A 20-year-long financial analysis identified low back and neck pain, musculoskeletal conditions, and diabetes as the costliest disorders with respect to US healthcare spending. Between 1996 and 2016, overall healthcare spending increased substantially, with the most drastic changes observed in public insurance, according to results published in JAMA.

Investigators used methods previously published by the Institute for Health Metrics and Evaluations for the Disease Expenditure Project (DEX) to estimate healthcare spending by payer between 1996 and 2016. Spending sources of interest included ambulatory care, emergency department, or dental visit; inpatient or nursing care facility stay; and pharmaceutical prescription. Data were abstracted from household surveys, public and private insurance claims databases, and health facility records. Government budgets and official US records were examined for all costs associated with healthcare administration, including employee salaries and management expenses. Healthcare spending was stratified by condition, age group, sex, type of care, and type of payer. Age- and population-standardized trajectories were calculated for each payer and health condition. Estimates were adjusted for relevant comorbidities. Confidence intervals (CIs) were generated using percentile interval bootstrapping with 1000 replications.

Data were extracted from 5.9 billion unique insurance claims; 150.4 million ambulatory, dental, or emergency department visits; 1.5 billion inpatient and nursing care facility bed-days; and 5.9 million pharmaceutical prescriptions. Overall, these data comprised 85.2% of total healthcare spending during the study period. Between 1996 and 2016, estimated total healthcare spending increased from $1.4 to $3.1 trillion, comprising 13.3% and 17.9% of the gross domestic product (GDP), respectively. In 2016, private insurance accounted for 48.0% (95% CI, 48.0-48.0%) of healthcare spending; public insurance for 42.6% (95% CI, 42.5-42.6%); and out-of-pocket payments for 9.4% (95% CI, 9.4-9.4%). The majority of public insurance spending was for patients ≥65 years of age (58.6%; 95% CI, 57.2-59.9%), while the majority of private insurance spending was allotted to patients ≤64 years (86.0%; 95% CI, 85.2-86.7%). After adjustments for population growth and aging, 108 of 154 studied health conditions had spending increases. In 2016, spending for low back and neck pain was estimated at $134.5 billion (95% CI, $122.4-$146.9 billion), followed by other musculoskeletal disorders ($129.8 billion; 95% CI, $116.3-$149.7 billion), and diabetes ($111.2 billion; 95% CI, $105.7-$115.9 billion). After adjusting for population growth and aging, 108 of 154 studied health conditions had spending increases. Across 20 years, the composition of healthcare payers shifted significantly, with public insurance paying for a significantly greater proportion of ambulatory care, inpatient bed-days, and pharmaceutical costs in 2016 vs 1996. After adjustments for inflation, population size, and age groups, health care spending increased at an annual rate of 2.9% (95% CI, 2.9-2.9%) for public payers, 2.6% (95% CI, 2.6-2.6%) for private payers, and 1.1% (95% CI, 1.0-1.1%) for out-of-pocket payers.

Continue Reading

Related Articles

Estimates for healthcare spending in the United States increased substantially between 1996 and 2016. The highest increases were observed for public payers. While spending for low back and neck pain, diabetes, and other musculoskeletal disorders was significantly higher than for any other disorder, costs varied considerably by payer and patient age stratum. Research will continue in the coming years to further elucidate healthcare spending trends in the United States.  

Disclosure: A total of 2 authors declared affiliations with the pharmaceutical industry.

Please see the original reference for a full list of authors’ disclosures.


Dieleman JL, Cao J, Chapin A, et al. US health care spending by payer and health condition, 1996-2016. JAMA. 2020 Mar 3;323(9):863-884