National Health Expenditure Projections, 2015–25: Economy, Prices, And Aging Expected To Shape Spending And Enrollment

Following the initial effects of the Affordable Care Act (ACA) on health care spending and insurance coverage, increases in economic growth, faster growth in medical prices, and population aging are expected to be the primary drivers of national health spending and coverage trends over the next decade. Growth in nominal (not inflation adjusted) national health expenditures is projected to average 5.8 percent for the period 2015–25, outpacing growth in the gross domestic product (GDP) by 1.3 percentage points. As a result, the health share of the economy is expected to climb from 17.5 percent in 2014 to 20.1 percent in 2025.

Millions of Americans gained health insurance coverage in 2014 as a result of the ACA, which expanded Medicaid eligibility and made subsidized Marketplace plans available. Health spending growth reflected this change, increasing from 2.9 percent in 2013 to 5.3 percent in 2014. These coverage expansions are anticipated to continue influencing health spending growth during the first two years of the 2015–25 projection period. For 2015, continued enrollment growth in Medicaid and the Marketplaces, as well as projected enrollment increases in employer-sponsored plans, is expected to have resulted in a slight acceleration in spending growth (5.5 percent) and a further substantial reduction in the number of uninsured people (7.2 million). By 2016 the transition of consumers into Medicaid and Marketplace plans and the associated declines in the number of uninsured people are expected to slow significantly, contributing to a lower rate of growth in health spending (4.8 percent).

The expectation for 2017–19 is for health spending growth to accelerate somewhat (averaging 5.7 percent), in part as a result of the effect of faster growth in health care prices. In addition, growth in Medicare spending is also projected to accelerate (averaging 6.7 percent), because members of the baby-boom generation will continue to age into that federal program and because existing beneficiaries are expected to use services more often than in the recent past. Over the same three-year time frame, Medicaid spending growth is expected to average 5.6 percent, as aged and disabled beneficiaries, who tend to require relatively more expensive care than those who are younger and nondisabled, represent an increasingly higher share of total beneficiaries. ¹ Lastly, private health insurance spending growth is expected to average 5.6 percent—its fastest rate for any subperiod examined in the projection period. That growth rate is largely related to rising disposable personal incomes, as well as the continued use of high-cost specialty drugs and faster growth in drug prices.

During the latter half of the projection period (2020–25), average annual national health spending growth is expected to be at its highest rate for the period (6.0 percent) but to remain below the average annual growth observed over the twenty-year period preceding the 2007–09 recession (nearly 8 percent). Influenced largely by the aging of the population, spending growth is expected to be the highest for Medicare among the major payers of health care, as one in five Americans are expected to be covered by the program by 2025. In addition to Medicare’s enrollment gains, its projected per enrollee spending is expected to reach nearly $18,000 in 2025, as the use of Medicare-covered goods and services increases to rates almost as high as its long-term average—which will result in more physician visits and hospital admissions. ² Projected growth in per enrollee private health insurance spending to nearly $8,600 in 2025 reflects expected additional use of health care goods and services as consumer incomes grow, with improved economic conditions expected throughout most of the projection period.

Model And Assumptions

The national health expenditure projections are developed using actuarial and econometric modeling methods, as well as judgments about future events and trends that influence health spending. ³ The projections are based on current law for Medicare and use the economic and demographic assumptions from the 2016 Medicare Trustees Report , updated to reflect the latest macroeconomic data. ² They are also consistent with assumptions from the 2015 Medicaid Actuarial Report . ¹

These projections are inherently subject to substantial uncertainty related to variable macroeconomic conditions. Additionally, although the initial impacts of the ACA have already occurred, longer-term indirect effects of the legislation on the market for health care remain uncertain, including the behavioral response to reform on the part of consumers, insurers, employers, and providers throughout the projection period.

The projection approach of the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary is based on analysis of more than fifty years of National Health Expenditure Accounts data that show a lagged, long-term relationship to economic (income) growth. Recent health spending trends through 2013, or the year before the occurrence of the major coverage expansions, while low by historical standards, were consistent with expectations inferred from economic trends. Thus, health spending growth is likely to accelerate in response to improvements in economic conditions that are projected over the coming decade. ⁴

Chronological Outlook Of Yearly Trends

2015

Driven in part by increased health care utilization among the newly insured, national health spending is projected to have grown 5.5 percent in 2015, compared to 5.3 percent in 2014, and to have reached $3.2 trillion ( Exhibit 1 ). Both the hospital sector and the physician and clinical services sector are projected to have experienced accelerations related to the projected decrease of 7.2 million people in the uninsured population (to 28.4 million), as consumers acquired coverage through either Medicaid or private health insurance plans (which include the federal and state-based Marketplaces) ( Exhibit 2 ). For hospitals, spending growth is projected at 4.9 percent in 2015, up from 4.1 percent in 2014 ( Exhibit 1 ), reflecting an expected second year of faster growth in the use of services following the coverage expansions. ⁵ The use of physician and clinical services also accelerated, with fewer people reporting that they had skipped needed medical care because of cost concerns. ⁶ Physician and clinical services spending growth is projected to have accelerated 0.8 percentage point, to 5.4 percent.

On the heels of slow growth in 2014 related to the health insurance expansions, growth in out-of-pocket spending is projected to have accelerated 1.3 percentage points in 2015, to 2.6 percent ( Exhibit 3 )—which is still well below 4.3 percent, the annual average for the previous twenty years. This represents the first year of an expected four-year trend of gradually increasing growth in this category after the initial impacts of coverage gains under the ACA fade, and as the number of people covered by high-deductible health plans—with their associated higher cost-sharing requirements—continues to grow. ⁷

Medical price inflation continued to slow in 2015, growing at a historically low rate of 0.8 percent (down from 1.4 percent in 2014) ( Exhibit 3 ), despite the increase in the use of health care goods and services driven by the gains in health insurance coverage. Hospital price growth slowed slightly in 2015, going from 1.3 percent in 2014 to 0.9 percent, and growth in physician prices declined, going from 0.5 percent in 2014 to −1.1 percent in 2015. ⁸ Underlying the change in physician price growth in 2015 was a significant decline in payment rates for Medicaid providers, ⁹ which coincided with the expiration of the temporary increase in payments to Medicaid primary care physicians. Medicaid spending growth on physician and clinical services is projected to have slowed from 22.8 percent in 2014 to 11.4 percent in 2015.

2016

Although national health spending per capita is projected to exceed $10,000 for the first time in 2016 ( Exhibit 3 ), aggregate national health spending growth (4.8 percent) is projected to slow temporarily, in large part because of slower growth in Medicaid spending ( Exhibit 3 ) after two years of rapid enrollment growth. The uninsured population is projected to decrease again, but by just 1.6 million, to 26.8 million people—with smaller increases in coverage in private health insurance and Medicaid than in 2014 and 2015 ( Exhibit 2 ). From a sponsor perspective, growth in health care expenditures paid for by federal, state, and local governments is projected to fall to 5.5 percent in 2016 (compared to 7.0 percent in 2015) ( Exhibit 4 ), reflecting smaller enrollment gains in Medicaid and its associated costs to government payers.

From a payer perspective, Medicaid spending growth is projected to slow to 5.3 percent in 2016 (from an average of 10.8 percent in 2014–15), following the program’s initial expansion-related enrollment growth in 2014–15 ( Exhibit 2 ). Growth in enrollment is projected to slow to 2.2 percent in 2016 (from an average of 8.9 percent in 2014–15). With fewer enrollment gains and continuing efforts by Medicaid managed care plans to ensure appropriate use of services, growth rates of nearly all service categories are expected to slow sharply. ¹ As a result, Medicaid hospital spending growth is expected to be 6.5 percent in 2016 (down from 12.4 percent in 2015), Medicaid physician and clinical services spending growth is projected to be 5.1 percent (down from 11.4 percent in 2015), and Medicaid prescription drug spending growth is expected to be 4.9 percent (down from 17.7 percent in 2015) (data not shown).

As seen in Exhibit 2 , growth in private health insurance spending in 2016 is projected to remain low, at 4.9 percent (the projected growth in 2015 is 5.1 percent). This similar rate reflects the net result of two offsetting trends. Slower growth in projected private health insurance enrollment of 0.7 percent (compared to 2.0 percent in 2015), primarily for employer-sponsored plans, is expected to exert downward pressure on spending growth. However, an uptick in projected medical price growth offsets that slowdown. Growth in the Personal Health Care Price Index is expected to remain low in 2016, at 1.5 percent, but to increase from the historically low rate of 0.8 percent in 2015 ( Exhibit 3 ). The expansion of narrow networks in some health plans is expected to help prevent sharp increases in health prices. ¹⁰

Unlike the other two major payers, Medicare is projected to have accelerated spending growth in 2016, to 5.2 percent from 4.6 percent in 2015 ( Exhibit 2 ). Underlying this trend is spending associated with Medicare hospital services, whose growth rate is expected to increase from 2.0 percent in 2015 to 4.4 percent in 2016 (data not shown). The acceleration is driven in part by an expected rebound in use of inpatient hospital services, which declined in 2015. ²

Finally, slowdowns are expected for two major health sectors in 2016. Physician and clinical services spending growth is projected to slow 0.9 percentage point, falling to 4.5 percent in 2016 ( Exhibit 1 ), in line with a moderation of the effects of the coverage expansions—particularly in Medicaid. Growth in prescription drug spending is also expected to slow, from 8.1 percent in 2015 to 6.3 percent in 2016, as the influence on spending from newly approved drugs is expected to fade after two years of above-average impacts. ¹¹

2017–19

In the period 2017–19, rates of spending growth are expected to rise across most sectors and payers. As a result, national health spending growth is projected to average 5.7 percent over this period, compared to 4.8 percent in 2016. This faster trend is primarily the result of a projected gradual acceleration in medical price growth and the impact of increased demand for care in response, on a lagged basis, to accelerating growth in disposable personal income.

Medical prices are projected to continue rising, and at a faster rate, in 2017–19, averaging 2.4 percent—compared with projected growth of 1.5 percent in 2016 ( Exhibit 3 ). The acceleration in medical prices is mostly driven by expected faster growth in economywide price inflation, as the two have exhibited similar patterns since 2012. ¹² In 2017–19, medical price inflation is anticipated to grow faster than in 2016, in part because of rising prices for the inputs required to provide health care—specifically, growth in health care wages.

Private health insurance spending growth is projected to average 5.6 percent during this period, compared to an expected growth rate of 4.9 percent in 2016 ( Exhibit 2 ), partly as demand for care, and thus spending, responds to faster income growth on a lagged basis. For prescription drugs, it is expected that there will be significantly fewer top-selling brand-name drugs losing patent protection in 2017 and 2018, compared to the period 2011–16. ¹³ As a result, a smaller number of new generic drugs (whose lower prices have typically helped offset annual increases in brand-name drug prices) is expected in these years, and therefore higher drug price growth is anticipated. However, the overall medical price acceleration is expected to be mitigated as a result of insurers’ continuing to experiment with different benefit design structures to limit the amount of premium increases each year. ¹⁴

Medicare spending growth is projected to continue to accelerate and to average 6.7 percent in 2017–19, compared to 5.2 percent in 2016. Strong projected annual enrollment gains of nearly 3 percent play an important role, as more baby boomers reach the age of entitlement ( Exhibit 2 ). Although somewhat mitigated by the continuing influx of younger beneficiaries, per beneficiary expenditures are expected to rise from 1.8 percent in 2016 to an average of 3.7 percent in 2017–19 ( Exhibit 2 ). The change reflects expectations that growth in the use and intensity of Medicare services will rise from recent historic low rates and become closer to longer-term averages. This is particularly true for hospital services—for which projected growth is an average of 5.9 percent per year over the period, relative to 4.4 percent in 2016 (data not shown).

Medicaid spending is projected to grow 5.6 percent on average in 2017–19—considerably slower than in 2014–15 but somewhat faster than in 2016. Underlying this overall expectation is slower, more stable average enrollment growth of 1.6 percent, following the mostly one-time transition impacts of people newly eligible for Medicaid. Offsetting slowing enrollment growth is faster growth in spending per enrollee, which is projected to average 4.0 percent, compared to 3.0 percent in 2016 ( Exhibit 2 ), as comparatively more expensive dually eligible beneficiaries (those enrolled in both Medicare and Medicaid) and disabled beneficiaries make up a growing proportion of the program’s population.

2020–25

In the second half of the projection period (2020–25), the increasing use of services in response to rising income growth and population aging is projected to increase growth in national health expenditures to an average of 6.0 percent per year—the highest for any of the subperiods examined. Medicare spending is projected to grow an average of 7.6 percent in 2020–25—faster than the spending of other major payers. This reflects the baby boomers’ continuing to age into the program. It also reflects existing Medicare beneficiaries increasing their use of hospital and physician services to rates that do not reach as high as the program’s long-term averages but that are above the program’s recent historical experience. Similarly, the aging of the Medicaid population is expected to lead to increased Medicaid spending growth (6.1 percent growth over the period on average), particularly for physician and clinical services and for prescription drugs. Average Medicaid spending per beneficiary in 2020–25 is expected to grow more rapidly (5.2 percent) than in 2017–19 (4.0 percent).

Growth in private health insurance spending is projected to remain at or above 5 percent, on average, throughout the latter half of the projection period but to generally slow in the final few years of the period in lagged response to slower growth in income. Notably, growth in private health insurance spending is expected to be outpaced by faster overall Medicare spending growth during this time, in part because of the continued shift of baby boomers out of private health insurance and into Medicare. Thus, private health insurance enrollment is projected to increase at an average rate of 0.5 percent per year, or 2.3 percentage points slower than Medicare enrollment.

Contributing to slower growth in private health insurance spending is the excise tax on high-cost employer-based insurance plans, which begins in 2020. As a result of the tax, some employers are expected to reduce benefits so they are not subject to the tax. Accordingly, this reduction in benefits is also expected to contribute to faster growth in out-of-pocket spending, which is projected to average 5.5 percent in 2020–25 (compared to 4.8 percent in 2017–19).

By 2025, changes are projected with respect to who ultimately pays for the nation’s health care. The proportion of health spending sponsored by federal, state, and local governments is expected to be 47 percent—almost 3 percentage points higher than it was in 2014—and to reach nearly $2.7 trillion. The proportion of spending by businesses and households is expected to be 53 percent in 2025—approximately 3 percentage points lower than it was in 2014—and to reach nearly $3.0 trillion. This expected higher share of spending by governments reflects the full impacts from the ACA’s coverage expansions, the continued transition of the baby-boom generation into Medicare, and a growing gap between dedicated Medicare financing and program outlays. ²

By the end of the projection period, medical price inflation is expected to be at its highest for the period, averaging 2.8 percent for 2020–25. Expectations for rising economywide inflation, together with higher input prices for providers, contribute to this faster increase in projected medical prices. However, the upward pressure is expected to be slightly offset by the continued effects of the ACA-mandated productivity adjustments and implementation of the Independent Payment Advisory Board, ² as well as the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which specified payment reductions to inpatient hospitals and postacute care providers (skilled nursing facilities, home health care, and hospice care).

Collectively, reductions in the number of uninsured people are expected as well as changes in the distribution of spending by payer and sector over the next decade. The insured share of the population is projected to be approximately 92 percent in 2025, up from 89 percent in 2014 ( Exhibit 2 ). The shares of spending by Medicare and Medicaid are projected to increase from 2014 (20.4 percent and 16.4 percent, respectively) to 2025 (22.8 percent and 17.3 percent, respectively), while shares of private health insurance and out-of-pocket spending decline from 2014 (32.7 percent and 10.9 percent, respectively) to 2025 (31.2 percent and 9.9 percent, respectively) (data not shown). By sector, the share of spending accounted for by prescription drugs is projected to increase (from 9.8 percent in 2014 to 10.9 percent in 2025), while the share of spending for physician and clinical services is projected to decline slightly (from 19.9 percent to 19.4 percent in the same period).

Major Topics In The Outlook For Medical Goods And Services

Hospital Services: Outlook For Hospital Prices

Growth in hospital prices, one of the key underlying drivers of overall hospital spending growth, decelerated from 1.3 percent in 2014 to just 0.9 percent in 2015, which is the slowest rate of price growth since 1998. ⁸ This deceleration was driven primarily by slower growth in payments by Medicare and Medicaid. ⁹ After 2015, hospital price growth is projected to accelerate, reaching 2.8 percent by 2019, because of an expectation of higher growth in input costs for hospital services—especially labor compensation, reflecting both expected increases in economywide wages and increasing competition for hospital employees. ¹⁵ In the second half of the projection period, hospital prices are anticipated to continue to grow at about 3 percent per year.

Physician And Clinical Services: Impact Of Increased Cost Sharing On Use

Despite expanded insurance coverage provided by the Marketplaces, growth in private health insurance spending on physician and clinical services is tempered somewhat over the projection period (averaging 4.9 percent in 2015–25) by the continued growth of high-deductible health plans, which are estimated to account for nearly one in four employer health plans in 2015, up from one in five in 2014. ⁷ Research has found that moving into high-deductible health plans or being subject to other increases in cost sharing tends to have a disproportionate impact on the use of physician and clinical services, such as preventive care. ^16,17 Increases in multiple types of cost sharing (including benefit-design changes, higher copayments, and higher deductibles) are expected to continue throughout the projection period and will act to limit the growth in the use of physician and clinical services. These increases in cost sharing are anticipated to contribute to an acceleration in the growth of out-of-pocket spending in this category, with projected average annual growth of 5.4 percent for 2020–25 (data not shown).

Prescription Drugs: Impact Of New Drugs

In 2015 there were forty-five new drug approvals in the United States, up from forty-one in 2014 and twenty-seven in 2013. ¹⁸ Many of these drugs have small target patient populations. Thus, the impact of new drugs approved in 2015 is likely to be smaller than in the previous two years—when fewer new drugs were approved, but several of them were intended for wide use.

Over the projection period, the impact on spending growth from newly approved drugs each year is expected to be lower than that observed in 2014 and 2015. The number of new drugs approved annually is anticipated to decrease. Moreover, a few of these new drugs are expected to be biosimilars, which are typically priced lower than the originator drug. ¹⁹

Selected Topics In The Outlook For Payers

Medicare: Upward Legislative Pressure On Growth

Certain legislative changes, as well as growth in economywide prices, are projected to exert upward pressure on spending growth in the Medicare program over the next decade. For example, an annual 0.5-percentage-point increase in hospital payments is legislated for fiscal year 2018 through fiscal year 2023, related to documentation and coding requirements in MACRA. Because of the same legislation, an increase in physician bonus payments is expected to begin in 2019, as doctors participate in Medicare’s transition to alternative payment models or the merit-based incentive payment systems. In addition, prices associated with the inputs required to furnish care to Medicare beneficiaries are expected to grow more rapidly in the coming years than in the recent past, including faster growth in health-sector wages and salaries associated with the expected tightening of labor markets.

Medicaid: Impact Of States Expanding Eligibility

Currently, thirty-one states and the District of Columbia have expanded their Medicaid eligibility under the ACA, while nineteen states have elected not to do so. ²⁰ One area of uncertainty in projections of Medicaid spending and enrollment concerns the prospect of additional states’ expanding Medicaid eligibility. These projections assume that there will be a small increase in Medicaid expansion going forward. Specifically, in 2016, it is assumed that 50 percent of the people who were potentially newly eligible to enroll in Medicaid resided in states that elected to expand Medicaid eligibility. In 2017 and beyond, this share is assumed to rise to 55 percent. ¹ As a result, Medicaid spending as a share of overall national health spending is expected to rise to 17.3 percent by 2025, up from 15.5 percent in 2013, before the major coverage expansion of Medicaid in 2014 (data not shown).

Conclusion

The health sector is in the midst of a unique period, in which various forces are exerting differential pressures on health spending growth. Economywide and medical-specific price growth have been very low, helping restrain inflation’s impact on health spending, and the Medicare program is experimenting with various alternative payment approaches. Meanwhile, many Americans are gaining access to health coverage for the first time, aging into Medicare, or finding that a greater share of their health expenses needs to be paid out of pocket. And the Medicaid program is evolving: Its population mix is increasingly likely to be covered through private plans.

For the period 2015–25, growth in health spending is projected to average 5.8 percent, influenced in part by an expectation of higher economywide and medical prices. By 2025, as economic, legislative, and demographic influences play out, the health spending share of the economy is projected to reach 20.1 percent, up from 17.5 percent in 2014, and governments are anticipated to sponsor 47 percent of health spending, up from 45 percent in 2014. The percentage of the US population that is uninsured is expected to be 8 percent in 2025, down from about 11 percent in 2014.

ACKNOWLEDGMENTS

The opinions expressed here are the authors’ and not necessarily those of the Centers for Medicare and Medicaid Services. The authors thank Paul Spitalnic, Stephen Heffler, John Shatto, Chris Truffer, and Aaron Catlin. [ Published online July 13, 2016. ]

NOTES

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