Most comprehensive study on U.S. health care spending by county reveals wide variation

• At $144 billion, type 2 diabetes was the most expensive single health condition.
• Emergency department care had the fastest growth.

SEATTLE, Wash., Feb. 14, 2025 – Researchers present the most comprehensive study on U.S. health care spending and variations across 3,110 counties by four payers, 148 health conditions, 38 age/sex groups, and seven types of care. That’s according to the newest and most extensive studies published in JAMA and JAMA Health Forum today.

As part of this study, researchers at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington’s School of Medicine examined over 40 billion insurance claims and nearly one billion facility records, as well as data from surveys.

The analysis identified some of the drastic fluctuations in health care expenses from coast to coast. For example, Nassau County in New York City’s metropolitan area is spending $13,332, the highest per capita health care expenditure in the U.S. That’s nearly four times some of the lowest figures in the country, like Clark County’s $3,410 in Idaho.

The research also found significant differences within the states from 2010 to 2019. For instance, Sumter County, a suburban area of Orlando, Florida, had the highest per capita health care expenditure of $11,680. That’s the 8^th highest in the U.S. and almost double the $5,899 total in Osceola County, which is also part of the Orlando area. Additionally, it’s 2.5 times the state’s lowest total of $4,698 in Gadsden County in the Tallahassee area.

The states with the lowest per capita health care spending were Idaho with $6,028, Utah with $6,147, and New Mexico with $6,368. In contrast, the states with the highest expenses were Alaska with $9,282, New York with $9,115, and Massachusetts with $9,097.

Health Conditions

The difference in expenses was also apparent by health condition. Nationally, type 2 diabetes was the most expensive health condition at $144 billion. It was followed by other musculoskeletal disorders at $109 billion, oral disorders at $93 billion, ischemic heart disease at $81 billion, and urinary diseases at $72 billion.

When accounting for diabetes as a single health condition, Sumter County’s per capita total of $1,216 was the highest in the state and in the U.S., while some of the lowest expenditures for type 2 diabetes were found in states like Georgia, Alaska, and Colorado, where expenses were about 90% less.

The health condition with the fastest average annual per capita growth rate and with at least $5 billion of spending was autism spectrum disorders at 13%. Opioid use disorders had the second fastest rate at 9%, followed by alcohol use disorders at 7% and substance use disorders other than alcohol and opioid at 6%.

Types of Care

Researchers also examined costs by the seven types of care: ambulatory, inpatient, pharmaceutical, nursing facility, dental, home health, and emergency department. Ambulatory, which includes all primary care and outpatient services, accounted for most of the expenditures at 42%, totaling more than $1 trillion. Inpatient care accounted for 24%, totaling $578 billion, while 14% was for prescription drugs, which cost Americans $331 billion. Emergency department care had the lowest spending at just 2%, totaling $56 billion, but it had the fastest growth and the largest variation in per capita spending.

Three counties in California were among the top 10 figures in the U.S. for ambulatory care. San Francisco Bay Area’s Marin County had the highest at $6,443, and San Mateo County, also in the Bay Area, had the third highest at $6,099. Placer County in the greater Sacramento area had the 10^th highest at $5,374. Comparing those totals with some of the lowest in the nation, counties in states like Texas spent 78% less for the same type of care. However, the highest figure within Texas was three times higher than the lowest, further demonstrating the disparities within state borders.

“The contrast in ambulatory care spending across the country highlights the urgent need to address gaps in access to primary care that take into account the extent to which people use services based on their geographic location, age, and health conditions,” said lead author and Associate Professor Dr. Joseph Dieleman at IHME.

Age

In addition to expenditure changes in the counties where people lived, dramatic variations occurred at different ages. More than 40% of expenses were for those older than 65 years, while less than 12% were for those under the age of 20. While more spending was on individuals aged 65 to 69 years than any other age group, the highest per capita spending was for the oldest age group of 85 and older.

Health Care Payers

Florida’s Sumter County had the highest per capita total in the U.S. for Medicare with $18,284. That’s three times higher than the lowest amounts in the country, which were in states such as Texas, Nebraska, and Vermont. The highest per capita private insurance figure was in D.C. at $10,955, making it seven to eight times the lowest costs in the U.S., which were in states such as Colorado, Kentucky, and Texas. The nation’s highest Medicaid spending was in Missouri at $12,420, which is four times the lowest spending, which was in states such as South Dakota, Alaska, and Oklahoma.
 
Understanding the Drivers

The main driver for the vast variations in health care expenditures was the utilization rate, or the extent to which people use health care services. It accounted for 65% of the variation in costs, while price and the intensity of services explained 24%. Age explained nearly 4% of the cost differences, while disease prevalence was not a major driver and accounted for 7% of spending variation. Utilization per prevalent case was most associated with insurance coverage, income, and obesity, while service price and intensity were most associated with median household income.

Differences in cross-state expenditures were also attributed to different factors. For Utah, the state with the least health care spending per capita, spending rates were lower for all types of care due to the young age profile. For Alaska, the state with the highest spending, spending rates were relatively high for ambulatory, hospital inpatient, and emergency department care.

Researchers believe these disparities in health care expenditures across states support the argument that some states have found more efficient ways to deliver care without escalating costs. Whether it is through innovative care models, more effective use of technology, or superior preventive care initiatives, they emphasize that these insights could guide a national strategy to modernize health care.

“If people had better insurance coverage, they would be more likely to pursue regular health checkups, potentially reducing the need for emergency care. This change would also lead to better health outcomes and allow emergency providers to focus on patients with urgent medical needs,” said Dr. Dieleman.

***EMBARGO: 11:00 am ET / 8:00 am PT Friday, Feb. 14, 2025*** 

Journalists can email IHMEMedia@UW.edu for embargoed interviews with the paper’s author.  

Journalists can also access embargoed copies of the paper, appendix, and datasets here:  
https://cloud.ihme.washington.edu/s/oRnLMpg7FSDDcJD

Password: IHMEHealthCareCosts021425
  
NOTE: THE ABOVE LINK IS FOR JOURNALISTS ONLY; IF YOU WISH TO PROVIDE A LINK FOR YOUR READERS, PLEASE USE THE FOLLOWING, WHICH WILL GO LIVE AT THE TIME THE EMBARGO LIFTS:  

Tracking US Health Care Spending by Health Condition and County:

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2024.26790?guestAccessKey=783582d7-4e27-4a8c-8b5a-ecebb4c21894&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=021425

Drivers of Variation in Health Care Spending Across US Counties:

https://jamanetwork.com/journals/jama-health-forum/fullarticle/10.1001/jamahealthforum.2024.5220?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=021425

IHME’s visualization tool will also be updated with the latest county level data from both papers by publication date/time.