Out-Of-Pocket Expenditure As Percentage Of Current Health Expenditure (2019): 11.31%

Source: Global Health Observatory. Out-of-pocket expenditure as percentage of current health expenditure (CHE) (%). Geneva: World Health Organization. Last accessed April 19, 2022.

Out-Of-Pocket Expenditure Per Capita (USD) (2018): $1,235

Source: Global Health Observatory. Out-of-pocket expenditure (OOP) per capita in US$. Geneva: World Health Organization. Last accessed April 19, 2022.

Domestic General Government Health Expenditure as Percentage of General Government Expenditure (%) (2018): 22.5%
Population with household expenditures on health greater than 10% of total household expenditure or income (2011-2018) (%): 4.8%
Population with household expenditures on health greater than 25% of total household expenditure or income (2011-2018) (%): 0.8%

Source: World health statistics 2021: monitoring health for the SDGs, sustainable development goals. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.

“Households experienced slower health care expenditure growth in 2020, increasing 1.1 percent after growth of 4.4 percent in 2019 (exhibit 2). Out-of-pocket spending (a 36 percent share of household expenditures) and households’ contributions to employer-sponsored private health insurance premiums (a 27 percent share) were the largest contributors to the deceleration (data not shown). Out-of-pocket spending declined 3.7 percent in 2020 after growing 4.4 percent in 2019, largely attributable to reductions in the use of dental services, hospital care, physician and clinical services, and retail prescription drugs (exhibit 3). In addition, households’ contributions to employer-sponsored insurance premiums increased 3.8 percent after growth of 5.5 percent in 2019 (data not shown). The slowdown was driven largely by a decline in enrollment in employer-sponsored insurance.”

Source: Hartman M, Martin AB, Washington B, Catlin A, The National Health Expenditure Accounts Team. National Health Care Spending In 2020: Growth Driven By Federal Spending In Response To The COVID-19 Pandemic [published online ahead of print, 2021 Dec 15]. Health Aff (Millwood). 2021;101377hlthaff202101763. doi:10.1377/hlthaff.2021.01763

“Private health insurance spending accounted for 28 percent of total health care expenditures, or $1.15 trillion, in 2020, decreasing by 1.2 percent because of a decline in enrollment and lower utilization as a result of the COVID-19 pandemic (exhibits 3 and 6).

“Total private health insurance spending for medical goods and services declined 3.5 percent in 2020 to $1.0 trillion (data not shown). Pandemic-related reductions in health care use, particularly for some elective procedures,^12,13 along with economic shutdowns and moratoria on certain procedures, led to declines in private health insurance spending for hospital care (-5.9 percent), physician and clinical services (-2.6 percent), and dental services (-3.8 percent) (data not shown).

“The combination of the health insurance tax (which was reinstated in 2020 after a moratorium in 2019) and a decline in private health insurance spending for most medical goods and services resulted in an increase in the net cost of insurance (the difference between revenues received by private health insurers and the amounts paid by private health insurers for medical care incurred).¹⁴ Spending attributable to the net cost of insurance, which includes administrative costs, taxes, fees, changes in reserves, and profits, increased by $21.6 billion in 2020 to reach $151.1 billion, or a 13.1 percent share of total private health insurance expenditures compared with a share of 11.1 percent in 2019 (data not shown).

“Private health insurance enrollment fell by 1.7 million in 2020 as pandemic-related job losses led to some people losing employer-sponsored health insurance coverage. This decrease in the number of enrollees was partially offset by an increase in enrollment in Marketplace plans. Per enrollee private health insurance spending decreased 0.4 percent in 2020 to $5,749, after increasing 2.3 percent to $5,770 in 2019 (exhibit 6).”

Source: Hartman M, Martin AB, Washington B, Catlin A, The National Health Expenditure Accounts Team. National Health Care Spending In 2020: Growth Driven By Federal Spending In Response To The COVID-19 Pandemic [published online ahead of print, 2021 Dec 15]. Health Aff (Millwood). 2021;101377hlthaff202101763. doi:10.1377/hlthaff.2021.01763

“• CFPB research shows $88 billion in medical debt on consumer credit records as of June 2021. The total amount of medical debt in collections in the U.S. is likely higher, since not all medical debts in collections are furnished to consumer reporting companies.

“• Most medical debt collection tradelines on consumer credit reports are under $500, although many people with medical debt have multiple medical collection tradelines.

“• As of 2021, 58 percent of all third-party debt collection tradelines were for medical debt, making medical debt the most common debt collection tradeline on credit records. The next most common collections tradeline was telecommunications debt, at only 15 percent of tradelines.

“• Past-due medical debt reported to consumer reporting companies can appear on a person’s credit reports and lower their credit scores. This may reduce their access to credit and make it harder to find a home or a job.

“• Medical debt collections are less predictive of future payment problems than other debt collections are. Certain newer credit models take this into account, but some widely-used models still weight medical and nonmedical collections equally.

“• Black and Hispanic people, and young adults and low-income individuals of all races and ethnicities, are more likely to have medical debt than the national average. As a result, these populations may be more heavily impacted by outdated credit models that overestimate the predictiveness of medical debt. Older adults and veterans are also heavily impacted by medical debt. Additionally, medical debt is more prevalent in the Southeastern and Southwestern U.S.

“• Medical bill amounts can be unpredictable and often vary widely based on patient and provider characteristics. Uninsured and out-of-network patients are often charged prices that are much higher than what in-network insurers pay—even though the uninsured may have little ability to pay. The prices charged to uninsured and out-of-network patients sometimes significantly exceed providers’ costs. Markups are especially high for emergency care, and for-profit investor-owned hospitals charge higher average markups.”

Source: Consumer Financial Protection Bureau. Medical Debt Burden in the United States. CFPB: Washington, DC. March 1, 2022.

“OOP [Out Of Pocket] payments are healthcare-related costs paid by consumers. They include direct payment for health services, coinsurance, co-payments and deductibles. While OOP payments have fallen as a percentage of the total, real OOP spending has actually risen considerably. This is because the size of the healthcare system has grown so fast. In 1980 per capita OOP spending was $253 of the $932 dollars spent on personal healthcare, representing a 27.1% share (Table 3.6). By 2015 US healthcare consumers spent $1060 in OOP payments of the $8479 dollars spent per capita on personal health expenditures, or 12.5%. In contrast, the consumer price index over this same period grew by only three-fold. In the midst of this general upward trend in OOP payments among OECD countries in recent decades, the United States has historically ranked second highest in per capita OOP spending, after Switzerland (OECD, 2018a).

“The growth rate in OOP payments was not distributed equally across subgroups of the US population and the services they use. The largest increases in OOP spending between 1995 and 2006 were experienced by those with non-Medicaid public insurance (60%), the uninsured (46%) and individuals at or below the poverty line (35%), compared to those with private coverage (15%) (Paez, Zhao & Hwang, 2009). Despite this disparity in OOP spending growth, OOP expenditures as a percentage of total health spending have been steadily decreasing since 2006 for non-elderly adults, with uninsured adults experiencing the largest decreases. Non-elderly, uninsured adults who incurred health expenses in 2006 paid 73% of those expenses OOP, whereas by 2014 that percentage had decreased to 61%.

“Privately insured adults saw decline as well, though to a lesser extent (from 33% in 2006 to 28% in 2014), as did publicly insured adults (13% to 9%) (Roemer, 2017). This trend was also observed for adults aged 65 and older, and by 2014 low-income elderly adults covered by Medicare and other public insurance paid 2.7% of total expenses OOP, compared to 12.9% for those with Medicare and private insurance, and 13.3% for those with Medicare alone (Gwet, Anderson & Machlin, 2016).”

Source: Rice T, Rosenau P, Unruh LY, Barnes AJ, van Ginneken E. United States of America: Health system review. Health Systems in Transition, 2020; 22(4): pp. i–441.

“Most covered workers make a contribution toward the cost of the premium for their coverage. On average, covered workers contribute 17% of the premium for single coverage and 28% of the premium for family coverage. Covered workers in small firms on average contribute a higher percentage of the premium for family coverage than covered workers in large firms (24% vs. 37%). Covered workers in firms with a relatively large share of lower-wage workers have higher average contribution rates for family coverage than those in firms with a smaller share of lower-wage workers (35% vs. 27%). Covered workers at private for-profit firms on average contribute a higher percentage of the premium for both single and family coverage than covered workers at other firms, while covered workers in public firms on average contribute a lower percentage of the premium for both single and family coverage. Covered workers in firms with a relatively large share of younger workers (where at least 35% of workers are age 26 or younger) have higher average contribution rates for single coverage (23% vs. 17%) and for family coverage (35% vs. 28%) than those in firms with a smaller share of younger workers.

“Twenty-nine percent of covered workers in small firms are in a plan where the employer pays the entire premium for single coverage, compared to only 5% of covered workers in large firms. In contrast, 31% of covered workers in small firms are in a plan where they must contribute more than one-half of the premium for family coverage, compared to 5% of covered workers in large firms [Figure C].

“The average annual dollar amounts contributed by covered workers for 2021 are $1,299 for single coverage and $5,969 for family coverage, similar to the amounts last year. The average dollar contribution for family coverage has increased 13% since 2016 and 45% since 2011 [Figure A]. Eight percent of covered workers, including 20% of covered workers in small firms, are in a plan with a worker contribution of $12,000 or more for family coverage.”

Source: Kaiser Family Foundation. Employer health benefits: 2021 annual survey. San Francisco, CA: KFF; Nov. 2021.

“Most covered workers must pay a share of the cost when they use health care services. Eighty-five percent of covered workers have a general annual deductible for single coverage that must be met before most services are paid for by the plan.

“Among covered workers with a general annual deductible, the average deductible amount for single coverage is $1,669, similar to last year. The average deductible for covered workers is higher in small firms than large firms ($2,379 vs. $1,397). The average single coverage annual deductible among covered workers with a deductible has increased 13% over the last five years and 68% over the last ten years.

“Deductibles have increased in recent years due to both higher deductibles within plan types and higher enrollment in HDHP/SOs. While growing deductibles in PPOs and other plan types generally increase enrollee out-of-pocket liability, the shift to enrollment in HDHP/SOs does not necessarily do so if HDHP/SO enrollees receive an offsetting account contribution from their employers. Twenty-seven percent of covered workers in an HDHP with a Health Reimbursement Arrangement (HRA), and 2% of covered workers in a Health Savings Account (HSA)-qualified HDHP receive an account contribution for single coverage at least equal to their deductible, while another 20% of covered workers in an HDHP with an HRA and 17% of covered workers in an HSA-qualified HDHP receive account contributions that, if applied to their deductible, would reduce their actual liability to less than $1,000.”

Source: Kaiser Family Foundation. Employer health benefits: 2021 annual survey. San Francisco, CA: KFF; Nov. 2021.

“A consistent finding between private and public insurance was the experience of medical debt. Those who had either form of private insurance (employer sponsored or individually purchased) were more likely to report medical debt compared with individuals covered by any form of public insurance. This is not surprising given that health care costs are increasing faster than the median income in most states.⁴ Reform efforts directed at increasing subsidies, reducing cost sharing and deductibles, and eliminating surprise medical billing may be important tactics for reducing medical debt experienced by those covered by private plans.^4,30-33“

Source: Wray CM, Khare M, Keyhani S. Access to Care, Cost of Care, and Satisfaction With Care Among Adults With Private and Public Health Insurance in the US. JAMA Netw Open. 2021;4(6):e2110275. doi:10.1001/jamanetworkopen.2021.10275.

“In a retrospective analysis of consumer credit reports, the mean amount of medical debt was high, and it was greater among individuals who lived in the South and in zip codes in the lowest income deciles. Medicaid expansion under the ACA was associated with reduced medical debt overall, and with reduced gaps in the amount of medical debt between low-income and high-income communities.

“During the last decade, medical debt has become the largest source of debt in collections. The reductions in nonmedical debt in collections between 2009 and 2020 occurred simultaneously with the economic recovery from the Great Recession, consistent with the well-documented association between unemployment and loan delinquency.¹⁴ In contrast, total medical debt in collections decreased by a more modest amount. As a result, as of June 2020 individuals had $39 more in mean medical debt in collections than they had in mean debt in collections from all other sources combined ($429 vs $390), including credit cards, utilities, and phone bills.”

Source: Kluender R, Mahoney N, Wong F, Yin W. Medical Debt in the US, 2009-2020. JAMA. 2021;326(3):250–256. doi:10.1001/jama.2021.8694

“At the national level, 17.8% of persons with a credit report had medical debt in collections and 13.0% accrued medical debt during the prior year. Conditional on having medical debt, the mean stock was $2424 and the mean flow was $2396.”

Source: Kluender R, Mahoney N, Wong F, Yin W. Medical Debt in the US, 2009-2020. JAMA. 2021;326(3):250–256. doi:10.1001/jama.2021.8694

“This survey study found differences in experiences related to access to care, costs of care, and satisfaction with care among public and private health insurance programs in the US. In analyses adjusted for baseline health status, individuals covered by employer-sponsored and individually purchased private insurance were less likely to report having a personal physician, stability in insurance coverage, and satisfaction with care compared with those covered by Medicare. Moreover, individuals with private health insurance were more likely to report difficulty seeing physicians because of cost, not taking medications because of costs, and having medical debt compared with individuals covered by Medicare. Similar patterns were observed in comparisons between private insurance and VHA or military coverage.

“These data are consistent with findings from prior research,^14-16,26 provide an update on US adults’ experiences with private and public coverage, and suggest that the experiences of individuals covered by private insurance compare less favorably with the experiences of individuals covered by publicly sponsored plans. Although we did not find recently published research comparing experiences among all 5 forms of coverage, our findings are consistent with data from a 2015 Gallup poll of a national sample of US adults that revealed that individuals with Medicare and VHA or military coverage were the most satisfied with the care they received.²⁷ Our findings are also consistent with results of research conducted in 2000 and 2010 that suggested greater overall satisfaction among Medicare beneficiaries compared with those covered by employer-sponsored insurance.^14,15,26“

Source: Wray CM, Khare M, Keyhani S. Access to Care, Cost of Care, and Satisfaction With Care Among Adults With Private and Public Health Insurance in the US. JAMA Netw Open. 2021;4(6):e2110275. doi:10.1001/jamanetworkopen.2021.10275.

Premiums for Single and Family Coverage

“• The average premium for single coverage in 2021 is $7,739 per year. The average premium for family coverage is $22,221 per year [Figure 1.1].

“• The average annual premium for single coverage for covered workers in small firms ($7,813) is similar to the average premium for covered workers in large firms ($7,709). The average annual premium for family coverage for covered workers in small firms ($21,804) is similar to the average premium for covered workers in large firms ($22,389). [Figure 1.3].

“• The average annual premiums for covered workers in HDHP/SOs are lower than the average premiums for coverage overall for both single coverage ($7,016 v. $7,739) and family coverage ($20,802 vs. $22,221). The average premiums for covered workers enrolled in PPOs are higher than the overall average premiums for both single coverage ($8,092 v. $7,739) and family coverage ($23,312 vs. $22,221) [Figure 1.1].

“• The average premiums for covered workers with single coverage are relatively high in the Northeast. The average premiums for covered workers with family coverage are relatively high in the Northeast and relatively low in the South [Figure 1.4].

“• The average premium for single coverage varies across industries. Compared to the average single premiums for covered workers in other industries, the average premiums for covered workers in the Manufacturing, and in the Agriculture/Mining/Construction categories are relatively low and the average premium for Health Care workers is relatively high [Figure 1.5].

“• The average premiums for covered workers in firms with a relatively large share of lower-wage workers (where at least 35% of the workers earn $28,000 annually or less) are lower than the average premium for covered workers in firms with a smaller share of lower-wage workers for both single coverage ($7,156 vs. $7,796) and family coverage ($20,315 vs. $22,407) [Figures 1.6 and 1.7].

“• The average annual premiums for covered workers in private for-profit firms are lower than average annual premiums for covered workers in other firms for both single and family coverage. Average annual premiums for covered workers in private not-for-profit firms are higher than average annual premiums for covered workers in other firms for both single and family coverage [Figures 1.6 and 1.7].

“• The average annual premiums for covered workers in firms with at least some union workers are higher than the average premiums for workers in firms with no union workers for both single coverage ($8,014 vs. $7,590) and family coverage ($23,095 vs. $21,747) [Figure 1.8].”

Source: Kaiser Family Foundation. Employer health benefits: 2021 annual survey. San Francisco, CA: KFF; Nov. 2021.

“Covered workers on average contribute 17% of the premium for single coverage and 28% of the premium for family coverage in 2021.¹ The average monthly worker contributions are $108 for single coverage ($1,299 annually) and $497 for family coverage ($5,969 annually). The average contribution amount for family coverage is higher for covered workers in small firms (3-199 workers) than for covered workers in large firms (200 or more workers) ($7,710 vs. $5,269).

“• In 2021, covered workers on average contribute 17% of the premium for single coverage and 28% of the premium for family coverage. The average percentage contributed for single coverage has remained stable in recent years. The average percentage contributed for family coverage is similar to the percentage (27%) last year [Figure 6.1].²
“– Covered workers in small firms on average contribute a much higher percentage of the premium for family coverage than covered workers in large firms (37% vs. 24%) [Figure 6.2].

“• Workers with single coverage have an average contribution of $108 per month ($1,299 annually), and workers with family coverage have an average contribution of $497 per month ($5,969 annually) toward their health insurance premiums [Figure 6.3], [Figure 6.4], and [Figure 6.5].
“– The average worker contribution in HDHP/SOs for family coverage is lower than the overall average worker contribution for family coverage ($5,129 vs. $5,969) [Figure 6.6].

“• Worker contributions also differ by firm size.
“– Covered workers in small firms on average contribute significantly more annually for family coverage than covered workers in large firms ($7,710 vs. $5,269). The average contributions amounts for covered workers in small and large firms are similar for single coverage [Figure 6.7].”

Source: Kaiser Family Foundation. Employer health benefits: 2021 annual survey. San Francisco, CA: KFF; Nov. 2021.

“Out-of-pocket spending (other than premiums) includes all amounts paid by the privately insured and other insured individuals for coinsurance, deductibles, and services not covered by insurance. It also includes any amounts paid by the uninsured for health care goods and services. Among all individuals, out-of-pocket spending totaled $365 billion (11.0% of total HCE) in 2017.”

Source: Congressional Research Service. In Focus: U.S. Health Care Coverage and Spending. Updated March 21, 2019.

Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and sixteen other nations.

Page last updated May 4, 2022 by Doug McVay, Editor.