4 10% Prescription Drugs $30.7 1% Dental $3.4 Outpatient Hospital $12.3 DSH Hospital Payments $17.1 25% Inpatient (Mental) $4.7 Hospital $76 Inpatient (General) $42 Collections -$5 FY 2005 Source: CMS, Office of the Actuary. 93 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 94. Table 4.29 Total State Spending and Federal Funds Provided to States, 2004 Over twenty-two percent of state total spending and over forty-four percent of federal funds provided to states were spent on Medicaid. Total State Spending Federal Funds Provided to States Elementary & Higher Higher Secondary Public Education Education Elementary & Education Assistance 10.9% 5.6% Secondary 11.4% 3.6% Education Public 21.4% Assistance Transportation 2.1% 8.0% Corrections 0.6% Transportation Medicaid 8.0% 22.3% Corrections All Other 3.5% 26.3% Medicaid 44.5% All Other 31.7% Source: National Association of State Budget Officers, 2004 State Expenditure Report. 94 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 95. Table 4.30 Medicaid Spending for Long-Term Care, 1999-2003 Home and community-based services are a growing share of Medicaid’s long term care spending. $100 $90 $77b $80 Real Spending in Billions $73b $66b $70 $59b $60 $55b $51 $50 $50 $47 $40 $44 $41 $30 $20 $26 $23 $19 $10 $15 $14 $0 1999 2000 2001 2002 2003 Selected Fiscal Year Home and Community Care Spending Institutional Care Spending Notes: The share of Medicaid spending on long term care devoted to home and community based settings increased from 25% of the total in FY1999, 26% in FY2000, 29% in FY2001, 32% in FY2002, to 34% of the total in FY2003. Institutional spending includes SNF’s, ICF’s, ICF- MR, and Psychiatric Hospitals. Sources: CMS, Center for Medicaid and State Operations, MSIS data. 95 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 96. Table 4.31 Births Financed by Medicaid as a Percent of Total Births by State, 2005 Medicaid pays for about 41% of the nation’s births. WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS TX LA FL AK AK Less than 32% 32.0% to 39.9% HI 40.0% to 47.9% 48% to 55.9% Source: Kaiser Family Foundation, State Health Facts, http://www.statehealthfacts.org Above 56.0% 96 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 97. Table 4.32 Medicaid Enrollment by Age, Sex, and Ethnicity, 2003 There were 55.2 million Medicaid enrollees in 2003. Age Sex Ethnicity 75-84 85+ Native Multiple Races/ Hawaiian/ Other 7% 65-74 4% 2% Pacific 4% 45-64 Islander 1% 10% Hispanic 21% Male White Female 40% 44% 60% Asian African 3% 50% 26% American American 21-44 0-18 23% Indian/ Native Alaskan 4% 1% 19-20 Source: MSIS State Summary for 2003. 97 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 98. Table 4.33 Medicaid Managed Care Enrollment, 1996-2004 Medicaid managed care enrollment grew rapidly over the last decade. 27.4 28 26.3 25 23.6 22 20.8 Num ber of People (in Millions) 18.8 19 17.8 16.6 15.3 16 13.3 13 10 7 4 1 1996 1997 1998 1999 2000 2001 2002 2003 2004 -2 % Enrolled in Managed Care 40% 48% 54% 56% 56% 57% 57% 60% 61% Note: The unduplicated managed care enrollment figures include enrollees receiving comprehensive benefits and limited benefits. This table also provides unduplicated national figures for the Total Medicaid population and Other population. The statistics also include individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards. Source: CMS, Center for Medicaid and State Operations: National Summary of Medicaid Managed Care Programs and Enrollment June 30, 2001. CMS, Medicaid Managed Care Enrollment Data, 2002-2004. 98 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 99. Table 4.34 Health Insurance Coverage of Children, 1988-2005 The percentage of children without health insurance has declined since SCHIP was Implemented in 1998. 100% 6 6 6 6 80% Other* Percent of All Children 57 62 63 64 57 56 60 62 Employer-Based 60% Uninsured 40% 14 12 12 14 Medicaid and 15 12 12 SCHIP 13 20% 26 24 26 23 22 20 20 16 0% 1988 1993 1995 1998 2000 2001 2003 2005 Selected Calendar Year *Other includes private non-group and other public insurance. A change in the census questionnaire allowed this category to be separately identified starting in 2000. see also Table 6.6 Notes: About 23% of children below poverty (or 4.1 million kids) had no health insurance in 2004. Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments. 99 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 100. Table 4.35 State Children’s Health Insurance Program Spending and Enrollment, 1998-2004 The SCHIP program covers a growing number of uninsured low-income children. Spending Enrollment* 7.0 7 6.1 million $6.1 $6.6 5.9 million 6 6.0 $5.4 5.4 million Dollars in Billions 5 5.0 4.6 million $3.8 4 4.0 3.3 million $2.8 3 3.0 2.0 million 2 2.0 $1.3 1.0 million 1 1.0 $0.2 0 0.0 CY98 FY99 FY2000 FY2001 FY2002 FY2003 FY2004 00 01 02 03 04 98 99 20 20 20 20 20 FY FY FY FY FY FY FY *Note: Ever enrolled in SCHIP during the year, not a point in time estimate. Source: Center for Medicaid and State Operations 100 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 101. Table 4.36 State Children’s Health Insurance Program Plan Type by State, 2006 ND WA* MT NH MN*^ ME VT WI^ SD ID OR+ WY MI*+ NY IA NE PA MA* OH IL*+ IN NV RI*^ UT CO+ MO CT# KS CA+* WV NJ^+ KY VA DE MD OK NC TN# AZ+ AR* NM^+ SC MS# AL# GA TX#* LA Puerto Rico FL AK Separate State Child Health Plans: 18 States Medicaid Expansions: 17 States & D.C HI Combination Programs: 21 States Key * Approved Unborn State Plan Amendments: 9 (AR, CA, IL, MA, MI, MN, RI, TX, WA) ^ Approved SCHIP 1115 Demonstrations: 6 (AK, MN, NM, NJ, RI, WI) + Approved HIFA Demonstrations: 13 (AZ, AR, CA, CO, ID, IL, MI, NJ, NV, NM, OR, UT, VA) # State no longer has a Medicaid expansion program as of September 30, 2002, due to the aging out of the children phased into the Medicaid program under OBRA’90. Summary Information (in order of submission/approval): Number of Approved Separate State Child Health Plans: 18 (CO, PA, OR, NV, UT, MT, GA, AZ, KS, VT, WA, WY, WV, AL, MS, TX, CT, NY) Number of Approved Medicaid Expansions: 17 (SC, OH, MO, OK, WI, PR, DC, NE, NM, VI, LA, AK, HI, GU, AS, CNMI, TN) Number of Approved Combination Plans: 21 (FL, MA, NJ, ME, NH, KY, MI, IA, NC, ND, IN, IL, MD, SD, VA, CA, RI, MN, DE, AR, ID) Total Number of Amendments Approved: 272 Number of Amendments Under Review: 13 (TN,VA-6th amend, IL-6th amend, IL-7th amend, CA-11th amend, WI-4th amend.)WV-6th-amend; FL-17th amend; PA-7th amend.; DE-3rd amend, WA-8th amend. Source: CMS Center for Medicaid andState Operations. 101 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 102. Table 4.37 State Health Spending as a Percent of Gross State Product 2004 Proportion of state output devoted to personal healthcare varies by state. National average is 13.4% WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS TX LA FL AK Low (9.5% - 13.1%) HI Medium (13.2% -16.8%) High (16.9% - 20.5%) Note: Data are for personal health care by state of provider. Source: CMS, Office of the Actuary, National Health Statistics Group. 102 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 103. Table 4.38 Share of State Health Spending Financed by Both Medicare and Medicaid, 2004 Medicare and Medicaid finance varying proportions of State health spending. WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA Low 26% - 32% MS TX AK Medium 32%-39% LA High 40%-51.1% FL HI National average is 36.6% Source: CMS, Office of the Actuary, National Health Statistics Group. 103 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 104. Table 4.39 Share of State Health Spending Financed by Medicare, 2004 Medicare finances a varying share of State health spending. WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS AK TX LA FL HI High 21.9%-28.1% Low 7.4%-15.5% Medium 15.6%-21.8% National average is 19.2% Source: CMS, Office of the Actuary, National Health Statistics Group. 104 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 105. Table 4.40 Share of State Health Spending Financed by Medicaid, 2004 Medicaid finances a varying share of State health spending. WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS TX LA AK FL HI High 24.1%–31.6% Low 9.1%-16.6% Medium 16.7%-24.0% Source: CMS, Office of the Actuary, National Health Statistics Group. National average is 17.4% 105 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 106. Section 5 Private Health Insurance 106 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 107. Table 5.1 National Health Spending From Out-of-Pocket and Private Health Insurance, 1980-2010 Over the last 25 years, the share of national health spending from out-of-pocket sources has declined, while that from private health insurance has increased. Out of Pocket Private Health Insurance Other Private 40 35.2% 35.1% 34.2% 33.5% 35 Percent of National Health Spending 30 27.8% 23.7% 25 19.7% 20 15% 15 12.6% 10.9% 10 7.2% 7.3% 6.1% 5.9% 5.7% 5 0 1980 1990 2000 2004 2010* *Projected Note: The remainder of national health spending is from public sources. This chart is a subset off Table 1.3 Source: CMS, Office of the Actuary, National Health Statistics Group. 107 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 108. Table 5.2 Changes in Employer Health Insurance Premiums, Overall Inflation, and Workers’ Earnings, 1989-2005 The rate of increase in employer health insurance premiums is slowing. 20 Health Insurance Premiums Workers' Earnings Overall Inflation 18.0 Percentage 15 13.9 12.9 11.2 11.0 10 8.3 9.2 8.5 4.8 5.1 5 4.4 3.3 3.7 4.3 3.5 3.2 3.5 3.7 3.3 4.1 2.9 2.7 2.6 3.1 2.3 2.2 2.2 2.9 2.5 2.3 1.6 1.4 0.8 0 1989 1993 1996 1998 1999 2000 2001 2002 2003 2004 2005 Source: Health Insurance Premiums from personal communication of data from KFF/HRET Employer Health Benefits Surveys from 1999, 2000, 2001, 2005: KPMG Survey of Employer-Sponsored Health Benefits: 1993, 1996; HIAA Employer-Sponsored Health Insurance Survey; 1989. Workers’ Earnings from Bureau of Labor Statistics Current Employment Statistics Survey (April-April), 1988-2001. Overall Inflation from Bureau of Labor Statistics, CPI estimates (April-April), 1988-2001, at www.bls.gov. Trends and Indicators in the Changing Health Care Marketplace, 2002 – Chartbook. 108 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 109. Table 5.3 Annual Change in Health Insurance Premiums by Firm Size, 2005 Small firms face higher premium growth than larger firms. 9.2% All Firms 9.8% All Small Firms (3-199 Workers) (3-24 Workers) (25-49 Workers) (50-199 Workers) 8.9% All Large Firms (200 or More Workers) Midsize (200-999 Workers) Large (1,000-4,999 Workers) 29% Jumbo (5,000+ Workers) 0% 2% 4% 6% 8% 10% 12% 14% Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2005. 109 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 110. Table 5.4 Employee Contributions to Health Insurance Premiums, 1988-2005 Employees are paying a higher dollar value, but smaller share of their health insurance premiums. Average Monthly Employee Percentage of Premium Paid Contribution, 1988-2005 by Employees, 1988-2005 35% $240 $226 30% 29% $201 28% $200 27% 27% 26% 25% $160 21% $138 20% $122 $120 16% 16% 15% 14% 11% $80 10% $52 $51 $37 $42 $40 $28 5% $8 0% $0 Single Coverage Family Coverage Single Coverage Family Coverage 2005 1988 1996 2000 2003 2005 1988 1996 2000 2003 Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2000, 2001, 2003, 2005; KPMG Survey of Employer- Sponsored Health Benefits: 1988, 1993, 1996. 110 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 111. Table 5.5 Average Annual Premium Costs by Plan Type, 2005 Average premiums vary by plan type. $4,024 All Plans $10,880 $3,782 Conventional FFS $9,979 Single $3,767 Family $10,456 HMO $4,150 $11,090 PPO $3,914 $10,801 POS $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2005. 111 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 112. Table 5.6 Changes in Employee Benefit Packages, 1980-2004 Employees were offered more generous benefit packages in recent years. 100% 97% 100% 96% 97% 90% 81% 80% 80% 1980 1991 2004 72% 70% Percent of Employees 58% 60% 56% 55% 50% 40% 36% 30% 30% 28% 30% 24% 21% 20% 10% ** ** ** ** ** ** 0% Extended Hom e Health Hospice Care Outpatient Dental Care Vision Care Hearing Care Physical Well-Baby Im m unization ** Care Facility Care Prescription Exam Care and Drugs Inoculation Note: Coverage for selected services offered by medium and large establishments, displayed by % of employees that have each benefit available to them. **Not available. 2004 data available only for physical exams and well baby exams. Sources: Dept. of Labor, Bureau of Labor Statistics. Report by Sophie Korczyk, “Trends in Employer-Provided Health Care Coverage: 1980-1997, Final Report March, 2000. 2004 data from Employer Health Benefits 2004 Annual Survey, Kaiser Family Foundation. 112 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 113. Table 5.7 Firms Offering Health Insurance Coverage by Firm Size, 1996-2005 Larger firms are more likely to offer health insurance than smaller firms. 97 99 99 98 100 87 93 93 90 87 78 79 80 72 1996 60 60 53 Percent 47 2000 40 2005 20 0 3-9 Workers 10-24 Workers 25-49 Workers 50-199 All Large Firms Workers (200+ Workers) Source: Employer Health Benefits, 2005 Annual Survey, The Kaiser Family Foundation, and Health Research and Educational Trust. 113 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 114. Table 5.8 Number of Health Plans Offered by Firm Size, 2005 Large firms are more likely to offer employees a choice of plans. 6 5 100% 14 25 14 80% 49 65 27 3 or More Plans 60% 2 Plans 81 40% 80 24 1 Plan 18 48 20% 27 17 0% All Firms Small (3- Midsize Large Jumbo 199 (200-999 (1,000- (5,000+ Workers) Workers) 4,999 Workers) Workers) Source: Employer Health Benefits, 2005 Annual Survey, The Kaiser Family Foundation, and Health Research and Educational Trust. 114 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 115. Table 5.9 Private Health Insurance Enrollment by Plan Type, 1988-2005 Since 1988, Conventional Fee-for-Service plans have almost disappeared, while PPOs have grown significantly. Conventional FFS HMO PPO POS 2005 3 21 61 15 2004 5 25 55 15 2003 5 24 54 17 2002 4 27 52 18 2001 7% 23% 48% 22% 2000 8% 29% 41% 22% 1999 9% 28% 38% 25% 1998 14% 27% 35% 24% 1996 27% 31% 28% 14% 1993 46% 21% 26% 7% 1988 73% 16% 11% 0% 20% 40% 60% 80% 100% Source: Employer Health Benefits, 2001-2005 Annual Survey, The Kaiser Family Foundation and Health Research and Educational Trust. Trends and Indicators in the Changing Health Care Marketplace, 2002 – Chartbook. 115 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 116. Table 5.10 Employees With a Choice of Health Plans, 1988-2005 In recent years, fewer employees have a choice of conventional FFS plans. A growing share have a choice of PPOs and POS plans. 1988 1996 2002 2005 100 90 90 82 80 74 Percent of Employees 70 64 60 52 50 50 45 46 44 40 34 30 28 30 18 20 14 12 10 ^ 0 Conventional FFS HMO PPO POS ^ Information was not obtained for POS plans in 1988. Source: KFF/HRET Survey of Employer-Sponsored Health Benefits, 2000-2005; KPMG Survey of Employer-Sponsored Health Benefits: 1988, 1993, 1996. 116 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 117. Table 5.11 Covered Employees in Firms That Offer Health Benefits, 2005 Not all eligible employees enroll in an employer’s health plan. Percentage of Workers Eligible Percentage of Workers Covered for Employer Health Benefits by Their Employers’ Health Benefits Small Firms (3-199 Workers) 81% 65% Large Firms (200+ Workers 67% 79% Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2005. 117 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 118. Section 6 The Uninsured 118 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 119. Table 6.1 Out-of-Pocket Spending by the Under 65 Population by Insurance Status by Income, 2001 and 2003 The percent of health spending from out-of-pocket sources by the uninsured is significantly higher than for those with insurance. Uninsured Insured 70% 70% 62% 60% 60% 55% 55% 52% 51% 50% 50% 45% 43% 42% 40% 36% 40% 35% 30% 30% 22% 22% 17% 18% 18% 20% 20% 15% 13% 12% 11% 13% 10% 10% 0% 0% 2001 2003 2001 2003 Negative or Poor (LT 100% POV Line) Negative or Poor (LT 100% POV Line) Near Poor (100%-124%) Near Poor (100%-124%) Low Incom e (125%-199%) Low Incom e (125%-199%) Middle Incom e (200%-399%) Middle Incom e (200%-399%) High Incom e (GE 400% POV Line) High Incom e (GE 400% POV Line) Note: Insured includes all types of insurance coverage. Source: Actuarial Research Corporation tabulations of Medical Expenditure Panel Survey. 119 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 120. Table 6.2 Out-of-Pocket Spending by the Under 65 Population by Insurance Status by Type of Service, 2001 and 2003 In 2003, the insured paid about 18% of their health expenses out-of- pocket, compared to about 52% for the uninsured. RX 88% RX 38% Other Equip/Supplies 45% Other Equip/Supplies 39% Glasses/Contact Lenses 95% Glasses/Contact Lenses 70% 100% 69% Hom e Health Non-Agency Hom e Health Non-Agency Hom e Health Agency 0% Hom e Health Agency 3% All Dental Care 85% All Dental Care 42% IP Hospital Stay - Dr 31% IP Hospital Stay - Dr 4% IP Hospital Stay - Facility 19% IP Hospital Stay - Facility 2% Em ergency Room - Dr 50% Em ergency Room - Dr 9% Em ergency Room - Facility 50% Em ergency Room - Facility 9% All OPD Visits - Dr 32% All OPD Visits - Dr 8% All OPD Visits - Facility 25% All OPD Visits - Facility 6% All Office-Based Visits 47% All Office-Based Visits 18% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2003 2003 Total 2001 43% of health spending out-of-pocket Total 2001 19% of health spending out-of-pocket 2003 52% 2003 18% Uninsured Insured Note: Insured includes all types of insurance coverage. Uninsured individuals may have some of their care financed in part by charity or providers as uncompensated care. Source: Actuarial Research Corporation tabulations of Medical Expenditure Panel Survey. 120 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 121. Table 6.3 The Percent Uninsured Within Age Categories, 1987-2005 25 Adults age 18-54 have twice the percentage uninsured as children in 2005 . 22% Percent of Age Group Without Insurance 20 18% 15 14% 13% 14% 12% 11% 10 <18 9% 18-54 5 55-64 Total 0 87 89 91 93 95 97 99 01 03 05 19 19 19 19 19 19 19 20 20 20 Note: Under 65 population. Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments. 121 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 122. Table 6.4 Percent Uninsured Within Income Category, 1987-2005 Lower-income groups are more likely to be uninsured than higher-income groups. 40 35 34% Percent of Income Group Uninsured 31% 30% 30 25% 25 20 18% 15 13% 12% 10 <100% 6% 100-200% 5 200+% Total 0 87 89 91 93 95 97 99 01 03 05 19 19 19 19 19 19 19 20 20 20 Note: Under 65 population. Colored lines represent income as a percentage of the poverty line. Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments. 122 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 123. Table 6.5 Percent Uninsured by Ethnicity, 1987-2005 About half of the uninsured are white, and the other half are racial or ethnic minorities. 40 Percent of G roup Without Insurance 34% Hispanic 35 Hispanic 30 29% Non-Hispanic 25 23% American Indian Non-Hispanic 23%American Indian 20 19% 21%Non-Hispanic Black 19% Non-Hispanic Black Non-Hispanic 18% Asian Total 13% Non-Hispanic Asian 15 13% Other Total 12% 10 Other 9% 5 0 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 Note: Under 65 population. Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments. 123 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 124. Table 6.6 The Uninsured by Age, 1987-2005 A growing majority of the uninsured are adults 18-54. 100% 7 7 7 7 7 8 8 8 8 8 8 8 8 8 8 8 8 9 9 90% 80% Percent of Uninsured 70% 65 66 66 67 68 70 67 67 69 67 67 67 60% 69 70 71 72 73 55-64 73 73 50% 18-54 <18 40% 30% 20% 28 27 27 26 25 23 25 25 24 25 24 25 23 22 21 20 19 10% 18 18 0% 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 Note: Under 65 population. See also table 4.34 Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments. 124 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 125. Table 6.7 The Uninsured by Income, 1987-2005 The share of the uninsured with incomes above 200% of poverty is growing. 100% 90% 33 36 36 37 36 37 36 38 38 39 40 80% 44 44 48 46 46 46 46 46 Percent of Uninsured 70% 60% 200+% 34 50% 100-200% 33 34 34 34 34 34 33 33 33 32 <100% 29 30 40% 28 29 29 30 28 29 30% 20% 33 31 30 29 30 29 30 29 29 29 28 27 26 24 25 25 25 25 25 10% 0% 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Note: Under 65 population. Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments. 125 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 126. Table 6.8 The Uninsured by Ethnicity, 1987-2005 About half of the uninsured are white, nearly one-third are Hispanic. 100% 3 3 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 90% Non-Hispanic Asian 17 19 17 17 17 18 18 18 17 16 17 17 16 15 15 15 16 16 17 80% Percent of Uninsured Non-Hispanic American Indian 70% 60% Non-Hispanic Black 48 48 48 48 47 47 47 55 52 53 51 55 53 55 55 56 57 50% 55 55 40% Non-Hispanic White 30% Hispanic 20% 30 30 30 30 29 29 29 26 24 25 24 24 23 23 22 22 22 22 22 10% 0% 87 89 91 93 95 97 99 01 03 05 19 19 19 19 19 19 19 20 20 20 Note: Under 65 population. Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments. 126 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 127. Table 6.9 The Uninsured by State, 2005 The South and West have higher rates of uninsured than the Mid-west and East. WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS TX LA FL AK HI Low (7% - 13.9%) Medium (14% - 17.9%) National average is 16% High (18%+) *Other includes private non-group and other public insurance (mostly Medicare and military-related). Medicaid includes CHIP. Source: Census Bureau, March Current Population Survey. 127 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation
  • 128. Table 6.10 Impact on Non-Elderly Adults of Being Uninsured, 2006 The uninsured face financial and other barriers to health care. 47% Postponed Care Due to Cost 15% 42% No Regular Source of Care 9% 37% Did not Fill Prescription Due to Cost 13% Uninsured 35% Needed Care but Did Not Get It Insured 9% 23% Medical Bills had Major Impact on Life 9% 23% Ever Contacted by a Collection Agency About Medical Bills 8% 0 10 20 30 40 50 Percent Note: Among adults under age 65. Source: Kaiser Foundation, The Uninsured: A Primer, Jan. 2006. 128 Centers for Medicare & Medicaid Services Office of the Assistant Secretary for Planning and Evaluation