APPENDIX C. NATIONAL AND INTERNATIONAL HEALTH CARE EXPENDITURES AND HEALTH INSURANCE COVERAGE NATIONAL HEALTH EXPENDITURES During 1965 (the year prior to the beginning of the Medicare and Medicaid programs) national health expenditures were $41.6 billion; by 1993 annual expenditures were $898 billion, over 21 times that amount (see table 1). Hospital care expenditures are the largest component of national health expenditures, representing 38 percent of total national health spending in 1993. In terms of per capita spending, $1,101 was spent for hospital care in 1991, compared to $681 in 1985, an increase of 62 percent over 6 years (see table 3). Adjusting for inflation, health care expenditures have still increased substantially, rising from $179.9 billion in 1965 (in constant 1991 dollars) to $751.8 billion in 1991, an increase of about 318 percent (see table 2). The largest increases occurred between 1965 and 1970 (45 percent) and 1985 to 1991 (41 percent). The annual rate of increase in inflation- adjusted per capita expenditures from 1980 to 1985 was 4.3 percent. For the years 1986 to 1991, the comparable rate was 5.4 percent. Of the various sources of payment for personal health care expenditures in 1993, private health insurance was the largest (see table 5). In 1993, private health insurance payments (including premiums paid for both employers and employees) were $289 billion and accounted for 32 percent of all payments for personal health care. The Federal Government accounted for 31 percent ($280 billion) of personal health spending (including payments for both Medicare and Medicaid), 14.5 percent ($130 billion) was paid by State and local sources, and 18 percent ($162 billion) was paid by direct (out-of-pocket) payments by individuals. Philanthropy and in-plant health services accounted for 4.1 percent.\1\ --------------------------------------------------------------------------- \1\Personal health expenditures accounted for 88 percent of national health expenditures in 1991. The remaining 12 percent was expended on program administration; administrative costs of private health insurance and profits earned by private health insurance; noncommercial health research; new construction; and government public health activities. --------------------------------------------------------------------------- TABLE C-1.--NATIONAL HEALTH EXPENDITURES: AGGREGATE AMOUNTS FOR SELECTED CALENDAR YEARS 1960-93 [Dollar amounts in billions] ---------------------------------------------------------------------------------------------------------------- 1960 1965 1970 1975 1980 1985 1990 1991 1993 2000\1\ ---------------------------------------------------------------------------------------------------------------- Total............ $27.1 $41.6 $74.4 $132.9 $250.1 $422.6 $675.0 $751.8 $898 $1,613 ------------------------------------------------------------------------------------------ Percent of GNP..... 5.3 5.9 7.4 8.4 9.2 10.5 12.2 13.2 (\1\) (\1\) Health services and supplies............ $25.4 $38.2 $69.1 $124.7 $238.9 $407.2 $652.4 $728.6 (\1\) (\1\) Personal health care.............. 23.9 35.6 64.9 116.6 219.4 369.7 591.5 660.2 (\1\) (\1\) Hospital care.... 9.3 14.0 27.9 52.4 102.4 168.3 258.1 288.6 340 604 Physicians' services........ 5.3 8.2 13.6 23.3 41.9 74.0 128.8 142.0 168 315 Dentists' services........ 2.0 2.8 4.7 8.2 14.4 23.3 34.1 37.1 43 69 Other professional services........ .6 .9 1.5 3.5 8.7 16.6 30.7 35.8 47 110 Home health care. .0 .1 .1 .4 1.3 3.8 7.6 9.8 18 47 Drugs and other medical nondurables..... 4.2 5.9 8.8 13.0 21.6 36.2 55.6 60.7 70 112 Vision products and other medical durables .8 1.2 2.0 3.1 4.6 7.1 11.7 12.4 14 23 Nursing home care 1.0 1.7 4.9 9.9 20.0 34.1 53.3 59.9 74 138 Other personal health care..... .7 .8 1.4 2.7 4.6 6.4 11.5 14.0 18 34 Program administration and net cost of private health insurance......... 1.2 1.9 2.8 5.1 12.2 25.2 38.9 43.9 (\1\) (\1\) Government public health activities. .4 .6 1.4 3.0 7.2 12.3 22.0 24.5 (\1\) (\1\) Research, and construction of medical facilities.. 1.7 3.5 5.3 8.3 11.3 15.4 22.7 23.1 (\1\) (\1\) ---------------------------------------------------------------------------------------------------------------- \1\Estimates prepared by the Congressional Budget office. Note: Numbers may not add to totals due to rounding. Source: Health Care Financing Administration, Office of the Actuary: Data from the Office of National Health Statistics. TABLE C-2.--NATIONAL HEALTH EXPENDITURES: IN CONSTANT 1991 DOLLARS, FOR SELECTED CALENDAR YEARS 1960-91 [Dollar amounts in billions] -------------------------------------------------------------------------------------------------------------------------------------------------------- 1960 1965 1970 1975 1980 1985 1986 1987 1988 1989 1990 1991 -------------------------------------------------------------------------------------------------------------------------------------------------------- Total................................. $125.0 $179.9 $261.1 $336.6 $413.4 $534.9 $565.3 $592.5 $628.7 $663.8 $703.4 $751.8 ----------------------------------------------------------------------------------------------------------- Health services and supplies................ 117.2 165.0 242.4 315.6 394.8 515.4 545.5 571.8 605.9 641.1 679.8 728.6 Personal health care...................... 110.1 154.0 227.8 295.1 362.6 468.0 498.1 526.7 555.8 583.2 616.3 660.2 Hospital care........................... 42.7 60.7 98.0 132.6 169.3 213.0 223.4 232.9 244.1 255.2 268.9 288.6 Physicians' services.................... 24.3 35.4 47.7 58.9 69.2 93.6 102.0 111.5 121.0 127.5 134.3 142.0 Dentists' services...................... 9.0 12.1 16.4 20.9 23.7 29.4 30.7 32.5 33.9 34.8 35.5 37.1 Other professional services............. 2.8 3.7 5.3 8.9 14.4 21.0 23.1 25.4 27.4 29.7 32.0 35.8 Home health care........................ .2 .3 .5 1.0 2.2 4.9 5.0 4.9 5.2 6.2 7.9 9.8 Drugs and other medical nondurables..... 19.6 25.5 30.9 33.0 35.7 45.8 49.4 51.7 53.3 55.4 58.0 60.7 Vision products and other medical durables............................... 3.7 5.4 7.1 7.8 7.5 9.0 10.0 10.9 11.7 11.4 12.2 12.4 Nursing home care....................... 4.5 7.3 17.1 25.2 33.0 43.2 45.6 47.6 49.3 52.2 55.6 59.9 Other personal health care.............. 3.2 3.6 4.8 6.9 7.5 8.1 8.8 9.3 10.1 10.7 12.0 14.0 Program administration and net cost of private health insurance................. 5.4 8.3 9.7 12.8 20.2 31.9 30.6 27.6 30.9 37.1 40.6 43.9 Government public health activities....... 1.7 2.7 4.9 7.7 11.9 15.6 16.8 17.5 19.1 20.8 22.9 24.5 Research, and construction of medical facilities................................. 7.8 14.9 18.7 21.0 18.6 19.5 19.8 20.7 22.8 22.7 23.6 23.1 -------------------------------------------------------------------------------------------------------------------------------------------------------- Note: Constant dollar expenditures are calculated using the consumer price index for all urban consumers (CPI-U). Source: Health Care Financing Administration, Office of the Actuary: Data from the Office of National Health Statistics. TABLE C-3.--NATIONAL HEALTH EXPENDITURES: PER CAPITA AMOUNTS FOR SELECTED CALENDAR YEARS 1960-91 [Dollar amounts per capita] -------------------------------------------------------------------------------------------------------------------------------------------------------- 1960 1965 1970 1975 1980 1985 1986 1987 1988 1989 1990 1991 -------------------------------------------------------------------------------------------------------------------------------------------------------- Total................................. $143 $204 $346 $592 $1,064 $1,711 $1,824 $1,962 $2,146 $2,352 $2,601 $2,868 ----------------------------------------------------------------------------------------------------------- Health services and supplies................ 134 187 322 555 1,016 1,648 1,760 1,893 2,068 2,271 2,513 2,779 Personal health care...................... 126 175 302 519 933 1,497 1,607 1,744 1,898 2,066 2,279 2,518 Hospital care........................... 49 69 130 233 436 681 721 771 833 904 994 1,101 Physicians' services.................... 28 40 63 104 178 299 329 369 413 452 496 542 Dentists' services...................... 10 14 22 37 61 94 99 108 116 123 131 141 Other professional services............. 3 4 7 16 37 67 75 84 93 105 118 137 Home health care........................ 0 0 1 2 6 16 16 16 18 22 29 37 Drugs and other medical nondurables..... 22 29 41 58 92 146 159 171 182 196 214 231 Vision products and other medical durables............................... 4 6 9 14 19 29 32 36 40 41 45 47 Nursing home care....................... 5 8 23 44 85 138 147 157 168 185 205 229 Other personal health care.............. 4 4 6 12 19 26 28 31 34 38 44 53 Program administration and net cost of private health insurance................. 6 9 13 23 52 102 99 91 106 131 150 167 Government public health activities....... 2 3 6 14 31 50 54 58 65 74 85 94 Research, and construction of medical facilities................................. 9 17 25 37 48 62 64 69 78 80 87 88 -------------------------------------------------------------------------------------------------------------------------------------------------------- Note: Numbers may not add to totals due to rounding. Source: Health Care Financing Administration, Office of the Actuary: Data from the Office of National Health Statistics. TABLE C-4.--NATIONAL HEALTH EXPENDITURES: PER CAPITA AMOUNTS, IN CONSTANT 1991 DOLLARS, FOR SELECTED CALENDAR YEARS 1960-91 [Dollar amount per capita] -------------------------------------------------------------------------------------------------------------------------------------------------------- 1960 1965 1970 1975 1980 1985 1986 1987 1988 1989 1990 1991 -------------------------------------------------------------------------------------------------------------------------------------------------------- Total................................. $658 $882 $1,216 $1,499 $1,758 $2,165 $2,266 $2,352 $2,471 $2,583 $2,710 $2,868 ----------------------------------------------------------------------------------------------------------- Health services and supplies................ 616 809 1,129 1,406 1,679 2,086 2,187 2,270 2,381 2,495 2,619 2,779 Personal health care...................... 579 755 1,061 1,314 1,542 1,894 1,997 2,091 2,185 2,269 2,374 2,518 Hospital care........................... 225 298 457 591 720 862 896 924 959 993 1,036 1,101 Physicians' services.................... 128 174 222 262 294 379 409 443 476 496 517 542 Dentists' services...................... 48 59 76 93 101 119 123 129 133 135 137 141 Other professional services............. 15 18 25 40 61 85 93 101 108 116 123 137 Home health care........................ 1 1 2 5 9 20 20 20 20 24 30 37 Drugs and other medical nondurables..... 103 125 144 147 152 185 198 205 209 216 223 231 Vision products and other medical durables............................... 20 26 33 35 32 37 40 43 46 45 47 47 Nursing home care....................... 24 36 80 112 141 175 183 184 194 203 214 229 Other personal health care.............. 17 17 22 31 32 33 35 37 40 42 46 53 Program administration and net cost of private health insurance................. 28 41 45 57 86 129 123 109 122 144 156 167 Government public health activities....... 9 13 23 34 51 63 67 69 75 81 88 94 Research, and construction of medical facilities................................. 41 73 87 93 79 79 80 82 90 88 91 88 =========================================================================================================== Average annual [percentage increase]........ 60-65 65-70 70-75 75-80 80-85 60-90 85-90 89-90 90-91 Total................................. 6.0 6.6 4.3 3.2 4.3 4.8 4.6 4.9 5.8 Health services and supplies................ 5.6 6.9 4.5 3.6 4.4 4.9 4.7 5.0 6.1 Personal health care...................... 5.4 7.1 4.4 3.3 4.2 4.8 4.6 4.6 6.1 Hospital care........................... 5.8 8.9 5.3 4.0 3.7 5.2 3.7 4.3 6.3 Physicians' services.................... 6.3 5.0 3.4 2.3 5.2 4.8 6.4 4.3 4.7 -------------------------------------------------------------------------------------------------------------------------------------------------------- Note: Constant dollar expenditures are calculated using the consumer price indices for all urban consumers (CPI-U). Average annual amounts are calculated on unrounded numbers. Source: Health Care Financing Administration, Office of the Actuary: Data from the Office of National Health Statistics. TABLE C-5.--PERSONAL HEALTH CARE EXPENDITURES: AGGREGATE AMOUNTS AND PERCENTAGE DISTRIBUTION FOR SELECTED CALENDAR YEARS 1960-93 ---------------------------------------------------------------------------------------------------------------- 1960 1965 1970 1975 1980 1985 1990 1991 1993\1\ 2000\1\ ---------------------------------------------------------------------------------------------------------------- Amount in billions of dollars ------------------------------------------------------------------------------------------- Total......... $23.9 $35.6 $64.9 $116.6 $219.4 $369.7 $591.5 $660.2 $898 $1,069 Private............. 18.8 28.4 42.5 71.3 132.3 221.5 349.2 377.0 411 789 Private health insurance........ 5.0 8.7 15.2 29.9 65.3 114.2 191.2 209.3 289 519 Out of pocket..... 13.3 19.0 25.6 38.5 59.5 94.4 136.5 144.3 162 246 Other private sources of funds. .4 .7 1.7 2.9 7.6 12.9 21.5 23.4 37 59 Public.............. 5.1 7.3 22.4 45.3 87.1 148.2 242.3 283.3 411 789 Federal........... 2.1 3.0 14.6 31.0 63.5 111.7 177.0 204.1 280 555 State and local... 3.0 4.3 7.8 14.4 23.6 36.6 65.3 79.1 130 234 ------------------------------------------------------------------------------------------- Percentage distribution ------------------------------------------------------------------------------------------- Total......... 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Private............. 78.6 79.6 65.4 61.1 60.3 59.9 59.0 57.1 54.3 51.1 Private health insurance........ 21.0 24.3 23.4 25.6 29.7 30.9 32.3 31.7 32.2 32.1 Out of pocket..... 55.9 53.4 39.5 33.1 27.1 25.5 23.1 21.9 18.0 15.2 Other private sources of funds. 1.7 1.9 2.6 2.5 3.5 3.5 3.6 3.6 4.1 3.7 Public.............. 21.4 20.4 34.6 38.9 39.7 40.1 41.0 42.9 45.7 48.9 Federal........... 8.9 8.3 22.6 26.6 28.9 30.2 29.9 30.9 31.2 34.4 State and local... 12.5 12.0 12.0 12.3 10.8 9.9 11.0 12.0 14.5 14.5 ---------------------------------------------------------------------------------------------------------------- \1\Estimates prepared by the Congressional Budget Office. Note: Numbers may not add to totals due to rounding. Percentage amounts are calculated on unrounded numbers. Source: Health Care Financing Administration, Office of the Actuary: Data from the Office of National Health Statistics. EXPENDITURES FOR HOSPITAL CARE In 1991, hospital expenses accounted for 38.4 percent, or $289 billion, of total national health expenditures, down from 41 percent in 1980. Table C-6 displays historical trends on increases in hospital costs from 1965 to the present, focusing specifically on community hospital expenditures. Community hospitals are defined as all non-Federal short-term general hospitals (excluding, after 1971, hospital units of institutions) and account for 85 percent of hospital spending. Four measures are presented (total expenses, adjusted expenses per inpatient day, adjusted expenses per admission, and inpatient expenses). Total expenses have been growing slightly faster than inpatient expenses over time, reflecting tremendous growth in outpatient services and decreasing admissions and length of stay. The total expenses of community hospitals, including inpatient and outpatient expenses, were $278.9 billion in 1993, an increase of 6.9 percent over the preceding year. The average cost of a day of hospital care (adjusted to include outpatient care) increased by 8.1 percent to $1,002 in 1993. The average cost per hospital admission (also adjusted to include outpatient care), or ``cost per case,'' rose to $6,226 in 1993, an increase of 5.4 percent. These were the lowest rates of growth in almost a decade for all of these measures. Figure 1 presents the annual percentage increases in expenses per adjusted admission, removing the effects of inflation. As of October 1993, the real rate of growth in expenses per adjusted admission was the slowest since 1980. TABLE C-6.--SELECTED COMMUNITY HOSPITAL EXPENSES DATA, TOTALS AND PERCENTAGE INCREASES, 1965-93 ---------------------------------------------------------------------------------------------------------------- Total expenses Adjusted Adjusted Inpatient --------------------- expenses per expenses per expenses\2\ inpatient admission -------------------- Year day\1\ ----------------- Amount Percent ----------------- Amount Percent (billions) change Amount Percent Amount Percent (billions) change change change ---------------------------------------------------------------------------------------------------------------- 1965................................ $9.220 8.6 $41 7.5 $315 8.1 $8.414 8.7 1966................................ 10.497 13.8 46 12.2 356 13.0 9.611 14.2 1967................................ 12.624 20.3 53 15.2 425 19.4 11.551 20.2 1968................................ 14.720 16.6 59 11.3 482 13.4 13.371 15.8 1969................................ 17.247 17.2 68 15.2 551 14.3 15.635 16.9 1970................................ 20.261 17.5 78 14.7 608 10.3 18.328 17.2 1971................................ 22.496 11.0 87 11.5 670 10.2 20.269 10.6 1972................................ 25.223 12.1 96 10.3 729 8.8 22.622 11.6 1973................................ 28.248 12.0 105 9.4 784 7.5 25.173 11.3 1974................................ 32.759 16.0 118 12.4 873 11.4 29.077 15.5 1975................................ 38.492 17.5 138 16.9 1,017 16.5 33.971 16.8 1976................................ 45.842 19.1 158 14.5 1,168 14.8 40.321 18.7 1977................................ 53.006 15.6 181 14.5 1,312 12.3 46.437 15.2 1978................................ 59.802 12.8 203 12.2 1,466 11.7 52.131 12.3 1979................................ 67.833 13.4 226 11.3 1,618 10.4 59.060 13.3 1980................................ 79.340 17.0 256 13.3 1,836 13.5 68.962 16.8 1981................................ 94.187 18.7 299 16.8 2,155 17.4 81.651 18.4 1982................................ 109.091 15.8 348 16.4 2,489 15.5 94.346 15.5 1983................................ 120.220 10.2 391 12.5 2,742 10.2 103.403 9.5 1984................................ 126.028 4.6 443 13.3 2,947 7.5 107.000 3.2 1985................................ 134.043 6.6 493 11.2 3,226 9.4 111.402 4.4 1986................................ 146.032 8.9 535 8.6 3,527 9.3 119.281 7.1 1987................................ 161.322 10.5 581 8.6 3,860 9.5 129.300 8.4 1988................................ 177.770 10.2 632 8.8 4,194 8.6 140.482 8.2 1989................................ 195.377 9.9 690 9.3 4,586 9.3 152.147 8.3 1990................................ 217.113 11.1 765 10.7 5,021 9.5 165.792 9.0 1991................................ 238.633 9.9 844 10.3 5,460 8.8 178.401 7.6 1992................................ 260.994 9.4 927 9.8 5,905 8.1 191.401 7.3 1993\3\............................. 278.928 6.9 1,002 8.1 6,226 5.4 202.179 5.6 ---------------------------------------------------------------------------------------------------------------- \1\Adjusted to account for the volume of outpatient visits. \2\Based on ratio of inpatient to total patient revenues applied to total expenses. \3\Estimate based on January through October 1993 compared with January through October 1992. Source: American Hospital Association, National Hospital Panel Survey. A variety of factors other than overall inflation contribute to aggregate changes in hospital expenses, including: population growth, aging of the population, inflation over and above general inflation in the prices of goods and services purchased by the hospitals (input factor prices), and changes in the type and mix (intensity) of services rendered (due to such factors as changes in the use of technology or treatment patterns). While more than half of the overall growth in inpatient hospital expenditures between 1980 and 1990 was due to overall inflation, more than 10 percent was attributable to population growth, and one-fifth to excess inflation in hospital prices (see Figure C-2). The remainder was due to changes in utilization and intensity. Expenditures for hospital care are financed primarily by third parties (see Table C-7). In 1991, private health insurers paid 35.2 percent of the total, Medicare and Medicaid paid 33.7 percent, and other government programs paid 15.9 percent. The amount financed out-of-pocket by consumers was an estimated 3.4 percent. Table C-7 also shows that the Medicare share of spending dropped steadily from 1985 to 1989, the first such decreases since the early 1970s. HCFA attributed this decline to the relatively slow growth in Medicare payments per hospital admission. TRENDS IN HOSPITAL UTILIZATION Admissions From 1978 to 1983, total admissions increased at an annual rate of 1.1 percent, and admissions for persons age 65 and over increased an average of 4.8 percent per year (see Table C-8). With the introduction of Medicare's prospective payment system (PPS), admissions of patients 65 and older declined sharply, contrary to most expectations. Admissions of younger patients, however, had been decreasing for several years before that. Between 1987 and 1992, total admissions continued to decrease, but at a slower rate, due to an increase among the older population. 1993 was the first time in 12 years that overall admissions increased due to a slower rate of decline among the under 65 population and an increase for the over 65 population. Even for the older group, however, admission rates have not returned to pre-PPS levels. Average length of stay Before the implementation of PPS, average length of stay (LOS) for all adults was relatively constant at between 7.0 and 7.2 days (see Table C-9). With the introduction of PPS, there was a significant drop in LOS. From 1982 to 1984, LOS dropped by 6.9 percent, to 6.6 days, for all adults and 10.9 percent, to 8.8 days, for adults age 65 and over in 1985. LOS stabilized at these levels throughout the rest of the 1980s. LOS began to decline again in 1990, and, as of 1993, had declined by 6 percent for all adults and 8 percent for adults aged 65 and over, to 6.2 and 8.0 days respectively. Hospital occupancy With slight increases in admissions and stable LOS, occupancy rates averaged around 75 percent in the early 1980s (see Table C-11). The number of hospital beds was increasing, exceeding 1 million by 1983. During the early years of PPS, however, occupancy rates decreased dramatically. From 1983 to 1986, the average occupancy rate fell from 72.2 percent to 63.4 percent. There was a slight increase in occupancy rates in the late 1980s, but by 1993 the average occupancy rate had fallen to 61.5 percent, despite a decline in the number of beds to just over 900,000. Hospital employment Hospitals experienced a significant downturn in total employment levels at the time PPS was introduced (see Table C- 10). During 1984 and 1985, total hospital FTEs declined 2.3 percent. Between 1986 and 1992, however, total hospital employment consistently increased. Much of this growth may be attributed to increased employment in the outpatient area. During the late 1980s, growth in the number of part-time personnel exceeded growth in the number of full-time personnel in every year. In 1992, the number of full-time personnel grew faster than the number of part-time personnel for the first time in at lease 15 years. This trend continued in 1993, but the rate of increase in both types of personnel slowed dramatically, from 1.7 percent to 1.0 percent for full-time personnel and .9 percent to .4 percent for part-time personnel. FIGURE C-1._REAL ANNUAL INCREASES IN EXPENSES PER ADJUSTED ADMISSION (IN PERCENT), 1965-93
FIGURE C-2._FACTORS ACCOUNTING FOR GROWTH IN NATIONAL INPATIENT HOSPITAL EXPENDITURES, 1980-90
TABLE C-7.--EXPENDITURES FOR HOSPITAL CARE, BY SOURCE OF FUNDS, 1980, 1985, AND 1988-91 [Amounts in billions] -------------------------------------------------------------------------------------------------------------------------------------------------------- 1980 1985 1988 1989 1990 1991 Source of payment ----------------------------------------------------------------------------------------------------------- Amount Percent Amount Percent Amount Percent Amount Percent Amount Percent Amount Percent -------------------------------------------------------------------------------------------------------------------------------------------------------- Total................................. $102.4 100.0 $168.3 100.0 $212.0 100.0 $232.4 100.0 $258.1 100.0 $288.6 100.0 ----------------------------------------------------------------------------------------------------------- Out of pocket............................... 5.3 5.2 8.8 5.2 10.4 4.9 10.8 4.7 10.3 4.0 9.9 3.4 Third-party payments........................ 97.1 94.8 159.5 94.8 201.6 95.1 221.6 95.3 247.7 96.0 278.7 96.6 Private health insurance.................. 37.5 36.6 59.6 35.4 76.2 36.0 84.3 36.3 94.3 36.6 101.5 35.2 Other private funds....................... 5.0 4.9 8.3 4.9 11.1 5.3 12.6 5.4 13.9 5.4 14.7 5.1 Government................................ 54.6 53.3 91.6 54.4 114.3 53.9 124.7 53.7 139.5 54.0 162.6 56.3 Federal................................. 41.3 40.4 71.8 42.7 86.2 40.6 94.0 40.4 104.0 40.3 119.1 41.3 Medicare.............................. 26.4 25.8 48.6 28.9 57.5 27.1 62.5 26.9 67.4 26.1 73.3 25.4 Medicaid\1\........................... 5.3 5.2 8.4 5.0 11.2 5.3 13.0 5.6 16.3 6.3 23.9 8.3 Other Federal programs................ 9.7 9.4 14.8 8.8 17.5 8.3 18.5 8.0 20.3 7.8 21.9 7.6 State and local......................... 13.3 12.9 19.7 11.7 28.1 13.2 30.7 13.2 35.5 13.7 43.5 15.1 Medicaid\2\........................... 4.4 4.3 7.1 4.2 8.8 4.2 9.9 4.3 12.6 4.9 19.4 6.7 Other State and local programs........ 8.9 8.7 12.7 7.5 19.3 9.1 20.8 8.9 22.9 8.9 24.0 8.3 -------------------------------------------------------------------------------------------------------------------------------------------------------- \1\Federal share only. \2\State and local share only. Note.--Numbers may not add to totals because of rounding. Source: Health Care Financing Administration, Office of the Actuary: Data from the Office of National Health Statistics. TABLE C-8.--PERCENT CHANGE IN HOSPITAL ADMISSIONS, 1978-93 ------------------------------------------------------------------------ Admissions -------------------------------------- Year Under age Age 65 and All 65 over ------------------------------------------------------------------------ 1978............................. 0.4 -1.0 4.9 1979............................. 2.7 1.7 5.3 1980............................. 2.9 1.5 6.7 1981............................. .9 0.0 3.0 1982............................. 0.0 -1.6 4.1 1983............................. -.5 -2.8 4.7 1984............................. -3.7 -4.2 -2.6 1985............................. -4.9 -4.7 -5.2 1986............................. -2.1 -2.5 -1.0 1987............................. -.6 -1.0 .4 1988............................. -.4 -1.6 2.0 1989............................. -1.1 -2.0 1.2 1990............................. -.5 -1.6 1.7 1991............................. -1.1 -2.9 2.5 1992............................. -0.8 -2.2 1.7 1993\1\.......................... 0.2 -1.0 2.2 Average annual change: 1978-83...................... 1.1 -.4 4.8 1984-93...................... -1.5 -2.4 0.3 ------------------------------------------------------------------------ \1\Estimate based on January through October 1993 compared with January through October 1992. Source: American Hospital Association National Hospital Panel Survey. TABLE C-9.--CHANGE IN AVERAGE LENGTH OF STAY, ALL ADULTS AND ADULTS AGE 65 AND OVER, 1978-93 ---------------------------------------------------------------------------------------------------------------- All adults Year length of Percent Age 65 and Percent stay (days) change over (days) change ---------------------------------------------------------------------------------------------------------------- 1978.................................................... 7.2 -0.3 10.6 -1.2 1979.................................................... 7.1 -1.1 10.4 -1.9 1980.................................................... 7.2 .6 10.4 -.1 1981.................................................... 7.2 .4 10.4 -.1 1982.................................................... 7.2 -.7 10.1 -2.3 1983.................................................... 7.0 -2.0 9.7 -4.4 1984.................................................... 6.7 -5.1 9.0 -7.5 1985.................................................... 6.6 -1.7 8.8 -2.1 1986.................................................... 6.6 .6 8.8 .4 1987.................................................... 6.6 .8 8.9 1.0 1988.................................................... 6.6 0.0 8.8 -.7 1989.................................................... 6.6 0.0 8.8 0.0 1990.................................................... 6.6 0.0 8.7 -1.1 1991.................................................... 6.5 -1.5 8.5 -2.3 1992.................................................... 6.4 -1.5 8.3 -2.4 1993\1\................................................. 6.2 -3.1 8.0 -3.6 Average annual change: 1978-83............................................. ........... -.5 ........... -1.7 1984-93............................................. ........... -1.2 ........... -1.9 ---------------------------------------------------------------------------------------------------------------- \1\Estimate based on January through October 1993 compared with January through October 1992. Source: American Hospital Association National Hospital Panel Survey. TABLE C-10.--PERCENT CHANGE IN HOSPITAL EMPLOYMENT, 1978-93 ------------------------------------------------------------------------ Total Personnel Year hospital ----------------------------------- FTE's Total Full-time Part-time ------------------------------------------------------------------------ 1978.................... 3.7 4.1 3.3 6.8 1979.................... 3.5 3.9 3.0 6.7 1980.................... 4.7 5.2 4.0 9.1 1981.................... 5.4 6.0 4.8 9.4 1982.................... 3.7 3.7 3.6 4.1 1983.................... 1.4 1.5 1.2 2.3 1984.................... -2.3 -2.1 -2.6 -.8 1985.................... -2.3 -1.8 -2.7 -.1 1986.................... .3 .4 .3 .7 1987.................... .7 .9 .4 2.3 1988.................... 1.1 1.4 .7 3.3 1989.................... 1.6 1.9 1.2 3.6 1990.................... 2.1 2.3 1.8 3.6 1991.................... .6 .7 .6 1.0 1992.................... 1.6 1.5 1.7 .9 1993\1\................. .9 .8 1.0 .4 Average annual change: 1978-83............. 3.7 4.1 3.3 6.4 1984-93............. .4 .6 .2 1.5 ------------------------------------------------------------------------ \1\Estimate based on January through October 1993 compared with January through October 1992. Source: American Hospital Association National Hospital Panel Survey. TABLE C-11.--CHANGE IN INPATIENT HOSPITAL OCCUPANCY RATES AND NUMBER OF BEDS, 1978-93 ------------------------------------------------------------------------ Percent ---------------------- Number of Percent Year Occupancy beds change rates Change ------------------------------------------------------------------------ 1978..................... 73.8 -0.8 954,001 0.9 1979..................... 74.5 .9 959,269 .6 1980..................... 75.9 1.9 970,456 1.2 1981..................... 75.8 -.1 986,917 1.7 1982..................... 74.6 -1.6 997,720 1.1 1983..................... 72.2 -3.2 1,003,658 .6 1984..................... 66.6 -7.8 992,616 -1.1 1985..................... 63.6 -4.5 974,559 -1.8 1986..................... 63.4 -.3 963,133 -1.2 1987..................... 64.1 1.1 954,458 -.9 1988..................... 64.5 .6 942,306 -1.3 1989..................... 65.2 1.1 930,994 -1.2 1990..................... 64.5 -1.1 921,447 -1.0 1991..................... 63.5 -1.6 911,781 -1.0 1992..................... 62.4 -1.7 907,661 -.5 1993\1\.................. 61.5 -1.4 901,985 -.6 Annual average: 1978-83.............. ......... -.5 ............ 1.0 1984-92.............. ......... -1.6 ............ -1.0 ------------------------------------------------------------------------ \1\Estimate based on January through October 1993. Source: American Hospital Association National Hospital Panel Survey. EXPENDITURES FOR PHYSICIANS' SERVICES Personal health care expenditures for physicians' services were $142.0 billion in 1991, an increase of 10.2 percent from the previous year (see table 12). In 1991, 18.9 percent of national health expenditures and 21.5 percent of personal health expenditures were for physicians' services (see table C- 1). Physicians, however, affect personal health care expenditures more than this might indicate. Physicians have considerable discretion in determining the volume of all medical services. It is estimated that physicians' decisions (such as ordering hospitalizations, drugs, laboratory tests) directly influence over 70 percent of all health care spending. Third-party (public expenditures and private insurance) payments financed a large majority of physicians' services. In 1991, private health insurance paid $66.8 billion (47 percent) for such services. The remainder was split between direct patient payments and public expenditures. Patients or their families paid $25.7 billion (18 percent) for physicians' services. Public programs paid $49.4 billion (35 percent) for such services, of which $32.8 billion was Federal Medicare payments (see table C-12). Inflation was a major cause of growth in spending for physicians' services. Physicians' fees have risen more rapidly (5.6 percent in 1993) than prices in the economy as a whole (3.0 percent) as measured by the Consumer Price Index (CPI) (see table C-13). An analysis done by the Health Care Financing Administration found that expenditures for physicians' services over a 10-year span increased from $41.9 billion in 1980 to $142.0 billion in 1991, an average annual growth rate of 11.7 percent. The average physician net income in 1991, after expenses but before taxes, was $170,600, a 6.3 percent increase over the previous year (see table C-14). Surgeons had the highest average net incomes in 1991 ($233,800) and general and family practitioners the lowest ($111,500). In 1991, the average net income of pediatricians increased faster than any other specialty (12.0 percent). By region, average net income growth varied greatly, ranging from -9.3 percent in Mountain region to 9.5 percent in the Middle Atlantic region. Physicians in the East South Central and West South Central regions had the highest average net incomes ($179,400 and $193,300 respectively). Physicians in the New England region had the lowest average net incomes ($143,800). The growth rates differed rather significantly between metropolitan and nonmetropolitan areas, as shown in table C-14. The average net incomes of self-employed physicians ($191,000) continued to be higher than those of employee physicians ($134,000). Table C-15 shows average physician net incomes in nominal and real (or constant) dollars. Real income is expressed in 1991 dollars. Physicians' average net income increased about 182 percent between 1977 and 1991. However, average real incomes increased about 26 percent during this period, at an average annual rate of 1.8 percent. Table C-16 shows physicians' median net incomes by specialty. Between 1981 and 1991, real net income increased in all specialties. Table C-17 shows the distribution of physicians' net incomes in 1991 for all physicians and selected specialties. While the average net income of all physicians was $170,600, half of all physicians earned less than $139,000. One-fourth of all physicians earned less than $95,000, while one-fourth earned more than $210,000. Anesthesiologists, radiologists, obstetricians/gynecologists and surgeons had the highest median incomes, with half earning $200,000 or more. The continuing survey of physicians' incomes conducted by the magazine Medical Economics showed that, on average, physicians received 83 percent of their 1992 gross practice incomes from third parties (see table C-18). On average, 17 percent came from commercial insurers, 14 percent from Blue Shield, 26 percent from Medicare, 10 percent from health maintenance organizations (HMOs) and independent practice associations (IPAs), and 6 percent from preferred provider organizations (PPOs). As table C-18 indicates, the importance of each source of payment varied by specialty. Cardio/thoracic surgeons received the highest percentage of gross pay from Medicare (50 percent), while pediatricians, on average, received only 1 percent of their gross income from Medicare. TABLE C-12.--EXPENDITURES FOR PHYSICIAN SERVICES\1\ BY SOURCE OF FUNDS, 1980, 1985, AND 1987-91 -------------------------------------------------------------------------------------------------------------------------------------------------------- 1980 1985 1987 1988 1989 1990 1991 ---------------------------------------------------------------------------------------------------------------------------- Amount Percent Amount Percent Amount Percent Amount Percent Amount Percent Amount Percent Amount Percent -------------------------------------------------------------------------------------------------------------------------------------------------------- Total................ $41.9 100.0 $74.0 100.0 $93.0 100 $105.1 100.0 $116.1 100.0 $128.8 100.0 $142.0 100.0 ---------------------------------------------------------------------------------------------------------------------------- Out-of-pocket payments..... 11.3 26.9 16.1 21.8 19.0 20.4 20.9 19.9 22.5 19.4 24.1 18.7 25.7 18.1 Third-party payments....... 30.6 73.1 57.8 78.2 74.0 79.6 84.3 80.1 93.6 80.6 104.8 81.3 116.3 81.9 Private health insurance............. 18.0 42.9 33.7 45.6 42.6 45.8 49.1 46.7 53.9 46.4 60.7 47.1 66.8 47.0 Other private funds.... (\2\) (\2\) (\2\) (\2\) (\2\) (\2\) (\2\) (\2\) (\2\) (\2\) (\2\) (\2\) (\2\) (\2\) Government............. 12.6 30.2 24.1 32.6 31.4 33.8 35.1 33.4 39.6 34.1 44.0 34.2 49.4 34.8 Federal............ 9.7 23.1 19.2 26.0 25.1 27.0 28.1 26.7 31.7 27.3 34.9 27.1 39.0 27.5 Medicare....... 7.9 19.0 16.7 22.5 21.7 23.3 24.2 23.0 27.4 23.6 29.7 23.1 32.8 23.1 Medicaid....... 1.2 2.8 1.6 2.2 2.0 2.2 2.2 2.1 2.5 2.2 3.1 2.4 4.0 2.8 Other Federal programs...... .5 1.3 1.0 1.3 1.4 1.5 1.7 1.6 1.8 1.5 2.0 1.6 2.2 1.6 State and local.... 3.0 7.1 4.9 6.6 6.3 6.8 7.0 6.7 7.9 6.8 9.1 7.1 10.4 7.3 Medicaid....... 1.0 2.3 1.2 1.7 1.5 1.7 1.5 1.5 1.7 1.5 2.1 1.7 2.9 2.0 Other State and local programs 2.0 4.8 3.6 4.9 4.8 5.1 5.5 5.2 6.2 5.3 7.0 5.4 7.5 5.3 -------------------------------------------------------------------------------------------------------------------------------------------------------- \1\Encompasses the cost of all services and supplies provided in physicians' offices, the cost for services of private practitioners in hospitals and other institutions, and the cost of diagnostic work performed in independent clinical laboratories. The salaries of staff physicians are counted with expenditures for the services of the employing institution. \2\Less than $50 million. Note: Numbers may not add to totals due to rounding. Source: Health Care Financing Administration: Office of the Actuary: Data from the Office of National Health Statistics. TABLE C-13.--ANNUAL RATES OF CHANGE IN THE CONSUMER PRICE INDEX (CPI- U),\1\ 1965-93 ------------------------------------------------------------------------ CPI, all items Medical CPI all less care Physicians' items medical total services care ------------------------------------------------------------------------ 1965...................... 1.6 1.6 2.4 3.6 1966...................... 2.9 3.1 4.4 5.6 1967...................... 3.1 2.1 7.2 7.2 1968...................... 4.2 4.2 6.0 5.6 1969...................... 5.5 5.4 6.7 7.0 1970...................... 5.7 5.9 6.6 7.5 1971...................... 4.4 4.1 6.2 7.0 1972...................... 3.2 3.2 3.3 3.0 1973...................... 6.2 6.4 4.0 3.4 1974...................... 11.0 11.2 9.3 9.2 1975...................... 9.1 9.0 12.0 12.1 1976...................... 5.8 5.3 9.5 11.4 1977...................... 6.5 6.3 9.6 9.1 1978...................... 7.6 7.6 8.4 8.4 1979...................... 11.3 11.5 9.2 9.1 1980...................... 13.5 13.6 11.0 10.5 1981...................... 10.3 10.4 10.7 11.0 1982...................... 6.2 5.9 11.6 9.4 1983...................... 3.2 2.9 8.8 7.8 1984...................... 4.3 4.1 6.2 6.9 1985...................... 3.6 3.4 6.3 5.9 1986...................... 1.9 1.5 7.5 7.2 1987...................... 3.6 3.5 6.6 7.3 1988...................... 4.1 3.9 6.5 7.2 1989...................... 4.8 4.6 7.7 7.4 1990...................... 5.4 5.2 9.0 7.1 1991...................... 4.2 3.9 8.7 6.0 1992...................... 3.0 2.8 7.4 6.3 1993...................... 3.0 2.7 5.9 5.6 ------------------------------------------------------------------------ \1\CPI index for all urban consumers. Source: U.S. Department of Labor, Bureau of Labor Statistics, Consumer Price Index. TABLE C-14.--PHYSICIANS' AVERAGE NET INCOME AFTER EXPENSES BUT BEFORE TAXES, SURVEY RESULTS, 1983-91 ---------------------------------------------------------------------------------------------------------------- Average net income\1\ (in thousands of dollars) ------------------------------------------------------------------------ Percent 1983 1984 1985 1986 1987 1988 1989 1990 1991 change1990-91 ---------------------------------------------------------------------------------------------------------------- All physicians\2\........ 104.1 108.4 112.2 119.5 132.3 144.7 155.8 164.3 170.6 6.3 Specialty: General/family practice............ 68.5 71.1 77.9 80.3 91.5 94.6 95.9 102.7 111.5 8.6 Internal medicine.... 93.3 103.2 101.0 109.4 121.8 130.9 146.5 152.5 149.6 -1.9 Surgery.............. 145.5 151.8 155.4 162.4 187.9 207.5 220.5 236.4 233.8 -1.1 Pediatrics........... 70.7 74.5 77.1 81.8 85.3 94.9 104.7 106.5 119.3 12.0 Obstetrics/gynecology 119.9 116.2 122.7 135.9 163.2 180.7 194.3 207.3 221.8 7.0 Radiology............ 148.0 139.8 150.8 168.8 180.7 188.5 210.5 219.4 229.8 4.7 Psychiatry........... 80.0 85.5 88.6 91.5 102.7 111.4 111.7 116.5 127.6 9.5 Anesthesiology....... 144.7 145.4 140.2 150.2 163.1 194.5 185.8 207.4 221.1 6.6 Census Division: New England.......... 84.5 87.3 108.3 107.1 110.6 132.9 128.3 142.5 143.8 .9 Middle Atlantic...... 98.6 98.4 107.9 114.6 126.1 135.0 152.5 156.1 171.0 9.5 East North Central... 114.3 109.4 118.9 126.6 137.6 147.0 155.6 172.4 174.1 1.0 West North Central... 110.5 110.7 113.7 120.7 133.9 138.0 159.2 151.4 164.2 8.4 South Atlantic....... 106.7 114.5 112.6 119.6 133.8 156.0 165.6 169.0 168.8 -.1 East South Central... 114.9 122.2 115.0 122.6 141.2 164.8 173.0 169.0 179.4 6.1 West South Central... 124.4 119.1 123.3 129.0 140.4 160.7 170.5 178.8 193.3 8.1 Mountain............. 91.4 102.3 97.5 108.5 125.5 132.1 142.6 170.9 155.0 -9.3 Pacific.............. 103.1 109.4 113.6 119.0 135.4 136.0 148.1 162.5 172.4 6.1 Location: Nonmetropolitan...... 87.2 90.9 94.2 107.7 117.9 120.9 129.4 130.5 150.4 15.2 Metropolitan: Less than 1,000,000....... 111.0 115.1 118.1 124.5 140.4 154.1 164.1 172.7 174.8 1.2 1,000,000 and over............ 106.3 106.4 112.8 117.5 127.9 140.7 153.4 163.3 170.4 4.3 Employment Status: Self-employed........ 115.9 118.6 124.5 131.1 146.2 160.0 175.3 185.6 191.0 2.9 Employee............. 77.6 80.4 83.8 91.7 99.6 113.0 119.2 119.8 134.0 11.8 ---------------------------------------------------------------------------------------------------------------- \1\Average net income after expenses but before taxes. These figures include contributions made into pension, profit-sharing, and deferred compensation plans. \2\Includes physicians in specialties not reported separately. Source: Socioeconomic Characteristics of Medical Practice, 1993, American Medical Association. TABLE C-15.--AVERAGE PHYSICIAN NET INCOME AFTER EXPENSES, BEFORE TAXES, 1977-91 [Dollars in thousands] ------------------------------------------------------------------------ Nominal Real (1991) ------------------------------------------------------------------------ 1977.......................................... $60.4 $135.8 1978.......................................... 64.6 134.5 1979.......................................... 77.4 145.2 1980.......................................... NA NA 1981.......................................... 89.9 134.7 1982.......................................... 97.7 137.9 1983.......................................... 104.1 142.4 1984.......................................... 108.4 142.1 1985.......................................... 112.2 142.0 1986.......................................... 119.5 148.5 1987.......................................... 132.3 158.6 1988.......................................... 144.7 166.6 1989.......................................... 155.8 171.1 1990.......................................... 164.3 171.2 1991.......................................... 170.6 170.6 ------------------------------------------------------------------------ NA: Not available. Note.--No data for 1980. Real (1991 dollars) incomes are calculated using the consumer price index for all urban consumers. Source: CRS analysis of data from: Gonzales, Martin L., and David W. Emmons, eds., ``Socioeconomic Characteristics of Medical Practice, 1993,'' American Medical Association. TABLE C-16.--MEDIAN PHYSICIAN NET INCOME AFTER EXPENSES, BEFORE TAXES, 1981 AND 1991 [Dollars in thousands] ------------------------------------------------------------------------ Median net income Average annual ------------------------------ percent change 1991 1991 ------------------- 1981 nominal real\1\ Nominal Real ------------------------------------------------------------------------ All physicians\2\..... $75 $139 $93 6.9 3.3 Specialty: General/family practice......... 60 98 65 5.4 0 Internal medicine. 72 125 83 4.2 0 Surgery........... 100 200 133 0 -4.3 Pediatrics........ 55 105 70 5.0 0 Obstetrics/gynecol ogy.............. 96 200 133 8.7 3.9 Radiology......... 105 223 149 1.2 7.2 Psychiatry........ 64 110 73 2.8 -1.4 Anesthesiology.... 105 210 140 5.0 .7 Pathology......... 75 153 102 2.0 -1.9 Census Division: New England....... 65 124 83 3.3 0 Middle Atlantic... 70 136 91 8.8 4.6 East North Central 80 133 89 -5.0 -8.3 West North Central 80 141 94 8.5 4.4 South Atlantic.... 77 130 87 -2.0 -5.4 East South Central 80 150 100 7.1 3.1 West South Central 80 150 100 0 -3.9 Mountain.......... 74 137 91 1.5 -3.2 Pacific........... 77 150 100 11.1 6.4 ------------------------------------------------------------------------ \1\In 1981 dollars. \2\Includes physicians in specialties not listed separately. Source: Gonzalez, Martin L., and David W. Emmons, eds. ``Socioeconomic Characteristics of Medical Practice, 1993,'' American Medical Association. TABLE C-17.--DISTRIBUTION OF PHYSICIAN NET INCOME AFTER EXPENSES, BEFORE TAXES, BY SPECIALTY AND CENSUS DIVISION, 1991 [In thousands of dollars] ------------------------------------------------------------------------ 125th 150th 175th Percentile Percentile Percentile Mean ------------------------------------------------------------------------ All physicians\1\........ 95 139 210 170.6 Specialty: General/family practice............ 74 98 128 111.5 Internal medicine.... 90 125 177 149.6 Surgery.............. 133 200 287 223.8 Pediatrics........... 80 105 145 119.3 Obstetrics/gynecology 124 200 300 221.8 Radiology............ 150 223 300 229.8 Psychiatry........... 88 110 159 127.6 Anesthesiology....... 157 210 275 221.1 Pathology............ 110 153 230 197.7 Census division: New England.......... 90 124 180 143.8 Middle Atlantic...... 95 136 210 171.0 East North Central... 90 133 208 174.1 West North Central... 100 141 200 164.2 South Atlantic....... 90 130 200 168.8 East South Central... 98 150 230 179.4 West South Central... 100 150 250 193.3 Mountain............. 97 137 200 155.0 Pacific.............. 93 150 220 172.4 ------------------------------------------------------------------------ \1\Includes physicians in specialties not listed separately. Source: Gonzalez, Martin L., and David W. Emmons, eds. ``Socioeconomic Characteristics of Medical Practice, 1993.'' American Medical Association. TABLE C-18.--THIRD PARTY SOURCES OF PHYSICIAN PAYMENT FOR SELECTED SPECIALTIES, 1992 -------------------------------------------------------------------------------------------------------------------------------------------------------- Commercial plans Blue Shield Medicare Medicaid HMOs/IPAs PPOs ----------------------------------------------------------------------------------------------------------------------------------- As As As As As As Specialty Average percent Average percent Average percent Average percent Average percent Average percent annual of gross annual of gross annual of gross annual of gross annual of gross annual of gross payment practice payment practice payment practice payment practice payment practice payment practice income income income income income income -------------------------------------------------------------------------------------------------------------------------------------------------------- Cardiologists....... $61,400 15 $56,100 14 $177,490 46 $18,220 5 $27,530 6 $16,730 4 Cardio/thoracic surgeons........... 61,200 12 70,670 14 241,890 50 31,410 6 44,000 10 17,980 4 Family practice..... 33,420 14 30,290 12 54,170 22 25,320 11 27,720 12 18,140 7 Gastroenterologists. 58,600 14 57,500 15 151,640 40 21,620 6 32,140 10 19,810 5 General practice.... 30,870 14 23,940 12 45,230 24 20,210 12 23,300 10 15,250 5 General surgeons.... 62,430 19 53,810 17 103,590 33 26,100 9 31,890 10 20,510 6 Pediatricians....... 36,860 15 33,350 14 810 1 53,800 24 31,890 15 22,830 9 Plastic surgeons.... 84,410 20 61,030 14 54,450 13 13,910 4 25,960 6 30,810 7 Psychiatrists....... 38,910 20 23,610 13 22,780 11 10,870 6 10,000 5 13,190 6 Internists.......... 31,060 12 33,700 12 101,320 39 12,380 5 22,230 10 16,290 6 Neurosurgeons....... 154,920 26 77,130 14 118,990 22 35,290 7 55,620 10 39,880 7 OBG specialists..... 96,590 24 80,930 20 24,290 7 47,860 11 58,280 15 48,860 11 Orthopedists........ 122,860 24 78,430 17 95,950 21 28,810 6 43,510 9 38,570 7 All surgical specialists........ 83,980 20 66,010 16 105,590 26 32,030 8 41,800 10 30,930 7 All non-surgical specialists........ 46,460 15 39,730 14 87,000 28 24,080 10 28,480 10 18,370 6 All M.D.s........... 55,600 17 45,710 14 86,070 26 26,390 10 32,150 10 22,030 6 -------------------------------------------------------------------------------------------------------------------------------------------------------- Source: Terry, Ken, ``Where more of your income is coming from,'' Medical Economics, Nov. 22, 1993. SUPPLY OF HOSPITAL BEDS The national supply of community hospital beds per 1,000 population steadily increased from the 1940's, reaching a peak of 4.6 beds per 1,000 population in 1975. By 1989, the number of beds had dropped to 3.8 per 1,000 population, and remained at that level in 1990. Similar trends can be seen in the nine census regions, except for New England, which has seen a reduction since 1940 from 4.4 beds to 3.4 beds per 1,000 population in 1990, and the Pacific region, where the reduction has been from 4.1 beds in 1940 to 2.7 beds in 1990. The area experiencing the largest increase has been the East South Central, where beds increased from 1.7 per 1,000 population in 1940 to 5.1 in 1980, falling back to 4.8 in 1990. (see table C- 19). TABLE C-19.--COMMUNITY HOSPITAL BEDS PER 1,000 POPULATION AND AVERAGE ANNUAL PERCENT CHANGE, ACCORDING TO GEOGRAPHIC DIVISION AND STATE: UNITED STATES, SELECTED YEARS 1940-90 [Data are based on reporting by facilities] -------------------------------------------------------------------------------------------------------------------------------------------------------- Beds per 1,000 civilian population Average annual percent change Geographic division ---------------------------------------------------------------------------------------------------------------------------------- and State 1940\1\ 1950\1\ 1960\2\ 1970 1980 1985 1988 1989 1990 1940-60\1\\2\ 1960-70\2\ 1970-80 1980-90 -------------------------------------------------------------------------------------------------------------------------------------------------------- United States........ 3.2 3.3 3.6 4.3 4.5 4.2 3.9 3.8 3.8 0.6 1.8 0.5 -1.7 New England.......... 4.4 4.2 3.9 4.1 4.1 4.0 3.6 3.5 3.4 -0.6 0.5 0.0 -1.9 Maine............ 3.0 3.2 3.4 4.7 4.7 4.2 3.9 3.8 3.8 0.6 3.3 0.0 -2.1 New Hampshire.... 4.2 4.2 4.4 4.0 3.9 3.4 3.2 3.1 3.1 0.2 -0.9 -0.3 -2.3 Vermont.......... 3.3 4.0 4.5 4.5 4.4 3.8 3.1 3.1 3.1 1.6 0.0 -0.2 -3.4 Massachusetts.... 5.1 4.8 4.2 4.4 4.4 4.4 4.0 3.8 3.6 -1.0 0.5 0.0 -2.0 Rhode Island..... 3.9 3.8 3.7 4.0 3.8 3.6 3.3 3.2 3.2 -0.3 0.8 -0.5 -1.7 Connecticut...... 3.7 3.6 3.4 3.4 3.5 3.3 3.0 3.0 2.9 -0.4 0.0 0.3 -1.9 Middle Atlantic...... 3.9 3.8 4.0 4.4 4.6 4.4 4.1 4.1 4.2 0.1 1.0 0.4 -0.9 New York......... 4.3 4.1 4.3 4.6 4.5 4.4 4.2 4.2 4.2 0.0 0.7 -0.2 -0.7 New Jersey....... 3.5 3.2 3.1 3.6 4.2 3.9 3.7 3.7 3.7 -0.6 1.5 1.6 -1.3 Pennsylvania..... 3.5 3.8 4.1 4.7 4.8 4.7 4.4 4.3 4.4 0.8 1.4 0.2 -0.9 East North Central... 3.2 3.2 3.6 4.4 4.7 4.5 4.1 4.0 3.9 0.6 2.0 0.7 -1.8 Ohio............. 2.7 2.9 3.4 4.2 4.7 4.6 4.2 4.0 4.0 1.2 2.1 1.1 -1.6 Indiana.......... 2.3 2.6 3.1 4.0 4.5 4.2 4.1 3.9 3.9 1.5 2.6 1.2 -1.4 Illinois......... 3.4 3.6 4.0 4.7 5.1 4.7 4.3 4.1 4.0 0.8 1.6 0.8 -2.4 Michigan......... 4.0 3.3 3.3 4.3 4.4 4.1 3.8 3.7 3.7 -1.0 2.7 0.2 -1.7 Wisconsin........ 3.4 3.7 4.3 5.2 4.9 4.6 4.0 3.9 3.8 1.2 1.9 -0.6 -2.5 West North Central... 3.1 3.7 4.3 5.7 5.8 5.4 5.1 4.9 4.9 1.6 2.9 0.2 -1.7 Minnesota........ 3.9 4.4 4.8 6.1 5.7 5.2 4.8 4.5 4.4 1.0 2.4 -0.7 -2.6 Iowa............. 2.7 3.2 3.9 5.6 5.7 5.2 5.2 5.0 5.1 1.9 3.7 0.2 -1.1 Missouri......... 2.9 3.3 3.9 5.1 5.7 5.2 4.9 4.8 4.8 1.5 2.7 1.1 -1.7 North Dakota..... 3.5 4.3 5.2 6.8 7.4 7.4 7.0 7.0 7.0 2.0 2.7 0.8 -0.6 South Dakota..... 2.8 4.4 4.5 5.6 5.5 6.6 5.6 5.8 6.1 2.4 2.2 -0.2 1.0 Nebraska......... 3.4 4.2 4.4 6.2 6.0 6.0 5.8 5.5 5.4 1.3 3.5 -0.3 -1.0 Kansas........... 2.8 3.4 4.2 5.4 5.8 5.2 4.7 4.8 4.8 2.0 2.5 0.7 -1.9 South Atlantic....... 2.5 2.8 3.3 4.0 4.5 4.1 3.8 3.7 3.7 1.4 1.9 1.2 -1.9 Delaware......... 4.4 3.9 3.7 3.7 3.6 3.5 3.1 3.0 3.0 -0.9 0.0 -0.3 -1.8 Maryland......... 3.9 3.6 3.3 3.1 3.6 3.4 2.9 2.9 2.9 -0.8 -0.6 1.5 -2.1 District of Columbia........ 5.5 5.5 5.9 7.4 7.3 7.8 7.8 7.9 7.5 0.4 2.3 -0.1 0.3 Virginia......... 2.2 2.5 3.0 3.7 4.1 3.8 3.5 3.4 3.3 1.6 2.1 1.0 -2.1 West Virginia.... 2.7 3.1 4.1 5.4 5.5 5.1 4.7 4.7 4.7 2.1 2.8 0.2 -1.6 North Carolina... 2.2 2.6 3.4 3.8 4.2 3.7 3.4 3.4 3.4 2.2 1.1 1.0 -2.1 South Carolina... 1.8 2.4 2.9 3.7 3.9 3.6 3.3 3.2 3.3 2.4 2.5 0.5 -1.7 Georgia.......... 1.7 2.0 2.8 3.8 4.6 4.3 4.1 4.1 4.0 2.5 3.1 1.9 -1.4 Florida.......... 2.8 2.9 3.1 4.4 5.1 4.6 4.2 4.0 4.0 0.5 3.6 1.5 -2.4 East South Central... 1.7 2.1 3.0 4.4 5.1 5.0 4.7 4.7 4.8 2.9 3.9 1.5 -0.6 Kentucky......... 1.8 2.2 3.0 4.0 4.5 4.4 4.3 4.3 4.4 2.6 2.9 1.2 -0.2 Tennessee........ 1.9 2.3 3.4 4.7 5.5 5.3 4.8 4.8 4.9 3.0 3.3 1.6 -1.1 Alabama.......... 1.5 2.0 2.8 4.3 5.1 5.0 4.6 4.6 4.6 3.2 4.4 1.7 -1.0 Mississippi...... 1.4 1.7 2.9 4.4 5.3 5.2 5.4 5.2 5.3 3.7 4.3 1.9 0.0 West South Central... 2.1 2.7 3.3 4.3 4.7 4.2 3.9 3.8 3.9 2.3 2.7 0.9 -1.8 Arkansas......... 1.4 1.6 2.9 4.2 5.0 4.8 4.5 4.5 4.7 3.7 3.8 1.8 -0.6 Louisiana........ 3.1 3.8 3.9 4.2 4.8 4.6 4.4 4.4 4.6 1.2 0.7 1.3 -0.4 Oklahoma......... 1.9 2.5 3.2 4.5 4.6 4.1 4.0 3.9 4.0 2.6 3.5 0.2 -1.4 Texas............ 2.0 2.7 3.3 4.3 4.7 4.1 3.7 3.6 3.5 2.5 2.7 0.9 -2.9 Mountain............. 3.6 3.8 3.5 4.3 3.8 3.5 3.3 3.1 3.1 -0.1 2.1 -1.2 -2.0 Montana.......... 4.9 5.3 5.1 5.8 5.9 5.5 5.6 5.7 5.8 0.2 1.3 0.2 -0.2 Idaho............ 2.6 3.4 3.2 4.0 3.7 3.5 3.2 3.2 3.2 1.0 2.3 -0.8 -1.4 Wyoming.......... 3.5 3.9 4.6 5.5 3.6 4.3 4.8 4.7 4.9 1.4 1.8 -4.1 3.1 Colorado......... 3.9 4.2 3.8 4.6 4.2 3.6 3.3 3.0 3.2 -0.1 1.9 -0.9 -2.7 New Mexico....... 2.7 2.2 2.9 3.5 3.1 2.9 2.8 2.9 2.9 0.4 1.9 -1.2 -0.7 Arizona.......... 3.4 4.0 3.0 4.1 3.6 3.2 2.9 2.8 2.7 -0.6 3.2 -1.3 -2.8 Utah............. 3.2 2.9 2.8 3.6 3.1 2.7 2.7 2.6 2.6 0.7 2.5 -1.5 -1.7 Nevada........... 5.0 4.4 3.9 4.2 4.2 3.7 3.2 3.0 2.9 -1.2 0.7 0.0 -3.6 Pacific.............. 4.1 3.2 3.1 3.7 3.5 3.2 2.9 2.8 2.7 -1.4 1.8 -0.6 -2.6 Washington....... 3.4 3.6 3.3 3.5 3.1 3.0 2.7 2.6 2.5 -0.1 0.6 -1.2 -2.1 Oregon........... 3.5 3.1 3.5 4.0 3.5 3.2 2.9 2.9 2.9 0.0 1.3 -1.3 -1.9 California....... 4.4 3.3 3.0 3.8 3.6 3.2 2.9 2.9 2.7 -1.9 2.4 -0.5 -2.8 Alaska........... ........ ........ 2.4 2.3 2.7 2.2 2.4 2.5 2.3 .............. -0.4 1.6 -1.6 Hawaii........... ........ ........ 3.7 3.4 3.1 2.8 2.7 2.7 2.8 .............. -0.8 -0.9 -1.0 -------------------------------------------------------------------------------------------------------------------------------------------------------- \1\1940 and 1950 data are estimated based on published figures. \2\1960 includes hospital units of institutions. Sources: American Medical Association: Hospital service in the United States. JAMA 116(11):1055-1144. 1941, and 146(2):109-184, 1951. (Copyright 1941 and 1951: Used with the Permission of the American Medical Association); American Hospital Association; Hospitals. JAHA 35(15):383-430, Aug. 1, 1961. (Copyright 1961; Used with the permission of the American Hospital Association.); Data computed by the Centers for Disease Control and Prevention, National Center for Health Statistics. Division of Analysis from data compiled by the Division of Health Care Statistics, National Master Facility Inventory and the American Hospital Association 1990 annual survey; U.S. Bureau of the Census; Current Population Reports. Series P-25, Nos. 72, 304, 460, 640, 970, 1010, 1044, and 1058. Washington. U.S. Government Printing Office. 1953, 1965, 1971, 1976, 1980, 1985, 1989, and 1990; Health, United States, 1991; DHHS Pub. No. (PHS) 93-1232. SUPPLY OF PHYSICIANS Physician supply has grown rapidly over the past three decades. The number of active physicians in the country has increased from 334,028 in 1970 to 653,062 in 1992. This growth rate exceeded the rate at which the population of the Nation grew during the decade. Table C-20 indicates that between 1965 and 1992, the number of physicians per 100,000 civilians grew from 161 to 255. As table C-21 below indicates, the ratio of nonfederal physicians- to-population increased from 148 physicians per 100,000 population in 1970 to 248 physicians per 100,000 population in 1992. This table also indicates variations in the supply of physicians relative to population by State. In 1992, the District of Columbia had the highest ratio (705 physicians per 100,000 population) while Alaska had the lowest ratio (146 physicians per 100,000 population). TABLE C-20.--PHYSICIAN SUPPLY BY MAJOR CATEGORIES, 1970-92 ---------------------------------------------------------------------------------------------------------------- 1970 1980 1990 1992 Category --------------------------------------------------------------------------- Number Percent Number Percent Number Percent Number Percent ---------------------------------------------------------------------------------------------------------------- Total Physicians.................... 334,028 ....... 467,679 ....... 615,421 ....... 653,062 ....... --------------------------------------------------------------------------- Federal......................... 29,501 9 17,787 4 20,475 3 19,216 3 Nonfederal...................... 301,323 91 443,502 96 592,166 97 631,137 97 Patient Care.................... 278,535 83 376,512 80 503,870 82 535,220 82 Nonpatient Care................. 32,310 10 38,404 9 43,440 8 42,888 7 Male............................ 308,627 92 413,395 88 511,227 83 534,543 82 Female.......................... 25,401 8 54,284 12 104,194 17 118,519 18 International medical graduates. 57,217 17 97,726 21 131,764 21 144,399 22 Metropolitan (nonfederal only).. 258,265 86 385,365 87 521,668 88 557,900 88 Nonmetropolitan (nonfederal only).......................... 43,058 14 58,137 13 70,498 12 73,237 12 Total physician-population ratio (per 100,000 persons).......... 161 ....... 202 ....... 244 ....... 255 ....... ---------------------------------------------------------------------------------------------------------------- Source: American Medical Association, 1993. TABLE C-21.--NON-FEDERAL PHYSICIAN/POPULATION RATIOS AND RANK BY STATE [Ratios: Non-Federal physicians (M.D.'s) per 100,000 civilian population] ---------------------------------------------------------------------------------------------------------------- 1992 State 1970 1975 1985 1990 1992 rank ---------------------------------------------------------------------------------------------------------------- United States\1\.................................... 148 169 220 237 248 ----------------------------------------------------- Alabama................................................... 90 103 152 170 183 40 Alaska.................................................... 74 95 137 155 146 51 Arizona................................................... 144 185 220 233 233 20 Arkansas.................................................. 92 103 150 165 179 33 California................................................ 194 219 266 272 273 11 Colorado.................................................. 178 186 216 232 245 16 Connecticut............................................... 192 224 302 332 346 5 Delaware.................................................. 134 155 203 217 228 21 District of Columbia...................................... 390 467 607 658 705 1 Florida................................................... 155 185 236 251 257 12 Georgia................................................... 108 126 172 187 196 35 Hawaii.................................................... 160 185 239 266 283 9 Idaho..................................................... 94 104 133 142 150 49 Illinois.................................................. 138 164 217 229 247 15 Indiana................................................... 102 116 156 171 181 41 Iowa...................................................... 103 113 149 167 175 44 Kansas.................................................... 118 137 179 195 203 32 Kentucky.................................................. 102 122 162 181 195 37 Louisiana................................................. 120 131 187 200 215 29 Maine..................................................... 111 133 193 208 218 26 Maryland.................................................. 183 217 334 360 374 3 Massachusetts............................................. 207 237 331 364 380 2 Michigan.................................................. 125 145 190 201 212 30 Minnesota................................................. 151 172 223 240 255 13 Mississippi............................................... 84 94 126 144 149 50 Missouri.................................................. 129 148 195 209 223 24 Montana................................................... 104 116 155 181 192 39 Nebraska.................................................. 116 134 170 185 202 33 Nevada.................................................... 114 129 173 175 166 47 New Hampshire............................................. 140 162 207 227 238 18 New Jersey................................................ 146 174 243 267 284 8 New Mexico................................................ 113 130 184 206 218 26 New York.................................................. 236 258 318 339 360 4 North Carolina............................................ 111 132 185 209 221 25 North Dakota.............................................. 96 106 168 184 202 33 Ohio...................................................... 133 147 199 213 226 23 Oklahoma.................................................. 103 113 149 160 168 46 Oregon.................................................... 144 171 215 233 243 17 Pennsylvania.............................................. 152 169 234 256 275 10 Rhode Island.............................................. 160 194 248 277 294 7 South Carolina............................................ 93 114 161 177 181 41 South Dakota.............................................. 81 90 143 154 170 45 Tennessee................................................. 119 139 189 210 227 22 Texas..................................................... 117 135 174 188 196 35 Utah...................................................... 138 155 185 200 208 31 Vermont................................................... 187 207 268 288 301 6 Virginia.................................................. 125 149 214 233 238 18 Washington................................................ 149 168 223 241 251 14 West Virginia............................................. 104 124 171 183 195 37 Wisconsin................................................. 120 137 188 207 216 28 Wyoming................................................... 101 108 140 156 158 48 ---------------------------------------------------------------------------------------------------------------- \1\Excludes counts of physicians in U.S. possessions and with unknown addresses. Source: American Medical Association, Physician Characteristics and Distribution in the U.S. 1993 edition. Table A-20. The number of physicians in the United States is expected to continue to grow at a faster rate than the general population. According to the American Medical Association, there were 248 non-federal physicians per 100,000 population in 1992. The Department of Health and Human Services projects ratios of 271 in 2000 and 298 in 2020. In 1992, about 35 percent of physicians were in primary care specialties, defined as general and family practice, internal medicine, and pediatrics. Currently, there are approximately 88,620 residents in training. Growth in the number of residencies over the past twenty years reflects both steep increases in the number of first-year positions during the late 1970s and the increased length of training in many specialties. The number of U.S. medical school graduates, which rose rapidly in the late 1960s and early 1970s, has been relatively stable over the past decade (see table C-23). Since the late 1970s, efforts to restrict the flow of international medical graduates (IMGs) have included stricter immigration laws and more rigorous competency requirements. As a result, table C-24 shows that IMGs dropped from over 40 percent of all residents in 1971 to about 17 percent in 1985. Since then, the percentage of IMGs has risen to 22 percent. TABLE C-22.--PHYSICIAN SUPPLY FOR SELECTED SPECIALTIES, 1980-92 ---------------------------------------------------------------------------------------------------------------- Federal and non-federal physicians ----------------------------------------------------------- 1980 1985 1992 Specialty ----------------------------------------------------------- Office Office Office Total based Total based Total based ---------------------------------------------------------------------------------------------------------------- Total physicians.................................... 467,679 272,000 552,716 330,197 653,062 389,364 Anesthesiology.................................. 15,958 11,338 22,021 15,300 28,148 19,998 Cardiovascular diseases......................... 9,823 6,729 13,224 9,063 16,478 11,460 Dermatology..................................... 5,660 4,378 6,582 5,333 7,912 6,318 Diagnostic radiology............................ 7,048 4,191 12,887 7,749 17,253 10,900 Emergency medicine.............................. ........ ........ 11,283 7,295 15,470 9,373 Family practice................................. 27,530 18,378 40,021 29,694 50,969 40,479 Gastroenterology................................ 4,046 2,737 5,917 4,136 7,946 5,724 General practice................................ 32,519 29,642 27,030 24,579 20,719 18,575 General surgery................................. 34,034 22,426 38,169 24,762 39,211 24,956 Internal medicine............................... 71,531 40,617 90,417 52,891 109,017 65,312 Neurology....................................... 5,685 3,253 7,776 4,700 9,742 6,330 Neurological Surgery............................ 3,341 2,468 4,019 2,880 4,501 3,310 Obstetrics/gynecology........................... 26,305 19,513 30,867 23,543 35,273 27,115 Ophthalmology................................... 12,974 10,603 14,881 12,221 16,433 13,742 Orthopedic surgery.............................. 13,996 10.728 17,166 13,045 20,640 15,832 Otolaryngology.................................. 6,553 5,266 7,267 5,755 8,373 6,646 Pathology\1\.................................... 13,642 6,081 15,767 7,054 17,428 8,155 Pediatrics\2\................................... 29,462 18,210 36,839 23,211 45,921 29,668 Plastic Surgery................................. 2,980 2,438 3,951 3,301 4,688 4,044 Psychiatry\3\................................... 30,752 17,965 36,038 20,887 41,023 24,811 Pulmonary diseases.............................. 3,715 2,048 5,083 3,038 6,337 4,009 Radiology....................................... 11,653 7,802 10,109 7,363 7,848 5,854 Urological surgery.............................. 7,743 6,228 8,836 7,089 9,452 7,688 Other surgical specialties\4\................... 2,852 2,261 3,000 2,434 2,989 2,394 Other remaining specialties\5\.................. 22,825 11,741 19,740 9,498 26,228 13,805 Unspecified..................................... 12,289 4,959 8,250 3,376 8,109 2,866 Other categories\6\............................. 52,763 ........ 55,576 ........ 74,954 ........ ---------------------------------------------------------------------------------------------------------------- Note: Data for 1992 are as of January 1. Data for 1985 and before are as of December 31. \1\Includes pathology and forensic pathology. \2\Includes pediatrics and pediatric cardiology. \3\Includes psychiatry and child psychiatry. \4\Includes colon and rectal surgery and thoracic surgery. \5\Includes aerospace medicine, allergy/immunology, general preventive medicine, nuclear medicine, occupational medicine, physical medicine and rehabilitation, public health, radiation oncology, and other. \6\Includes not classified, inactive, and address unknown: these categories are included in total physicians only, not in office-based physicians. Source: AMA Physician Masterfile for 1980, 1985, and 1992. TABLE C-23.--MEDICAL SCHOOL GRADUATES, FIRST-YEAR RESIDENTS AND TOTAL RESIDENTS, 1965-92 ------------------------------------------------------------------------ Medical school First-year Total Year graduates residents residents ------------------------------------------------------------------------ 1965.................... 7,409 9,670 31,898 1966.................... 7,574 10,316 31,898 1967.................... 7,743 10,419 33,743 1968.................... 7,973 10,464 35,047 1969.................... 8,059 10,808 37,139 1970.................... 8,367 11,552 39,463 1971.................... 8,974 12,066 42,512 1972.................... 9,551 11,500 45,081 1973.................... 10,391 11,031 49,082 1974.................... 11,613 11,628 52,685 1975.................... 12,714 13,200 54,500 1976.................... (\1\) 14,258 56,872 1977.................... 13,607 15,900 59,000 1978.................... 14,393 16,800 63,163 1979.................... 14,966 17,600 64,615 1980.................... 15,135 18,702 61,465 1981.................... 15,667 18,389 69,738 1982.................... 15,985 18,976 69,142 1983.................... 15,824 18,794 73,000 1984.................... 16,327 19,539 75,125 1985.................... 16,319 19,168 75,514 1986.................... 16,125 18,183 76,815 1987.................... 15,836 18,067 81,410 1988.................... 15,887 17,941 81,093 1989.................... 15,620 18,131 82,000 1990.................... 15,336 18,322 82,902 1991.................... 15,481 19,497 86,217 1992.................... 15,386 19,794 88,620 ------------------------------------------------------------------------ \1\Not available. Source: JAMA Medical Education issues. TABLE C-24.--INTERNATIONAL GRADUATE MEDICAL RESIDENTS BY LOCATION OF EDUCATION AND CITIZENSHIP, 1971-92 ------------------------------------------------------------------------ Percent of Total all U.S. Foreign residents citizens nationals ------------------------------------------------------------------------ 1971................ 17,515 41 1,063 16,452 1976................ 16,634 29 1,783 14,851 1981................ 11,596 17 2,908 8,688 1983................ 14,084 19 4,961 9,123 1985................ 12,509 17 6,868 5,609 1991................ 17,017 20 5,107 11,910 1992................ 19,084 22 5,015 \1\14,069 ------------------------------------------------------------------------ \1\Includes 6,192 permanent resident aliens. Source: American Medical Association 1986 and JAMA Medical Education issues. HEALTH INSURANCE COVERAGE HEALTH INSURANCE STATUS IN 1992 Most people have some form of health insurance. In 1992, an estimated 85.4 percent of the total noninstitutionalized population had public or private coverage during at least part of the year. However, an estimated 37.3 million Americans, or 14.7 percent of the population, were without health insurance in 1992. All but 0.35 million of the uninsured were under age 65; consequently 16.6 percent of the nonelderly population were uninsured. These estimates are based on an analysis of the March 1993 Current Population Survey (CPS), a household survey conducted by the Census Bureau of the Department of Commerce. Each year's March CPS asks whether individuals had coverage from selected sources of health insurance at any time during the preceding calendar year. Thus the March 1993 CPS reflects respondents' recollections of coverage during all of 1992.\2\ --------------------------------------------------------------------------- \2\Some analysts have suggested that respondents may actually be reporting their coverage status at the time of the survey, rather than for the previous year. --------------------------------------------------------------------------- The questionnaires used in March 1988-93 differed from those used in previous years. In addition to the standard series of questions about sources of health insurance coverage, a separate part of the survey included further health insurance questions. Some respondents reported that they had no health insurance in one part of the questionnaire and reported that they had coverage in another part. Different analyses of the CPS data have used different assumptions in reconciling these discrepancies and other potential sources of error in the survey responses. Also, the March 1988-93 surveys included responses from population groups not surveyed in earlier surveys, including retirees and other nonworking individuals. CHARACTERISTICS OF THE UNINSURED Some segments of the population are more likely to have health insurance coverage than others, and different groups rely to a different extent on private insurance coverage and on public programs such as Medicare and Medicaid. Tables C-25 to C-27 divide the population according to age and income and show the sources of coverage for each group.\3\ (The total noninstitutionalized population in 1992 was 253.9 million.) --------------------------------------------------------------------------- \3\About 13 percent of the population reported more than one source of coverage during the year. The dual coverages many have been either at different points during the year or simultaneous. For the purpose of these tables, CRS has assigned each individual to one primary source of coverage according to the ``coordination of benefits'' rules typically used by private sector insurance companies. --------------------------------------------------------------------------- TABLE C-25.--PERCENT OF U.S. NONINSTITUTIONALIZED POPULATION OBTAINING HEALTH INSURANCE COVERAGE FROM SPECIFIED SOURCES, BY AGE, 1992 ---------------------------------------------------------------------------------------------------------------- Family Own job member's Medicare Medicaid Other\1\ Uninsured job ---------------------------------------------------------------------------------------------------------------- Age: Under 18....................................... 0.1 60.9 0.1 17.4 9.3 12.37 18 to 24....................................... 20.9 23.4 0.6 8.7 17.3 28.9 25 to 34....................................... 48.2 15.4 1.2 7.1 7.2 20.9 35 to 44....................................... 50.5 20.2 1.5 4.2 8.2 15.5 45 to 54....................................... 50.8 20.0 2.1 3.3 9.9 14.0 55 to 64....................................... 45.2 18.9 5.6 3.4 14.0 12.9 65 and over.................................... 4.4 9.0 84.8 0.1 0.5 1.2 ------------------------------------------------------------ Total........................................ 28.0 29.0 11.5 8.0 8.9 14.7 ---------------------------------------------------------------------------------------------------------------- \1\``Other'' includes, for example, privately purchased health insurance and Department of Veterans Affairs health care services. Source: CRS analysis of data from the March 1993 Current Population Survey. As table C-25 shows, the rate of insurance coverage is lowest among young adults; 28.9 percent of persons aged 18 to 24 were without coverage in 1992. Over the next several age groups, coverage rates increase, chiefly because older workers are more likely to obtain insurance through their own employment. Finally, the availability of Medicare to most individuals aged 65 and over meant that about 1 percent of this group was uninsured. Table C-26 shows the percentage of the total uninsured population of each age group. Of the 37.3 million uninsured, 22.1 percent are children. Young adults (ages 18 to 24) total 18.8 percent and persons 25 to 34 total 23.4 percent of the uninsured. TABLE C-26.--PERCENT OF U.S. NONINSTITUTIONALIZED POPULATION WITHOUT HEALTH INSURANCE, BY AGE, 1992 ------------------------------------------------------------------------ Percent of Age the uninsured ------------------------------------------------------------------------ Under 18................................................... 22.1 18 to 24................................................... 18.8 25 to 34................................................... 23.4 35 to 44................................................... 16.7 45 to 54................................................... 10.7 55 to 64................................................... 7.3 65 and over................................................ .95 ------------ Total................................................ 100.0 ------------------------------------------------------------------------ Note.--Items do not sum to 100.0 due to rounding. Source: CRS analysis of data from the March 1993 Current Population Survey. Table C-27 shows coverage rates by family income, expressed as a percentage of the Federal poverty income level. Those in the lowest income groups are least likely to have coverage. If they have coverage, the source is most likely to be Medicaid. As family income rises, both overall coverage rates and the degree of reliance on employer coverage increase. TABLE C-27.--PERCENT OF U.S. NONINSTITUTIONALIZED POPULATION OBTAINING HEALTH INSURANCE COVERAGE FROM SPECIFIED SOURCES, BY FAMILY INCOME, 1992 ---------------------------------------------------------------------------------------------------------------- Family Income as percent of poverty Own job member's Medicare Medicaid Other\1\ Uninsured job ---------------------------------------------------------------------------------------------------------------- Under 50........................................... 2.3 4.0 6.1 49.2 8.7 29.6 50 to 99........................................... 5.3 8.6 17.7 32.2 8.4 27.8 100 to 133......................................... 10.5 17.1 21.3 13.8 9.5 27.8 134 to 185......................................... 16.7 24.5 18.6 6.7 9.3 24.3 185 to 249......................................... 24.0 33.1 14.8 2.5 9.0 16.7 250 and over....................................... 39.2 34.0 8.0 0.7 8.8 7.4 ------------------------------------------------------------ Total........................................ 28.0 28.9 11.5 7.9 8.9 14.7 ---------------------------------------------------------------------------------------------------------------- \1\``Other'' includes for example, privately purchased health insurance and Department of Veterans Affairs health care services. Note.--Rows may not sum to 100.0 due to rounding. Source: CRS analysis of data from the March 1993 Current Population Survey. Table C-28 combines age and income and shows the percent of persons in each age/income group without health insurance. Overall, the trends shown in this table are similar to those in the previous tables: the rate of those without insurance drops with increasing age and income. TABLE C-28.--PERCENT OF THE U.S. NONINSTITUTIONALIZED POPULATION WITHOUT HEALTH INSURANCE, BY AGE AND INCOME, 1992 ---------------------------------------------------------------------------------------------------------------- Under 18 to 25 to 35 to 45 to 55 to 65 and Income as a percent of poverty level 18 24 34 44 54 64 over ---------------------------------------------------------------------------------------------------------------- Under 50................................................ 17.8 41.1 41.8 46.1 42.0 43.7 8.9 50 to 99................................................ 22.1 42.9 38.4 41.2 42.6 30.4 1.8 100 to 133.............................................. 24.7 42.8 42.7 38.5 41.6 27.4 1.2 134 to 185.............................................. 20.2 41.1 33.5 33.4 35.0 26.3 0.9 185 to 249.............................................. 13.0 34.5 23.4 18.7 22.5 14.7 1.0 250 and over............................................ 4.5 18.1 11.7 6.9 6.5 6.3 0.7 ---------------------------------------------------------------------------------------------------------------- Source: CRS analysis of data from the March 1993 Current Population Survey. FACTORS IN EMPLOYMENT-BASED COVERAGE In the United States, health insurance offered on a job is the single most important source of coverage. Employer plans covered 150.5 million Americans in 1992, or approximately 59.3 percent of the population. If only the nonaged are considered, this figure rises to over two-thirds. Persons covered under employer plans are almost equally divided between those obtaining coverage through their own work (77.0 million) and those obtaining coverage as dependents on another family member's policy (73.6 million). One important factor in employment-based coverage is the degree of attachment to the labor force. Employers who provide coverage to their full-time workers may not offer that coverage to part-time employees. Workers in seasonal industries, who are employed only part of the year, are also less likely to be covered. Table C-29 shows the workforce attachment of the population without health insurance coverage in 1992. Over one- third of the uninsured, 14.0 million, worked only part time or part of the year, or were dependents of part time or part year workers, while another 16.1 percent had no work force attachment. However, 46.4 percent of the uninsured, approximately 17.3 million persons, were full year, full time workers or the dependents of such workers. All told, 31.4 million uninsured persons had at least some ties to the workforce. The likelihood that workers will obtain coverage through their jobs is largely tied to two characteristics of employers: the size of the firm and the type of industry. Tables C-30 and C-32 show insurance coverage in 1992 for workers classed according to these two characteristics of their employers. As table C-30 indicates, workers in the smallest firms were least likely to obtain employer-based coverage and most likely to be uninsured. TABLE C-29.--PERSONS WITHOUT HEALTH INSURANCE COVERAGE, BY ATTACHMENT TO THE WORKFORCE, 1992 [Thousands] ------------------------------------------------------------------------ Percent of Workers Dependents Total uninsured ------------------------------------------------------------------------ Nonworker........... 0 6,003 6,003 16.1 Full year/full time worker............. 9,633 7,708 17,342 46.4 Full year/part time worker............. 1,892 813 2,706 7.2 Part year/full time worker............. 5,811 2,403 8,215 22.0 Part year/part time worker............. 2,529 560 3,090 8.3 --------------------------------------------------- Total......... 19,866 17,489 37,355 100.0 ------------------------------------------------------------------------ \1\Includes both heads of household and dependents with no workforce attachment. Note.--Items may not sum to total due to rounding. Full year workers were employed 50 or more weeks during the year. Full time workers worked an average of 35 or more hours per week during the weeks they were employed. Source: CRS analysis of data from the March 1993 Current Population Survey. TABLE C-30.--PERCENT OF WORKERS OBTAINING HEALTH INSURANCE COVERAGE FROM SPECIFIED SOURCES, BY SIZE OF EMPLOYER, 1992 ---------------------------------------------------------------------------------------------------------------- Family Firm size\1\ Own job member's Medicare Medicaid Other\2\ Uninsured job ---------------------------------------------------------------------------------------------------------------- 1 to 9............................................. 14.0 25.6 5.1 6.2 21.9 27.2 10 to 24........................................... 25.0 29.0 2.3 7.1 11.3 25.3 25 to 99........................................... 33.3 31.7 2.1 5.7 8.1 19.2 100 to 499......................................... 39.3 35.7 1.6 4.8 5.5 12.9 500 to 999......................................... 41.3 39.4 1.1 3.3 5.5 9.3 1,000 and over..................................... 42.4 39.8 1.2 3.1 5.6 7.8 Unemployed or not in labor force................... 5.0 6.8 48.9 21.1 6.2 11.9 ------------------------------------------------------------ Total........................................ 28.0 29.9 11.5 7.9 8.9 14.7 ---------------------------------------------------------------------------------------------------------------- \1\Firm size is that of the firm employing the worker for the longest period during the year. \2\``Other'' includes, for example, privately purchased health insurance and Department of Veterans Affairs health care services. \3\Persons reporting coverage through their own current or past employment and also reporting that they did not work during the year. These include retirees, as well as some persons who responded inaccurately to one of the questions. Source: CRS analysis of data from the March 1993 Current Population Survey. TABLE C-31.--NUMBER OF WORKERS WITH HEALTH INSURANCE COVERAGE FROM SPECIFIED SOURCES, BY FIRM SIZE, 1992 [Thousands] -------------------------------------------------------------------------------------------------------------------------------------------------------- Family Firm size\1\ Own job member's Medicare Medicaid Other\2\ Uninsured Total job -------------------------------------------------------------------------------------------------------------------------------------------------------- 1 to 9................................................... 5,478.9 7,207.1 1,507.4 816.2 5,649.4 7,628.4 28,287.0 10 to 24................................................. 4,345.6 2,695.5 293.8 421.2 1,428.1 3,017.4 12,202.0 25 to 99................................................. 9,073.1 3,103.2 399.5 504.2 1,490.9 3,538.6 18,110.0 100 to 499............................................... 11,642.0 2,846.5 357.0 430.9 1,146.8 2,676.3 19,100.0 500 to 999............................................... 4,818.1 1,136.4 90.5 123.4 450.8 802.9 7,422.3 1,000 plus............................................... 33,262.0 6,749.7 693.2 923.7 3,006.6 4,760.5 49,396.0 ---------------------------------------------------------------------------------------------- Total.............................................. 68,619.3 23,738.3 3,341.4 3,219.7 13,172.6 22,424.6 134,516.0 -------------------------------------------------------------------------------------------------------------------------------------------------------- \1\Firm size is that of the firm employing the worker for the longest period during the year. \2\``Other'' includes, for example, privately purchased health insurance and Department of Veterans Affairs health care services. Source: CRS analysis of data from the March 1993 Current Population Survey. Table C-32 shows insurance coverage for workers by industry class. The industries showing the lowest rates of job-based coverage are those where employment is seasonal (as in agriculture or construction) and those that tend to use low- wage workers and/or part time workers (as in personal services, entertainment, and retail trade). Employer-provided health insurance is most common in industries with a stable work force, such as government, and those whose workers are generally in collective bargaining arrangements, such as manufacturing, transportation, and mining. TABLE C-32.--PERCENT OF WORKERS OBTAINING HEALTH INSURANCE COVERAGE FROM SPECIFIED SOURCES, BY MAJOR INDUSTRY CLASS, 1992 ---------------------------------------------------------------------------------------------------------------- Family Industry class\1\ Own job member's Medicare Medicaid Other\2\ Uninsured job ---------------------------------------------------------------------------------------------------------------- Agriculture, forestry and fisheries............... 10.6 19.1 5.8 8.2 26.6 29.4 Mining............................................ 37.0 46.3 1.1 2.8 5.0 7.7 Construction...................................... 22.2 31.0 1.7 5.9 12.4 26.6 Manufacturing, durable goods...................... 39.2 42.9 1.1 2.6 4.2 9.9 Manufacturing, nondurable goods................... 40.0 37.9 1.5 4.1 4.9 13.5 Transportation, communications, and utilities..... 38.9 41.1 0.8 2.3 5.6 11.1 Wholesale trade................................... 35.4 40.5 1.2 2.2 8.9 11.7 Retail trade...................................... 25.3 26.8 2.8 8.1 12.3 24.6 Finance, insurance, and real estate............... 40.6 35.9 2.1 2.3 10.1 9.0 Business and repair services...................... 24.6 29.0 2.7 7.4 12.3 23.9 Personal services, including household............ 17.2 21.6 6.1 10.5 13.7 30.9 Entertainment and recreation services............. 27.5 24.6 4.3 7.5 13.7 22.3 Professional and related services................. 40.5 33.5 2.6 3.8 9.7 9.8 Public administration............................. 41.9 44.3 1.4 1.6 6.5 4.2 ---------------------------------------------------------------------------------------------------------------- \1\Industry is that in which the worker was employed the longest during the year. \2\``Other'' includes, for example, privately purchased health insurance and Department of Veterans Affairs health care services. Source: CRS analysis of data from the March 1993 Current Population Survey. One major trend in employer health benefit plans in recent years is a shift towards self-insurance, under which an employer directly assumes the financial risk for health care costs incurred by their employees. A self-insured firm may use an insurance company only to perform administative tasks, such as claims processing, or it may carry out these functions in- house. Some firms are ``partially insured''; they retain responsibility for most health care costs but buy protection for extraordinary expenses. Because of the financial risks involved, smaller firms are more likely to buy full coverage from a health insurance company. TABLE C-33.--INSURANCE FUNDING ARRANGEMENTS BY FIRM SIZE, 1992 [Percent of conventional plans using arrangement] ------------------------------------------------------------------------ 1000 or Number of employees 1 to 24 25 to 99 100 to 999 more ------------------------------------------------------------------------ Fully insured....... 91 90 67 46 Self-insured........ 9 10 33 54 ------------------------------------------------------------------------ Source: Health Insurance Association of America, Employer Sponsored Health Insurance in Private Sector Firms, 1992. TRENDS IN HEALTH INSURANCE COVERAGE An examination of the trends in health insurance coverage using the Current Population Survey is problematic because the health insurance questions asked by this survey and the types of individuals surveyed were changed beginning with the March 1988 survey. These changes result in a drop in the number of uninsured from 1986 to 1987 (and later years) that is unrelated to actual changes in insurance coverage. Thus, the data for 1986 and prior years are not comparable to data for 1987 and later years. Between 1979 and 1986, the percent of the nonaged population who were uninsured increased from 14.6 percent to 17.5 percent. The number of uninsured would have been expected to grow from 28.4 to 30.8 million simply because the overall nonaged population grew. However, the number of nonaged uninsured actually grew from 28.4 million to 36.8 million. That is, the number of uninsured increased by 8.4 million people, yet only 2.4 million or 29 percent of the growth was due to an expanding nonaged population. Table C-34 shows trends in the nonaged uninsured for selected years from 1979 to 1992. Most of the change in health insurance coverage occurred between 1979 and 1984; from 1984 to 1986, coverage rates remained fairly constant. The number and percent of the nonaged uninsured increased each year over the 1987-92 period, with the nonaged uninsured increasing to 37.0 million persons and 16.6 percent of the population in 1992. To examine why the uninsured increased since 1979, table C- 35 displays insurance coverage by source and year. TABLE C-34.--NUMBER AND PERCENT OF THE NONAGED POPULATION WITHOUT HEALTH INSURANCE, 1979 AND 1983-92 -------------------------------------------------------------------------------------------------------------------------------------------------------- 1979 1983 1984 1985 1986 1987\1\ 1988\1\ 1989\1\ 1990\1\ 1991\1\ 1992\1\ -------------------------------------------------------------------------------------------------------------------------------------------------------- Number uninsured (millions).................... 28.4 34.8 36.8 36.7 36.8 30.7 32.4 33.0 34.4 35.2 37.0 Percent uninsured (percent).................... 14.6 16.9 17.7 17.6 17.5 14.4 15.1 15.3 15.7 15.9 16.6 -------------------------------------------------------------------------------------------------------------------------------------------------------- \1\Data for years after 1986 are not comparable to that for 1986 and prior years because of changes in the questions asked and the population groups surveyed. Source: Table prepared by CRS based on data from the March 1980, and the March 1984 through the March 1993 CPS. Information from 1980 to 1982 is not presented due to errors on the CPS computer tapes for those years. TABLE C-35.--SOURCES OF HEALTH INSURANCE COVERAGE BY YEAR FOR NONAGED POPULATION, 1979 AND 1983-92 -------------------------------------------------------------------------------------------------------------------------------------------------------- Percentage of nonelderly population -------------------------------------------------------------------------------------------------------- 1979 1983 1984 1985 1986 1987\1\ 1988\1\ 1989\1\ 1990\1\ 1991\1\ 1992\1\ -------------------------------------------------------------------------------------------------------------------------------------------------------- Employment-based plans: Covered on own job......................... 33.1 32.5 32.6 33.1 33.4 32.9 33.0 33.4 32.6 32.3 31.3 Covered through someone else............... 34.3 32.1 31.4 31.2 31.4 33.4 33.1 33.5 32.6 32.3 31.7 -------------------------------------------------------------------------------------------------------- Total employment-based................... 67.4 64.6 64.0 64.3 64.8 66.3 66.1 66.9 65.2 64.6 63.0 Other plans\2\................................. 17.9 18.5 18.3 18.1 17.7 19.3 18.8 17.8 19.0 19.5 20.4 Uninsured...................................... 14.6 16.9 17.7 17.6 17.5 14.4 15.1 15.3 15.7 15.9 16.6 -------------------------------------------------------------------------------------------------------- Total.................................... 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 -------------------------------------------------------------------------------------------------------------------------------------------------------- \1\Data for years after 1986 are not comparable to that for 1986 and prior years because of changes in the questions asked and the population groups surveyed. \2\Excludes persons covered by employment-based plans. Note.--Percentages may not add to 100.0 due to rounding. Source: Table prepared by CRS based on data from the March 1980, and the March 1984 through the March 1993 CPS. Information from 1980 to 1982 is not presented due to errors on the CPS computer tapes for those years. The most dramatic trend shown in table C-35 is the decline from 1979 to 1986 in the percent of the non-aged population covered by employment-based plans through another family member, from 34.3 percent to 31.4 percent. This proportion declined consistently between 1979 and 1984, and then leveled off. On the other hand, the percent of the nonelderly population covered by health insurance from their own work actually increased between 1979 and 1986 from 33.1 to 33.4 percent. This coverage declined during the early 1980s but increased by nearly a full percentage point between 1983 and 1986. Coverage through one's own job increased slightly in 1988 and 1989 and has been declining since then to 31.3 percent in 1992. Coverage from someone else's job declined slightly in 1988, rose slightly in 1989, and has declined to 31.7 percent in 1992 below the 1987 level of 33.4 percent. Coverage from plans not employment-based declined from 1987 to 1989, then increased in 1991 exceeding the 1987 level. UNCOMPENSATED CARE COSTS IN PPS HOSPITALS, 1980-92 Uncompensated care is a term used to describe inpatient and outpatient care given to patients who are unable or unwilling to pay. It includes charity care and bad debts. Charity care is care given for which no payment is expected. Bad debt consists of charges that are not paid by uninsured individuals or partial charges, such as copayments, that are not paid by insured individuals. For this analysis, these charges have been adjusted to reflect the cost of care that was provided but not paid for. Public hospitals and some private institutions receive government operating subsidies that at least partially offset their uncompensated care losses. These subsidies are not always directed specifically towards charity care, but they nonetheless serve to lessen the burden of a high charity care load. This analysis thus examines uncompensated care both before and net of government subsidies. The information for this analysis was provided by the American Hospital Association from their Annual Survey of Hospitals. It describes the trend and distribution of uncompensated care in hospitals from 1980 to 1992. The financial burden of uncompensated care increased substantially through the 1980s and continues to grow. Before offsetting operating subsidies from State and local governments, total uncompensated care costs in community hospitals increased 11.7 percent per year, reaching $14.9 billion by 1992 (see table C-36). Over the 12-year period, this is about 1 percent faster than the growth in total hospital costs. However, this masks the slowdown that occurred in more recent years. From 1980 to 1986, uncompensated care costs grew almost 3 percent faster than total hospital costs, but from 1986 to 1992, they grew almost 1 percent slower. The portion of uncompensated care costs that was not covered by government operating subsidies grew even faster: 13 percent per year. This is because government subsidies have not increased as fast as total hospital cost inflation, with the lag being most pronounced starting in 1988 (see chart C-1). Between 1980 and 1992, the proportion of uncompensated care costs covered by government subsidies dropped from 28 percent to 19 percent. The burden of uncompensated care is widespread. Uncompensated care has traditionally been associated with large, urban public hospitals; over the last decade, however, the problem increasingly affected the entire industry. In 1992, uncompensated care accounted for 6 percent of hospital costs before government subsidies and 5 percent net of government subsidies (see table C-37). Urban government and major public teaching hospitals carried the largest uncompensated care burden as a percentage of total expenses both before and after government subsidies; however, they also received the most relief from government subsidies. Geographically, rural hospitals receive proportionally less support than urban hospitals. Voluntary and proprietary hospitals, on average, receive almost no relief from uncompensated care through government subsidies, although they provide an amount of uncompensated care equal to 5 percent and 4 percent of total costs, respectively. While a hospital's uncompensated care load is an important determinant of its overall financial condition, it is not the predominant factor in predicting financial performance. Perhaps the most important factor in this regard is the degree to which hospitals are able to generate revenue from other payers and non-patient care sources to cover their uncompensated care costs and Medicaid shortfalls. TABLE C-36.--HOSPITAL UNCOMPENSATED CARE COSTS AND GOVERNMENT OPERATING SUBSIDIES, 1980-92 ---------------------------------------------------------------------------------------------------------------- Amount (in billions) Average annual percent -------------------------------- change Measure -------------------------- 1980 1986 1991 1992 1980-86 1986-92 1980-92 ---------------------------------------------------------------------------------------------------------------- Uncompensated care costs before government subsidies. $3.6 $8.9 $13.4 $14.9 14.7 8.9 11.7 Government operating subsidies....................... 1.1 2.0 2.6 2.8 10.6 6.0 8.2 Uncompensated care costs net of government subsidies. 2.8 6.9 10.8 12.1 16.1 9.7 12.8 ---------------------------------------------------------- Proportion of uncompensated care costs covered by government subsidies (percent)...................... 27.7 22.3 19.6 18.9 ....... ....... ....... ---------------------------------------------------------------------------------------------------------------- Note.--Includes all community hospitals. Source: ProPAC analysis of American Hospital Association Annual Survey data. CHART C-1. CUMULATIVE GROWTH IN UNCOMPENSATED CARE COSTS AND GOVERNMENT SUBSIDIES, 1980-92 TABLE C-37.--HOSPITAL UNCOMPENSATED CARE COSTS AS A PERCENT OF TOTAL COSTS, BY HOSPITAL GROUP, 1992 [In percent] ------------------------------------------------------------------------ Uncompensated Uncompensated care costs care costs Hospital group before net of government government subsidies subsidies ------------------------------------------------------------------------ All hospitals............................. 6.0 4.9 Large urban............................... 6.4 4.9 Other urban............................... 5.6 4.9 Rural..................................... 5.3 4.8 Voluntary................................. 4.8 4.6 Proprietary............................... 3.9 3.9 Urban government.......................... 14.4 6.9 Rural government.......................... 6.5 5.0 Major teaching: Public................................ 17.9 7.3 Non-public............................ 5.3 4.8 Other teaching............................ 4.9 4.9 Non-teaching.............................. 4.6 4.6 Disproportionate share: Large urban........................... 8.3 5.7 Other urban........................... 6.8 5.6 Rural................................. 6.5 6.2 Non-disproportionate share................ 4.2 4.1 ------------------------------------------------------------------------ Note: Includes data for all community hospitals, except teaching and DSH hospitals which are PPS hospitals only. Source: ProPAC analysis of American Hospital Association Annual Survey data. INTERNATIONAL HEALTH SPENDING\4\ This section analyzes trends in health expenditures for 24 Organization for Economic Cooperation and Development (OECD) countries from 1970 to 1991. Table C-38 illustrates total health expenditures as a percentage of gross domestic product (GDP). In 1970, the mean percent of GDP was 5.1 percent, with the United States being 45 percent higher than the average with 7.4 percent of GDP. By 1991, the overall mean percent of GDP comprised of health expenditures had increased to 7.9 percent while the United States health spending as a share of GDP had increased to 13.4 percent, some 70 percent greater than the overall average. --------------------------------------------------------------------------- \4\The data and analysis in this section are from Health Affairs, ``Health Care Systems in Twenty-four Countries,'' by George J. Schieber, Jean-Pierre Poullier, and Leslie M. Greenwald, Fall 1991. Also, OECD press release, March 5, 1993. --------------------------------------------------------------------------- The second to the last column in table C-38 presents per capita health expenditures denominated in U.S. dollars. The last column illustrates public health expenditures as a percent of total health spending. This ranged from 61 percent in the United States to over 90 percent in Luxembourg, Norway, Sweden, Germany, Iceland, Ireland, Spain, Switzerland, and the U.K. with an OECD average of 84.2 percent. TABLE C-38.--TOTAL HEALTH EXPENDITURE AS A PERCENTAGE OF GROSS DOMESTIC PRODUCT [GDP], PER CAPITA HEALTH SPENDING AND PERCENT OF MEDICAL EXPENDITURES COVERED BY PUBLIC INSURANCE SCHEME, FOR SELECTED CALENDAR YEARS 1960-91 [In percent except per capita] ---------------------------------------------------------------------------------------------------------------- Per Country 1960 1970 1980 1985 1990 1991 capita Percent\1\ ---------------------------------------------------------------------------------------------------------------- Australia....................................... 4.9 5.7 7.3 7.7 8.2 8.6 $1,407 70.0 Austria......................................... 4.4 5.4 7.9 8.1 8.3 8.4 1,448 84.0 Belgium......................................... 3.4 4.1 6.6 7.4 7.6 7.9 1,377 86.0 Canada.......................................... 5.5 7.1 7.4 8.5 9.5 10.0 1,915 84.0 Denmark......................................... 3.6 6.1 6.8 6.3 6.3 6.5 1,151 85.0 Finland......................................... 3.9 5.7 6.5 7.2 7.8 8.9 1,426 82.0 France.......................................... 4.2 5.8 7.6 8.5 8.8 9.1 1,650 74.5 Germany......................................... 4.8 5.9 8.4 8.7 8.3 8.5 1,659 92.0 Greece.......................................... 2.9 4.0 4.3 4.9 5.4 5.2 404 85.0 Iceland......................................... 3.5 5.2 6.4 7.1 8.3 8.4 1,447 93.0 Ireland......................................... 4.0 5.6 9.2 8.2 7.0 7.3 840 90.0 Italy........................................... 3.6 5.2 6.9 7.0 8.1 8.3 1,408 75.0 Japan........................................... 3.0 4.6 6.6 6.6 6.6 6.6 1,267 87.0 Luxembourg...................................... N/A 4.1 6.8 6.8 7.2 7.2 1,494 91.0 Netherlands..................................... 3.9 6.0 8.0 8.0 8.2 8.3 1,360 71.0 Norway.......................................... 3.3 5.0 6.6 6.4 7.4 7.6 1,305 90.0 New Zealand..................................... 4.3 5.2 7.2 6.5 7.2 7.6 1,050 N/A Portugal........................................ N/A 3.1 5.9 7.0 6.7 6.8 624 N/A Spain........................................... 1.5 3.7 5.6 5.7 6.6 6.7 848 90.0 Sweden.......................................... 4.7 7.2 9.4 8.8 8.6 8.6 1,443 94.0 Switzerland..................................... 3.3 5.2 7.3 7.6 7.8 7.9 1,713 91.0 Turkey.......................................... N/A N/A 4.0 2.8 4.0 4.0 142 N/A United Kingdom.................................. 3.9 4.5 5.8 6.0 6.2 6.6 1,035 93.0 United States................................... 5.3 7.4 9.2 10.5 12.4 13.4 2,867 61.0 OECD Average.................................... 3.9 5.1 7.0 7.2 7.6 7.9 1,262 84.2 ---------------------------------------------------------------------------------------------------------------- \1\Percent of medical expenditures covered by public insurance scheme. Source: Schieber, George J. and Jean-Pierre Poullier. ``International Health Spending: Issues and Trends.'' Health Affairs, Spring 1991 p. 109; Schieber, George J., Jean-Pierre Poullier, and Leslie M. Greenwald, ``Health Care Systems in Twenty-four Countries.'' Health Affairs, Fall 1991, p. 24. Also, OECD press release, March 5, 1993.