It's no surprise that Americans spend a huge amount of money on healthcare each year. High insurance premiums, high deductibles, copays, and other out-of-pocket expenses are just some of the costs associated with health and wellness in the country.
One reason for rising healthcare costs is government policy. Since the inception of Medicare and Medicaid—programs that help people without health insurance—providers have been able to increase prices.
Still, there's more to rising healthcare costs than government policy. Read on to find out how much the U.S. spends on health costs, which factors shape prices in this industry, how the COVID-19 pandemic changed the entire cost-structure conversation, and how recent legislation offers both hope and help.
- Healthcare costs in the U.S. have been rising for decades and are expected to keep increasing.
- The U.S. spent more than $3.8 trillion on health care in 2019 and was expected to exceed $4 trillion in 2020, according to a study by the Peterson and Kaiser Foundations.
- A JAMA study found five factors that affect the cost of healthcare: a growing population, aging seniors, disease prevalence or incidence, medical-service utilization, and service price and intensity.
- In the long term, the financial impact of COVID-19 related healthcare spending is not expected to significantly affect healthcare spending in general.
- The No Surprises Act—and other legislation included in the Consolidated Appropriations Act, 2021—offers some help when it comes to unexpected healthcare billing and costs.
Overall Costs of Healthcare
Healthcare costs have risen dramatically in the U.S. over the past several decades. According to a study by the Peterson Center on Healthcare and the Kaiser Family Foundation (KFF), healthcare spending in the U.S. rose nearly a trillion dollars between 2009 and 2019, when adjusted for inflation.
The study reported that healthcare spending in the U.S. during 2019 was nearly $3.8 trillion, or $11,582 per person. By 2028, these costs are expected to climb to $6.2 trillion—roughly $18,000 per person.
Where does that money go? According to the Centers for Medicare and Medicaid Services (CMS), 2019 health care spending can be broken down into 10 categories:
- Hospital care (31%)
- Physician services (20%)
- Prescription drugs (10%)
- Other personal healthcare costs (5%)
- Nursing care facilities (5%)
- Dental services (4%)
- Home healthcare (3%)
- Other professional services (3%)
- Other nondurable medical products (2%)
- Durable medical equipment (2%)
Why Are Healthcare Costs Rising?
A 2017 Journal of the American Medical Association (JAMA) study investigated how five key factors were associated with healthcare increases from 1996 to 2013:
- Service price and intensity
- Population growth
- Population aging
- Disease prevalence or incidence
- Medical service utilization
The authors found that service price and intensity, including the rising cost of pharmaceutical drugs, made up more than 50% of the increase. Other factors, which comprised the rest of the cost increase, varied by type of care and health condition.
A more recent study by the Peter G. Peterson Foundation pinned the blame for rising prices on the same top three drivers identified by the American Medical Association (AMA): population growth, population aging, and rising prices.
Protection Against Rising Healthcare Costs
The No Surprises Act and other legislation contained in the Consolidated Appropriations Act (CAA), 2021, is designed to protect consumers from billing surprises and lack of transparency. This legislation takes effect Jan. 1, 2022.
Services, Growing, and Aging Population
Healthcare gets more expensive when the population expands—as people get older and live longer. Therefore, it’s not surprising that 50% of the increase in healthcare spending comes from increased costs for services, especially inpatient hospital care. Nor is it a shock that the two next highest factors increasing such spending are population growth (23%) and population aging (12%)
Increase in Chronic Illnesses
The authors of the JAMA study point to diabetes as the medical condition responsible for the greatest increase in spending over the study period. The increased cost of diabetes medications alone was responsible for $44.4 billion of the $64.4 billion increase in costs to treat that disease.
After diabetes, conditions with the greatest increase in costs were:
- Low-back and neck pain: $57.2 billion
- High blood pressure: $46.6 billion
- High cholesterol: $41.9 billion
- Depression: $30.8 billion
- Urinary disease: $30.2 billion
- Osteoarthritis: $29.9 billion
- Bloodstream infection: $26 billion
- Falls: $26 billion
- Oral disease: $25.3 billion
Increased Ambulatory Costs
Ambulatory care, including outpatient hospital services and emergency room care, increased the most of all treatment categories studied. Outpatient costs rose from an annual cost of $381.5 billion to $706.4 billion. Emergency department costs across all health conditions rose 6.4% over the same time period.
Rising Health Insurance Premiums
For those with employer-provided healthcare, average annual premiums for family coverage rose 37% from $15,545 in 2015 to $21,342 in 2020. Meanwhile, average unsubsidized family premiums for the Affordable Care Act (ACA) from 2015 through 2020 rose 97% from $8,724 to $17,244.
Rising Costs of Medicare and Medicaid
Government programs like Medicare and Medicaid have increased overall demand for medical services—resulting in higher prices as well. What's more, increases in the incidence of chronic conditions such as diabetes and heart disease, especially among seniors, have had a direct impact on increases in the cost of medical care. Chronic diseases constitute 85% of healthcare costs, and more than half of all Americans have a chronic illness.
Demand for medical services has increased because of Medicare and Medicaid, resulting in higher prices.
Higher Out-of-Pocket Costs
Higher insurance premiums are only part of the picture. Americans are paying more out-of-pocket than ever before. A shift to high-deductible health plans (HDHPs) that impose out-of-pocket costs of up to $14,000 per family has added greatly to the cost of healthcare.
Employer contributions to HDHPs do help mitigate the higher deductible and in fact, according to one 2018 study, HDHP enrollees paid 20% of their total premium while PPO enrollees paid up to 27% of theirs.
Patients Avoiding Care Due to Cost and COVID-19
People avoiding needed medical care due to concerns about costs has been a problem for several years. A 2019 survey by the Physicians Advocacy Institute (PAI) found patients avoiding care due to inability to afford covering deductibles under their HDHPs.
A poll by the Kaiser Family Foundation (KFF) now suggests that up to 50% of the public have either avoided or postponed medical care due to concerns about the COVID-19 pandemic, further exacerbating what was already a serious problem. Avoiding care results in higher overall healthcare costs as the delay makes treatable conditions more costly to treat.
Cost of COVID-19 Testing, Treatment, and Care
COVID-19, with the increased need for testing, treatment, and care, was expected to change the cost of healthcare. Some experts expected costs to rise, others expected them to fall. Early on, spending on healthcare did fall mostly due fewer patients seeking care, as discussed above. More recently, utilization and spending have both rebounded.
In the grand scheme, COVID may not alter the trajectory of healthcare spending a great deal. While spending fell short-term, it is expected to grow at an average annual rate of 5.4% and reach $6.2 trillion by 2028.
Inefficiency and Lack of Transparency
Thanks to a lack of transparency and underlying inefficiency, it’s difficult to know the actual cost of healthcare. Most people know the cost of care is going up, but with few details and complicated medical bills, it’s not easy to know what you're paying for.
Fortunately, lack of transparency in healthcare was addressed in the Coronavirus Appropriations Act (CAA), 2021. One section of the act increases transparency by removing gag clauses on price and quality information. Another requires disclosure of direct and indirect compensation for brokers and consultants to employer-sponsored health plans as well as to enrollees in plans on the individual market. This legislation, to become effective Jan. 1, 2022, is also designed to strengthen parity in metal health and substance-use disorder benefits and in reporting on pharmacy benefits and drug costs
The No Surprises Act
Additional CAA legislation, known as the No Surprises Act, also slated to go into effect Jan. 1, 2022, guards against surprise billing, another leading cause of rising healthcare costs.
In addition to outlawing surprise medical and hospital bills, the Act ends surprise air ambulance bills, requires transparency regarding in-network and out-of-network deductibles and out-of-pocket limitations, implements protections against provider discrimination, and requires health plan external review in the case of certain surprise bills.
Dispute resolution, patient protection, and transparency are mandated, as well as a requirement that providers issue fair and honest advance cost estimates. Other requirements include ensuring continuity of care, maintaining a price comparison tool, and several other provisions.
The legislation included in the CAA is designed to be a start, with more healthcare cost containment provisions expected in forthcoming legislation under the Biden administration's American Rescue Plan being discussed in Congress currently.