Geographical Variation in Health Spending Across the US Among Privately Insured Individuals and Enrollees in Medicaid and Medicare

Abstract

Importance: Little is known about small-area variations in health care spending and utilization across the 3 major funders of health care in the US: Medicare, Medicaid, and private insurers. Objective: To measure regional health spending and utilization across Medicare, Medicaid, and the privately insured; to observe whether there are regions that are simultaneously low spending for all 3 payers; and to determine what factors are correlated with regional spending and utilization by payer. Design, Setting, and Participants: Observational cross-sectional analysis of the US health system in 2016 and 2017 for 241 of 306 hospital referral regions (HRRs) and 2 states. Participants include individuals with employer-sponsored coverage from Aetna, Humana, or UnitedHealth; individuals with Medicaid fee-for-service coverage in 2016 and 2017; and individuals with Medicare coverage. The analysis was carried out from January 2020 to May 2022. Main Outcomes and Measures: Spending per beneficiary and inpatient days per beneficiary by payer and overall. Results: The data include 25381167 individuals with employer-sponsored coverage, 69891299 with Medicaid coverage in 2016 and 2017, and 26711426 individuals with Medicare fee-for-service coverage. The percentage of enrollees who identified as female was 54.1% in the Medicaid program, 56.2% in the Medicare program, and 50.4% in private insurance. The mean (SD) age was 26.9 (21.8) years for Medicaid and 75.0 (7.9) years for Medicare enrollees; for private insurance enrollees, just age brackets were reported: 18 to 24 years (15.9%), 25 to 34 years (24.2%), 35 to 44 years (21.3%), 45 to 54 years (20.8%), and 55 to 64 years (17.8%). In 2017, the mean (SD) HRR-level spending per beneficiary was $4441 ($710) for private insurance, $10281 ($1294) for Medicare, and $6127 ($1428) for Medicaid. Across HRRs, the correlation coefficients and 95% CIs were 0.020 (-0.106 to 0.146; P =.76) for private insurance and Medicare spending, 0.213 (0.090 to 0.330; P