DataView: State Health Expenditure Accounts: Building Blocks for State Health Spending Analysis

Abstract

The dynamics of financing health care among various levels of government and the private sector are rapidly changing; structural relationships among health care providers are also being altered. These changes are placing increased importance on State-level expenditure estimates that will be instrumental in measuring the differential impact of Federal policies and State-specific initiatives on individual States. This article presents personal health care expenditures (PHCE) for 1980-93. Statistics show wide variation in level and rate of growth of regional spending per person. These statistics also quantify differences in both the percent of health care costs in each State borne by Medicare and Medicaid and in the proportion of each State's economy devoted to the provision of health care.

Introduction

State health expenditure accounts (SHEA) are important building blocks for health care policy analysis. Like its national health expenditure (NHE) account counterpart (Levit et al., 1994), SHEA provides a framework for measuring health care spending on services and products and the sources of revenue used to pay those costs. As a time-series measure, it also tracks changes in spending patterns over time and can record the impact of policy changes on payers and providers of health care. In the future, SHEA may also serve as a basis for projecting future State health costs or as controls for further disaggregation of costs to substate areas. The State accounts presented in this article expand on earlier published estimates (Levit et al., 1993; Levit, 1985) to present spending by State for all PHCE for 1980-93. Medicare and Medicaid spending for each personal health category are also included.

The current effort to develop and expand SHEA began during the 1993-94 health reform debate, as policymakers began to question the effect of national policy options on individual States. Those health reform efforts waned; subsequently, the focus has shifted to the efforts of States as they grapple with the continued rise in the number of uninsured, lack of availability of health insurance to many employed workers, mandated Medicaid expansions, State budget constraints, aging populations, and uncompensated care.

Some States are moving forward with changes to their health care delivery and payment systems. For example, Oregon is rationing Medicaid services to fund expansion of services to more persons; Florida has instituted purchasing alliances that make affordable insurance policies available to small businesses. More global proposals are under consideration by Congress that would affect the payment system through Medicare vouchers and/or Medicaid block grants. These changes would affect payers responsible for reimbursing providers for more than one-third of health care spending in 1993. Measuring and analyzing the differential impact of such changes on States will be a daunting task.

For many States, only fragmented information on health care spending within their borders is available, making informed policy decisions difficult. Several States have undertaken the task of comprehensively measuring the costs of this swelling economic sector; these statistics have proven invaluable in decisionmaking. But the lack of consistency in definitions and data among accounts developed by individual States make interstate comparisons difficult at best. Consequently, States have little information to use in comparing their experience with that of neighboring States.

The SHEA for 1980-93 are a step forward in providing consistent State-level health care expenditure information. These accounts present spending by State of provider of services, measuring the impact of health care on each State's economy. In addition, regional costs per capita and some possible causes for different levels and growth of spending are discussed. For most services, per capita costs are not analyzed by State because border crossing by patients to neighboring States to receive services distorts this measure.¹ At the regional level, the net effect of border crossing is minimal. Development is under way on border-crossing adjustments that will permit interstate comparisons of per capita costs for 1991. These residence-based estimates that will permit a more complete analysis of spending difference by State will be available later this year. Further work is in progress to develop the information necessary to convert 1992 and 1993 PHCE from State of provider to State of residence, so that time-series per capita spending estimates can be analyzed.

Tables 11-28, presented at the end of this article, list State and regional estimates of PHCE for each service type, PHCE as a share of gross State product (GSP), and Medicare and Medicaid expenditures.

Table 11. Personal Health Care Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	216,525	375,236	608,246	727,377	778,510	10.3
New England	12,804	22,213	38,282	44,427	47,449	10.6
Connecticut	3,151	5,588	9,976	11,572	12,216	11.0
Maine	928	1,590	2,702	3,196	3,433	10.6
Massachusetts	6,651	11,261	19,170	21,969	23,421	10.2
New Hampshire	701	1,388	2,522	3,117	3,452	13.0
Rhode Island	975	1,705	2,731	3,173	3,428	10.2
Vermont	397	681	1,182	1,400	1,499	10.8
Mideast	44,387	76,067	123,174	145,912	155,994	10.2
Delaware	559	999	1,710	2,081	2,260	11.3
District of Columbia	1,389	2,282	3,535	4,018	4,285	9.1
Maryland	4,077	7,033	11,839	14,171	15,154	10.6
New Jersey	6,459	11,638	19,951	23,978	25,741	11.2
New York	20,142	33,231	53,716	62,928	67,033	9.7
Pennsylvania	11,762	20,883	32,423	38,736	41,521	10.2
Great Lakes	40,186	65,206	99,946	118,537	126,240	9.2
Illinois	11,706	18,362	27,422	32,856	34,747	8.7
Indiana	4,569	7,678	12,549	15,259	16,401	10.3
Michigan	9,358	14,779	21,972	25,458	27,136	8.5
Ohio	10,120	17,406	26,682	31,433	33,456	9.6
Wisconsin	4,433	6,982	11,322	13,530	14,502	9.5
Plains	16,594	27,375	42,220	49,608	52,761	9.3
Iowa	2,599	3,920	6,020	6,962	7,341	8.3
Kansas	2,262	3,586	5,508	6,562	6,903	9.0
Minnesota	4,241	7,289	11,511	13,328	14,194	9.7
Missouri	4,823	8,190	12,592	14,890	15,949	9.6
Nebraska	1,460	2,277	3,477	4,137	4,400	8.9
North Dakota	629	1,154	1,619	1,920	2,021	9.4
South Dakota	580	960	1,493	1,809	1,953	9.8
Southeast	43,634	79,689	136,582	165,841	178,023	11.4
Alabama	3,158	5,448	9,157	11,228	12,060	10.9
Arkansas	1,745	3,003	4,847	5,752	6,111	10.1
Florida	9,795	19,897	35,127	41,958	44,811	12.4
Georgia	4,570	8,471	15,287	18,620	20,104	12.1
Kentucky	2,716	4,721	7,826	9,745	10,384	10.9
Louisiana	3,577	6,494	9,888	12,067	13,014	10.4
Mississippi	1,768	2,935	4,714	5,663	6,187	10.1
North Carolina	4,211	7,303	13,700	16,889	18,241	11.9
South Carolina	2,092	3,725	6,699	8,364	9,029	11.9
Tennessee	4,069	7,210	12,177	15,086	16,203	11.2
Virginia	4,347	7,863	13,254	15,636	16,682	10.9
West Virginia	1,586	2,618	3,904	4,832	5,197	9.6
Southwest	18,639	34,032	54,923	67,078	72,370	11.0
Arizona	2,452	4,857	8,480	9,897	10,635	11.9
New Mexico	920	1,792	2,895	3,567	3,878	11.7
Oklahoma	2,578	4,348	6,279	7,521	8,041	9.1
Texas	12,689	23,035	37,268	46,092	49,816	11.1
Rocky Mountains	5,372	9,652	14,951	18,133	19,561	10.5
Colorado	2,735	5,035	7,724	9,359	10,066	10.5
Idaho	627	1,058	1,657	2,092	2,277	10.4
Montana	621	1,039	1,606	1,938	2,103	9.8
Utah	1,051	1,929	3,170	3,827	4,118	11.1
Wyoming	337	592	794	918	998	8.7
Far West	34,909	61,002	98,168	117,841	126,111	10.4
Alaska	447	887	1,239	1,490	1,573	10.2
California	26,524	46,267	74,116	88,215	94,178	10.2
Hawaii	919	1,671	2,733	3,260	3,485	10.8
Nevada	836	1,534	2,767	3,477	3,747	12.2
Oregon	2,356	3,844	6,137	7,349	7,999	9.9
Washington	3,828	6,799	11,176	14,051	15,129	11.1

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 28. Medicaid Personal Health Care Expenditures as a Share of Total Personal Health Care Expenditures, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993
	Percent
United States	11.4	10.4	11.8	14.3	14.5
New England	14.6	13.0	15.9	18.2	16.6
Connecticut	11.0	11.2	12.8	16.0	16.4
Maine	15.9	15.5	16.6	20.9	21.0
Massachusetts	16.3	13.7	18.1	17.9	15.8
New Hampshire	10.7	8.8	10.3	21.2	12.9
Rhode Island	16.4	15.1	17.6	23.0	23.1
Vermont	15.8	12.8	13.4	16.2	15.5
Mideast	16.2	15.5	16.2	19.1	19.1
Delaware	8.4	7.3	8.0	10.6	11.0
District of Columbia	11.8	13.3	11.8	14.8	15.8
Maryland	10.8	9.1	10.1	12.8	12.7
New Jersey	11.7	10.1	12.4	14.8	15.0
New York	22.4	23.0	23.4	26.3	26.9
Pennsylvania	11.0	9.3	9.8	13.3	12.3
Great Lakes	11.2	10.8	11.5	14.1	14.3
Illinois	11.1	9.3	8.8	12.8	13.3
Indiana	8.6	10.0	12.2	15.8	16.9
Michigan	12.8	11.5	12.3	13.8	14.2
Ohio	8.6	10.5	12.5	14.5	13.9
Wisconsin	17.0	14.5	13.2	14.8	14.7
Plains	9.6	9.5	10.5	12.7	12.7
Iowa	9.4	9.4	10.9	13.0	13.1
Kansas	8.8	7.5	9.2	10.4	11.1
Minnesota	14.4	14.1	12.9	14.6	15.7
Missouri	6.5	6.7	8.6	12.0	10.3
Nebraska	7.7	7.5	9.5	12.0	12.7
North Dakota	8.2	10.7	12.4	13.2	13.3
South Dakota	10.5	9.9	11.5	13.3	13.5
Southeast	9.1	8.2	10.4	13.0	13.4
Alabama	9.3	8.0	8.9	10.7	10.6
Arkansas	14.2	12.5	12.6	16.0	16.5
Florida	4.3	4.8	7.3	9.7	10.5
Georgia	10.6	9.1	10.4	12.3	13.7
Kentucky	11.8	11.5	13.9	16.7	16.2
Louisiana	11.7	11.5	14.8	19.3	20.5
Mississippi	12.6	9.7	13.4	17.0	16.8
North Carolina	10.2	9.3	11.5	13.6	14.1
South Carolina	12.7	9.5	13.7	14.9	14.7
Tennessee	9.4	8.6	12.1	14.1	13.5
Virginia	8.7	7.2	7.9	9.5	9.7
West Virginia	7.1	6.9	11.2	19.3	20.7
Southwest	7.4	6.7	8.8	11.9	12.1
Arizona	0.0	2.1	6.7	12.0	11.9
New Mexico	8.2	8.6	10.3	14.2	14.9
Oklahoma	11.2	10.6	11.5	13.4	12.6
Texas	8.0	6.8	8.7	11.5	11.9
Rocky Mountains	7.6	6.9	8.6	10.5	11.2
Colorado	7.0	6.1	7.4	8.5	9.6
Idaho	8.4	7.1	9.9	12.9	12.7
Montana	11.0	10.0	12.3	14.4	15.3
Utah	7.4	7.9	9.0	11.3	11.6
Wyoming	4.5	5.0	9.0	13.4	13.7
Far West	10.9	8.7	9.4	11.4	12.2
Alaska	8.8	7.8	12.5	14.6	17.4
California	11.5	9.0	9.4	11.1	12.0
Hawaii	10.6	8.5	7.7	9.1	10.2
Nevada	5.9	4.5	5.5	9.5	9.2
Oregon	7.9	6.8	8.9	11.2	11.9
Washington	9.9	9.1	11.3	13.6	14.3

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Highlights

• The GSP measures the value of goods and services produced in each State. Nationwide, health care expenditures in 1992² represented 12.1 percent of total GSP, up from 8.1 percent in 1980. By State, 1992 health spending ranged from 15.7 percent of GSP in West Virginia to 5.7 percent in Alaska.

• Health spending's share of GSP increased most rapidly in Louisiana and West Virginia. In these States, the GSP share rose 7.0 percentage points or more between 1980 and 1992, compared with 4.1 percentage points nationwide during the same period.

• U.S. PHCE per capita grew 9.3 percent annually between 1980 and 1992. The fastest growth occurred in the Southeast, where spending increased at a 10.1-percent annual rate; the slowest growth occurred in the Far West, where spending increased at an 8.2-percent annual rate.

• New England led the Nation in health spending per capita: In 1993, New England's PHCE spending averaged $3,585, 19 percent higher than the U.S. average. As it has since 1980, the Rocky Mountains continued to spend the lowest amounts per capita: PHCE spending amounted to $2,497 per capita in 1993,17 percent below the U.S. average.

• The Medicare and Medicaid programs funded more than one-third of all PHCE in 1993. By State, funding of health care by these two programs ranged from 44.6 percent in New York to 23.8 percent in Alaska.

Personal Health Care

PHCE in the United States reached $778.5 billion in 1993, growing at an average annual rate of 10.3 percent since 1980. PHCE measures spending on therapeutic goods or services rendered to treat or prevent a specific disease or condition in a specific person (Lazenby et al., 1992). In 1993, Americans spent an average of $3,020 on PHCE per person, more than three times the $953 per person spent in 1980 (Table 1). During this period, spending per capita in the Southeast grew the fastest, averaging 10.1 percent annually. The Far West region, maintaining the highest concentration of health maintenance organization (HMO) enrollees in the Nation, experienced the slowest growth in PHCE per capita (8.2 percent annually).

Table 1. Personal Health Care Expenditures per Capita and Average Annual Percent Growth, by Region: Selected Calendar Years 1980-93.

Region of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
United States	$953	$1,577	$2,439	$2,852	$3,020	9.3
New England	1,035	1,743	2,896	3,365	3,585	10.0
Mideast	1,050	1,778	2,818	3,310	3,523	9.8
Great Lakes	964	1,574	2,375	2,777	2,939	9.0
Plains	964	1,573	2,387	2,765	2,918	8.9
Southeast	825	1,418	2,297	2,715	2,875	10.1
Southwest	870	1,408	2,163	2,551	2,699	9.1
Rocky Mountains	815	1,347	2,048	2,377	2,497	9.0
Far West	1,065	1,693	2,421	2,799	2,956	8.2

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

New England led the Nation in the level of health spending per capita: In 1993, New England's PHCE spending averaged $3,585 (Figure 1), 19 percent higher than the U.S. average. Per capita health spending in New England, the Mideast, and the Southeast grew faster than the nationwide per capita from 1980 to 1993. Per capita PHCE in all other regions grew more slowly than the U.S. average, and their per capita spending relative to the U.S. average fell. As it has since 1980, the Rocky Mountains continued to spend the lowest amounts per capita: PHCE spending in 1993 amounted to $2,497 per capita, 17 percent below the U.S. average.

Figure 1. Per Capita Personal Health Care Expenditures, by Region of Provider:¹ 1993.

¹ United States per capita equals $3,020.

SOURCE: Health Care Financing Administration, Office of the Actuary: Data from the Office of National Health Statistics.

Nationwide, the distribution of services among PHCE categories shifted significantly between 1980 and 1993. While hospital care remained the single largest component of PHCE, its prominence declined from 46.9 percent in 1980 to 41.6 percent in 1993. Most of this decline, concentrated in the 1983-88 period, resulted from the implementation of the Medicare prospective payment system (PPS) and the tightening of admission and length-of-stay guidelines by private health insurers. These public and private sector actions were aimed at reducing the growth of hospital spending. Larger PHCE shares for physician, other professional, and home health services offset most of the decline in hospital share. By region and State, the largest declines in hospital share of PHCE occurred in New England and the States of Massachusetts, Rhode Island, and Maryland. Massachusetts, with 54.8 percent of PHCE for hospital care, spent the highest proportion of any State on hospital care in 1980; by 1993, that share had fallen more than any other State's share to 42.8 percent. Almost no change in hospital share occurred in Montana, Alaska, South Dakota, Texas, or South Carolina, while the hospital share of PHCE increased in three States (Arkansas, Idaho, and Hawaii).

Medicare and Medicaid funded more than one-third of all PHCE in 1993, up from 28.2 percent in 1980. By State, funding for health care by these two programs ranged from 44.6 percent in New York to 23.8 percent in Alaska.

One way of measuring the importance of health spending on a State's economy is as a share of GSP GSP measures the market value of goods and services produced by the labor and property located within a State (Beemiller and Dunbar, 1994). SHEA measure the value of output for the health care industry. In 1992 (the latest year for which GSP is available), health care accounted for 12.1 percent of GSP nationwide, up from 8.1 percent in 1980. In West Virginia, the health care sector represented 15.7 percent of the 1992 GSP; in Florida, 15.6 percent (Table 2). In contrast, Alaska consumed 5.7 percent of its output in health care.

Table 2. Personal Health Care Expenditures, by Region and State as a Percent of Gross State Product: Selected Calendar Years 1980-92¹.

Region and State of Provider	1980	1985	1990	1992
	Percent
United States	8.1	9.3	11.0	12.1
New England	9.1	9.7	11.7	12.9
Connecticut	7.8	8.5	10.6	11.7
Maine	9.2	10.2	11.7	13.3
Massachusetts	9.9	10.2	12.4	13.6
New Hampshire	7.7	8.3	10.7	12.2
Rhode Island	10.2	11.6	13.2	14.7
Vermont	8.3	9.1	10.5	11.8
Mideast	8.7	9.8	11.4	12.5
Delaware	7.6	8.4	8.7	8.8
District of Columbia	7.8	8.9	9.6	9.9
Maryland	9.0	9.5	10.8	12.2
New Jersey	7.2	8.1	9.6	10.7
New York	9.1	9.7	11.5	12.6
Pennsylvania	9.1	11.7	13.3	14.5
Great Lakes	8.3	9.6	11.2	12.2
Illinois	8.1	9.1	10.1	11.2
Indiana	7.8	9.4	11.3	12.5
Michigan	9.1	9.7	11.7	12.5
Ohio	8.2	10.2	12.0	13.0
Wisconsin	8.3	9.5	11.4	12.4
Plains	8.5	9.8	11.5	12.3
Iowa	7.7	9.4	11.0	11.7
Kansas	8.1	8.9	10.7	11.7
Minnesota	8.6	10.1	11.5	12.1
Missouri	9.2	10.4	12.2	13.3
Nebraska	8.3	9.0	10.3	11.1
North Dakota	8.3	10.6	13.5	14.7
South Dakota	8.8	9.9	11.6	12.0
Southeast	8.1	9.6	11.8	12.9
Alabama	8.9	10.4	13.0	14.4
Arkansas	8.8	10.4	12.6	13.1
Florida	10.2	12.2	14.4	15.6
Georgia	8.2	8.8	11.2	12.1
Kentucky	7.4	9.4	11.7	12.9
Louisiana	5.5	7.7	10.8	12.5
Mississippi	8.0	9.6	11.9	12.8
North Carolina	7.1	7.7	9.7	10.6
South Carolina	7.7	8.8	10.5	12.0
Tennessee	9.0	10.6	12.8	13.9
Virginia	7.5	8.3	9.4	10.2
West Virginia	8.5	11.3	13.9	15.7
Southwest	6.3	7.8	10.3	11.5
Arizona	8.3	10.0	12.5	13.4
New Mexico	5.6	7.8	10.7	11.2
Oklahoma	6.8	8.5	11.0	12.5
Texas	6.1	7.3	9.8	11.1
Rocky Mountains	6.5	8.1	10.1	10.8
Colorado	7.3	8.8	10.6	11.3
Idaho	6.4	8.1	9.1	10.0
Montana	6.7	9.5	12.0	12.7
Utah	6.9	8.1	10.3	10.8
Wyoming	3.1	4.4	6.3	7.0
Far West	7.9	8.9	9.7	11.0
Alaska	2.9	3.4	4.5	5.7
California	8.3	9.1	9.8	11.2
Hawaii	7.4	9.3	9.4	9.8
Nevada	7.1	8.4	8.7	9.4
Oregon	7.8	9.7	10.9	11.7
Washington	7.5	9.3	10.0	11.0

¹Latest year for which gross State product is available.

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

A State's share of GSP devoted to health care is influenced by the age distribution of its population. People 65 years of age or over consume four times as much health care as those under 65 years of age (Waldo et al., 1989). In both West Virginia and Florida in 1993,15.3 percent or more of the population was 65 years of age or over (Table 3), compared with 12.7 percent nationwide. In Alaska, only 4.5 percent of the population is elderly.

Table 3. Total Population and Population 65 Years of Age or Over, by Region and State: July 1,1980 and July 1,1993.

Region and State	Total Population			65 Years of Age or Over			65 Years of as a Age or Over Percent of Total
	1980	1993	Average Annual percent Growth 1980-93	1980	1993	Average Annual Percent Growth 1980-93	1980	1993
	Thousands			Thousands
United States	227,225	257,783	1.0	25,707	32,773	1.9	11.3	12.7
New England	12,372	13,235	0.5	1,529	1,833	1.4	12.4	13.9
Connecticut	3,113	3,278	0.4	368	461	1.8	11.8	14.1
Maine	1,127	1,240	0.7	142	171	1.5	12.6	13.8
Massachusetts	5,746	6,018	0.4	730	843	1.1	12.7	14.0
New Hampshire	924	1,124	1.5	104	134	2.0	11.2	11.9
Rhode Island	949	1,000	0.4	128	155	1.5	13.4	15.5
Vermont	513	576	0.9	58	70	1.4	11.4	12.1
Mideast	42,272	44,278	0.4	5,104	6,076	1.4	12.1	13.7
Delaware	595	698	1.2	60	87	3.0	10.0	12.5
District of Columbia	638	579	-0.7	74	77	0.3	11.6	13.3
Maryland	4,228	4,958	1.2	399	551	2.5	9.4	11.1
New Jersey	7,376	7,859	0.5	865	1,069	1.6	11.7	13.6
New York	17,567	18,153	0.3	2,166	2,389	0.8	12.3	13.2
Pennsylvania	11,868	12,030	0.1	1,540	1,903	1.6	13.0	15.8
Great Lakes	41,694	42,956	0.2	4,520	5,522	1.6	10.8	12.9
Illinois	11,435	11,686	0.2	1,268	1,475	1.2	11.1	12.6
Indiana	5,491	5,706	0.3	589	728	1.6	10.7	12.8
Michigan	9,256	9,460	0.2	918	1,167	1.9	9.9	12.3
Ohio	10,801	11,061	0.2	1,176	1,476	1.8	10.9	13.3
Wisconsin	4,712	5,044	0.5	568	677	1.4	12.0	13.4
Plains	17,208	18,082	0.4	2,209	2,525	1.0	12.8	14.0
Iowa	2,914	2,821	-0.2	389	436	0.9	13.4	15.5
Kansas	2,369	2,535	0.5	308	352	1.1	13.0	13.9
Minnesota	4,085	4,524	0.8	482	568	1.3	11.8	12.6
Missouri	4,922	5,235	0.5	650	741	1.0	13.2	14.2
Nebraska	1,572	1,613	0.2	207	229	0.8	13.1	14.2
North Dakota	654	637	-0.2	81	94	1.1	12.4	14.7
South Dakota	691	716	0.3	91	105	1.1	13.2	14.7
Southeast	52,881	61,927	1.2	6,255	8,369	2.3	11.8	13.5
Alabama	3,900	4,181	0.5	442	546	1.6	11.3	13.1
Arkansas	2,289	2,426	0.4	314	361	1.1	13.7	14.9
Florida	9,840	13,726	2.6	1,704	2,526	3.1	17.3	18.4
Georgia	5,486	6,902	1.8	520	698	2.3	9.5	10.1
Kentucky	3,664	3,794	0.3	412	484	1.3	11.2	12.8
Louisiana	4,223	4,290	0.1	406	489	1.4	9.6	11.4
Mississippi	2,525	2,640	0.3	290	330	1.0	11.5	12.5
North Carolina	5,899	6,952	1.3	608	867	2.8	10.3	12.5
South Carolina	3,135	3,630	1.1	290	427	3.0	9.2	11.8
Tennessee	4,600	5,094	0.8	520	651	1.7	11.3	12.8
Virginia	5,368	6,473	1.4	509	712	2.6	9.5	11.0
West Virginia	1,951	1,818	-0.5	239	278	1.2	12.2	15.3
Southwest	21,426	26,815	1.7	2,186	2,985	2.4	10.2	11.1
Arizona	2,738	3,945	2.8	311	532	4.2	11.4	13.5
New Mexico	1,309	1,616	1.6	117	178	3.3	8.9	11.0
Oklahoma	3,041	3,233	0.5	378	440	1.2	12.4	13.6
Texas	14,338	18,022	1.8	1,379	1,836	2.2	9.6	10.2
Rocky Mountains	6,592	7,834	1.3	577	817	2.7	8.8	10.4
Colorado	2,909	3,564	1.6	249	359	2.8	8.6	10.1
Idaho	948	1,100	1.2	95	130	2.5	10.0	11.8
Montana	789	841	0.5	85	112	2.1	10.8	13.4
Utah	1,473	1,860	1.8	110	164	3.1	7.5	8.8
Wyoming	474	470	-0.1	37	51	2.5	7.9	10.9
Far West	32,780	42,656	2.0	3,329	4,646	2.6	10.2	10.9
Alaska	405	598	3.0	12	27	6.5	2.9	4.5
California	23,801	31,217	2.1	2,432	3,299	2.4	10.2	10.6
Hawaii	968	1,166	1.4	77	138	4.6	8.0	11.8
Nevada	810	1,382	4.2	67	156	6.7	8.3	11.3
Oregon	2,641	3,035	1.1	306	417	2.4	11.6	13.7
Washington	4,155	5,259	1.8	435	610	2.6	10.5	11.6

SOURCE: ( U.S. Bureau of the Census, 1994).

Hospital Care

Americans spent $323.9 billion for hospital care in 1993, accounting for 41.6 percent of PHCE. These expenditures paid for all hospital-based services provided to patients and billed by the hospital. The annual rate of growth in total hospital expenditures decelerated for the third straight year in 1993 because of more rigorous hospital reviews and shorter lengths of stay encouraged by most third-party payers. Annual growth in spending during the 1980-93 period averaged 9.4 percent; the growth rates in both 1992 (8.4 percent) and 1993 (6.7 percent) fell below this 13-year average.

The five States exhibiting the highest average annual growth rate in hospital expenditures for 1980-93 were New Hampshire, South Carolina, New Mexico, Hawaii, and Georgia. Higher-than-average demand for hospital services in these States paralleled their higher-than-average population growth, while high demand for hospital services in Georgia and Hawaii also corresponded to growth in the number of community hospital inpatient days (American Hospital Association, 1993). Four States exhibited annual expenditure growth under 8 percent for this 13-year period: Iowa, Kansas, Michigan, and Illinois. Population growth in these States was one-half or less than the overall U.S. rate; both community hospital admissions and inpatient days showed declines greater than the overall U.S. rate (American Hospital Association, 1993).

In 1993, 88 percent of all hospital care expenditures in the United States was spent in short-term, acute-care community hospitals. Regionally, this share varied from 85.1 percent in the Southwest to 92.4 percent in the Great Lakes. In Alaska, a large number of Federal hospitals deliver care to the Native American and defense communities. This State recorded the smallest percentage of hospital care expenditures in community hospitals (61.8 percent) of any State.

Five States accounted for more than one-third (37.4 percent) of total spending for hospital care in 1993: California, New York, Texas, Pennsylvania, and Florida. Not surprisingly, these States also boasted the highest resident population counts. From a regional perspective, two regions, the Mideast and the Southeast, accounted for 44.2 percent of total hospital expenditures in 1993. The share of total hospital expenditures held by 6 of the 8 regions has remained relatively constant over the last 13 years. However, the share of hospital spending in the Great Lakes region, driven by the decline in the share of spending in Illinois, dropped from 19.3 percent in 1980 to 16.7 percent in 1993. More than offsetting this decline, the share of spending in the Southeast region rose from 20.3 percent in 1980 to 23.4 percent in 1993, driven by share increases in Florida, Georgia, and North Carolina. Slow population growth contributed to the decline in share of total hospital expenditures in the Great Lakes region, as stronger-than-average population growth contributed to an increased share of spending in the Southeast.

In 1993, the level of regional hospital spending per capita varied significantly across the Nation. Spending per capita for hospital care in New England and the Mideast averaged, respectively, 15 and 21 percent more than the U.S. per capita (Table 4). The Great Lakes, Plains, and Southeast regions each showed per capita spending levels approximately equal to the U.S. average. In the Southwest, Rocky Mountains, and Far West, the regional per capita expenditures dropped below the U.S. average by 9 to 20 percent.

Table 4. Regional per Capita Personal Health Care Expenditures as a Percent of U.S. Spending: Calendar Years 1980 and 1993.

Region of Provider	Total	Hospital Care	Physician Services	Dental Services	Other Professional Services	Home Health Care	Drugs and Other Medical Non-Durables	Vision Products and Other Medical Durables	Nursing Home Care	Other Personal Health Care
					Percent
1980
United States	100	100	100	100	100	100	100	100	100	100
New England	109	117	84	104	101	135	93	84	146	128
Mideast	110	114	93	101	97	203	95	110	147	125
Great Lakes	101	105	97	101	101	75	98	99	98	92
Plains	101	102	96	91	105	64	94	110	136	81
Southeast	87	87	90	78	81	74	102	84	67	91
Southwest	91	86	102	84	91	62	108	116	76	89
Rocky Mountains	86	79	90	101	93	58	90	114	79	124
Far West	112	102	138	147	137	81	110	102	79	95
1993
United States	100	100	100	100	100	100	100	100	100	100
New England	119	115	105	119	119	132	106	94	172	179
Mideast	117	121	102	108	113	139	102	115	150	114
Great Lakes	97	100	92	96	91	73	98	100	114	79
Plains	97	98	91	90	91	72	90	103	126	96
Southeast	95	97	92	83	93	128	105	91	79	96
Southwest	89	91	88	81	97	93	97	99	67	101
Rocky Mountains	83	80	84	106	86	60	85	112	68	112
Far West	98	87	130	129	108	60	99	97	59	88

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

From 1980 to 1993, most regions exhibited only small changes in their per capita spending for hospital care relative to the U.S. average. For the Southeast and Far West, however, spending relative to the U.S. average changed dramatically. In the Southeast in 1980, spending per capita was 13 percent below the U.S. average; by 1993, spending per capita had moved to within 3 percentage points of the U.S. average. In the Far West in 1980, hospital spending per capita approximated the national average (102 percent); by 1993, spending had plunged to 13 percent below the U.S. average. This region maintains the highest penetration of HMO enrollees (29.3 percent) (InterStudy, 1991-95) and the highest percentage of the population receiving Medicaid services (14.2 percent) which account, in part, for smaller spending shares in the hospital sector.

Physician Services

From 1980 to 1993, expenditures for physician services in the United States averaged an annual growth of 10.8 percent. These expenditures totaled $171.2 billion and accounted for 22.0 percent of PHCE in 1993. These expenditures include care provided in offices and clinics of physicians, care provided and billed by physicians for hospital visits, services provided at ambulatory surgical centers, and independent medical laboratory costs. These expenditures also cover spending for physician services provided through HMOs, specifically including all services provided at staff-model HMOs.³ Professional fees received by physicians from hospitals are excluded from physician expenditures; these fees are paid from hospital revenues and are included with hospital estimates.

Many different factors influence growth in physician expenditures, including changes in population and its distribution by age and disability status, physician concentrations, personal income per capita, managed-care penetration, physician practice patterns, and type of insurance coverage (or lack thereof). The States with the fastest annual growth rates in physician expenditures during 1980-93 were New Hampshire (14.8 percent) and Nevada (13.1 percent). The slowest growing States included Wyoming, Michigan, Iowa, Montana, the District of Columbia, West Virginia, and Nebraska, each with average annual growth rates below 9.0 percent.

New England, the region with the fastest average annual growth, moved in rank from the lowest per capita physician spending region in 1980 to the second highest in 1993, as the region substituted physician services for more expensive hospitalizations. Per capita personal income growth (U.S. Bureau of Economic Analysis, 1994) and growth in physicians per 100,000 residents (Table 5) in New England were the highest in the United States during this period. The Great Lakes showed the slowest growth (9.5 percent) in spending per capita for physician services. This region also experienced the slowest regional growth in population in the United States, but maintained near average growth in per capita personal income, physicians per 100,000 residents, and per capita PHCE. The level of physician spending per capita ranged from 84 percent of the U.S. average in the Rocky Mountains to 130 percent in the Far West (Table 4). The Far West region maintained the highest per capita spending for physician services for the entire 13-year period. Higher-than-average physician expenditures per capita in the Far West region in 1993 have been offset by lower per capita spending in other components of spending, such as hospital, nursing home, and home health care. While the penetration of HMOs⁴ influenced the choice of services in the Far West in 1993, PHCE per capita for the Far West amounted to $2,956, just below the U.S. average in 1993.

Table 5. Physicians¹ per 100,000 Residents and Average Annual Percent Growth: Calendar Years 1980 and 1993.

Region	1980	1993	Average Annual Percent Growth 1980-93
United States	124	164	2.2
New England	146	206	2.7
Mideast	140	198	2.7
Great Lakes	116	156	2.3
Plains	113	151	2.3
Southeast	104	147	2.6
Southwest	112	141	1.8
Rocky Mountains	120	153	1.9
Far West	151	175	1.1

¹Includes non-Federal office-based physicians practicing in the United States (excluding the Pacific Islands, Virgin Islands, and Puerto Rico) and active non-Federal doctors of osteopathy.

SOURCES: Data from the American Medical Association and the American Osteopathic Associations; Estimates prepared by the Office of National Health Statistics, Health Care Financing Administration.

HMOs are growing rapidly, asserting more influence on physician expenditures. In 1993, 16.3 percent of the U.S. population—42 million individuals—were enrolled in HMOs (Figure 2), up from 4.0 percent in 1980. As more individuals have enrolled in HMOs, the mix of services delivered has changed. HMOs are perceived as controlling costs by negotiating favorable payment rates with health care providers, reducing hospital visits and lengths of stays, limiting access to specialized services, and emphasizing preventive care.

Figure 2. HMO Enrollment as a Percent of Population, by Region: 1980-93.

During this same period, many physicians in private practice have entered into agreements with managed-care plans, such as group-model HMOs, individual practice associations (IPAs), and preferred provider organizations (PPOs). In 1988,61 percent of physicians in practice had a managed-care contract; by 1993 this number had grown to 75 percent (Emmons and Simon, 1994). In 1993, the regions with the greatest managed-care participation rates by physicians were the Far West and the Great Lakes, both with 82 percent. The Far West region also had the highest percentage of the population enrolled in HMOs throughout the 1980-93 period (29.3 percent in 1993). This region, which includes California, was a front runner of the HMO movement and had a large percentage of the population enrolled in HMOs before the 1980s (InterStudy, 1991). In contrast, the Southeast had the lowest penetration of HMO enrollment per population in 1993 (7.6 percent). This region also experienced the highest growth in enrollment, increasing at an average annual rate of 23.4 percent between 1980 and 1993.

Dental Services

Expenditures for dental services grew from $13.3 billion in 1980 to $37.4 billion in 1993, increasing at an 8.3-percent average annual rate. This rate of growth made this component the slowest growing medical care category in PHCE. In 1980, spending for dental services was 6.2 percent of PHCE nationwide; by 1993, this share had dropped to 4.8 percent.

Six States exhibited double-digit average annual growth rates throughout the 1980-93 period: Alaska, New Hampshire, Maine, Utah, Florida, and Nevada. Three States showed average annual growth rates below 7 percent: Michigan, Iowa, and Montana. With the exception of Maine, States experiencing double-digit growth in dental spending were growing more rapidly in population than the United States overall for the 1980-93 period; similarly, population growth in the slowest growing dental spending States was minimal or negative.

By region, dental spending per capita in the Far West, New England, Mideast, and Rocky Mountains ranged from 6 to 29 percent above the U.S. average in 1993. In the Great Lakes, Plains, Southeast, and Southwest, spending per capita fell below the U.S. average by 4 to 19 percent. These spending differentials paralleled differences in personal income per capita, except in the Rocky Mountain region, where personal income per capita was 92 percent of the U.S. per capita. These spending differentials also paralleled the differences in the concentration of dentists (American Dental Association, 1993) by region, except in the Great Lakes, where the concentration was at the U.S. level.

Other Professional Services

Other professional services collectively represent the second fastest growing component of PHCE, averaging 17.4 percent growth for the period 1980-93. This segment reached $51.2 billion in 1993, accounting for 6.6 percent of PHCE. Other professional services expenditures include spending for services provided in offices and clinics of licensed other professionals such as chiropractors, optometrists, and podiatrists. Additionally, spending in kidney dialysis clinics, alcohol treatment centers, rehabilitation clinics, and other specialty clinics and other health care establishments not elsewhere classified are included with other professional services. Medicare ambulance expenditures are also included in this category.

The regions with the fastest growth were the Southeast and Southwest, both with average annual growth of 18.9 percent. Slowest growing regions included the Plains and Great Lakes. In 1993, per capita spending was 19 percent higher than the U.S. average in New England and 14 percent lower in the Rocky Mountains (Table 4). The Far West region showed the most change in per capita spending, dropping from 37 percent to 8 percent above the U.S. average from 1980 to 1993.

Nevada had the highest growth in expenditures for other professional services for the 1980-93 period (21.3 percent). Similar to the trend shown in physician expenditures, population increases drove the exceptionally high growth in other professional expenditures in Nevada. Other States with high growth included Delaware, Georgia, Maryland, and North Carolina. The lowest average annual growth rates (15.0 percent or less) in the United States were found in Iowa, Idaho, Wyoming, North Dakota, and Minnesota.

Home Health Care

Home health care expenditures totaled $23.0 billion in 1993, 3.0 percent of all PHCE. Although the smallest component of PHCE in 1980, home health care did not retain this rank for long: It grew faster than any other personal health spending category since 1980, averaging increases of 19.1 percent annually.

Expenditures for home health care in SHEA cover spending for services and products provided by public and private freestanding home health agencies. These agencies may be certified to participate in either Medicare and/or Medicaid, or certified in neither program. Agencies delivering Medicaid-funded personal-care services in the home are also counted here. Personal-care services under Medicaid can cover a broader range of services in the home and be delivered by a wider range of qualified persons than those narrowly specified under Medicare and Medicaid as home health benefits. Expenditures for home health services that are delivered through hospital-based agencies are excluded from the SHEA category of home health care; expenditures for those services are counted with hospital expenditures.

Several factors coalesced to boost the demand for home health services in the 1980-93 period. Home health care use is concentrated in the elderly population. This population cohort increased in size at a faster rate than the overall population, rising from 11 percent of total population in 1980 to 13 percent in 1993. Medicare pays for a high percentage of health care expenditures for this burgeoning population group. During this period, major changes to Medicare stimulated the use of home health services by the elderly. In the early 1980s, the 3-day prior hospitalization requirement and the 100-visit limit were dropped. This period also saw the expansion in the availability of health care technologies deliverable in the home. In the mid-1980s, introduction of the hospital PPS encouraged physicians to discharge hospitalized beneficiaries sooner, and researchers theorized that patients would require more frequent followup care in the home. Higher utilization did not initially materialize due to certain administrative and regulatory changes that occurred during the mid-1980s (Helbing, Sangl, and Silverman, 1993). The most important factor, however, occurred in the late 1980s: The coverage rules that had been the basis for intermediaries' denial of beneficiaries' coverage for home health services were clarified to broaden and more uniformly interpret the “part-time and intermittent” care requirement for coverage (Vladeck and Miller, 1994).

These changes encouraged more uniform spending on behalf of the elderly for home health services across States, although spending for home health services in rural States remained lower than the U.S. average. In the Mideast, where the provision of home health services was already well-established and expenditures per aged person greatly exceeded the U.S. average (Table 6), spending on home health services grew more slowly than the U.S. average—13.4 percent annually. In contrast, spending per aged person in the Southeast was lower than the U.S. average in 1980, but spending grew at an average annual rate of 21.7 percent to boost spending per aged person above the U.S. average by 1993. In predominantly rural regions such as the Rocky Mountains and Plains, however, development of the home health care market proceeded more slowly; spending per aged person remained well below the U.S. average and grew at only average rates throughout the 1980-93 period. Researchers speculate that the concentration of home health users (predominantly the elderly) in rural areas is not dense enough to support financially viable home health providers. Longer travel times to deliver services in rural areas may increase costs above reimbursement levels (Kenney, 1993).

Table 6. Regional Home Health Care and Nursing Home Care Expenditures per Aged Person as a Percent of U.S. Spending per Aged Person: Calendar Years 1980 and 1993.

Region	Home Health Care	Nursing Home Care
	Percent
1980
United States	100	100
New England	124	134
Mideast	190	138
Great Lakes	78	103
Plains	56	120
Southeast	71	64
Southwest	69	84
Rocky Mountains	75	103
Far West	90	88
1993
United States	100	100
New England	121	158
Mideast	129	139
Great Lakes	72	112
Plains	65	115
Southeast	120	74
Southwest	107	77
Rocky Mountains	74	83
Far West	71	69

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Together, home health care and nursing home services provide long-term care for patients who need continuing care in less acute care settings (e.g., persons recently discharged from the hospital). Depending on the intensity of care, availability of other home care givers, availability of nursing home beds and home health providers, and social norms of an area, choices are made by the consumer between these two long-term care services. The substitution of home health services for nursing home care by patients can be seen in long-term spending patterns across States and regions. Nationwide in 1993, one-quarter of long-term care services purchased from freestanding home health agencies and freestanding nursing homes⁵ were for home health services. In the Southeast and Southwest, these data show that patients have a higher preference for care delivered in the home: At least one-third of long-term care was purchased from freestanding home health agencies. In rural Plains States where elderly population density is low, only 16.5 percent of long-term care services are delivered by freestanding home health agencies.

The two largest payers of home health services are Medicare and Medicaid. Together these two programs paid for 39.4 percent of home health services nationwide in 1980, rising to 48.7 percent in 1993. In 1993, funding by these programs ranged from 34.6 percent of services in the Plains (where spending on home health services per elderly person is the lowest in the Nation) to 63.9 percent of home health services in New England (where home health spending per elderly person exceeded the U.S. average).

Over 50 percent of all U.S. Medicaid spending on home health care was spent under New York's Medicaid program in 1993, down from 60 percent in 1980. Approximately three-fourths of New York's $1.6 billion expenditures on home health care in 1993 was delivered as personal-care services.

Drugs and Other Medical Non-Durables

This category represents expenditures for prescription and over-the-counter drugs and sundries. This class of expenditure is limited to spending that occurs in retail outlets such as food stores, drug stores, HMO pharmacies, or through mailorder pharmacies. In 1993, it represented 9.6 percent of PHCE nationwide.

Expenditures for non-durable medical products reached $75.0 billion in 1993. Regional spending per capita for nondurable medical products clustered closely around the U.S. average, ranging from 97 percent of the U.S. per capita in the Southwest to 106 percent in New England. In two regions, the Plains and Rocky Mountains, however, spending per capita on non-durable medical products was 10 or more percent below the U.S. average. Similar expenditure patterns existed in physician services, suggesting that lower utilization of physician services may result in fewer prescriptions being written and filled.

Like per capita spending levels, aggregate spending growth between 1980-93 varied little among regions: New England grew the fastest at 10.6 percent average annual rate while growth in the Plains was the slowest at 9.1 percent average annual rate. Nevada and Florida led the nation in spending growth for non-durable products, with average annual rates of 12.6 percent and 12.1 percent, respectively.

Two-thirds of spending for non-durable medical products went for the purchase of prescription drugs in 1993. The largest amounts spent on prescription drugs occurred in California, New York, Texas, and Florida. States with the fastest average annual prescription drug spending growth for the entire 1980-93 period included Nevada at 15.8 percent, Utah at 14.2 percent, Arizona at 14.7 percent, and Florida at 13.7 percent. Three of these States—Arizona, Nevada, and Florida—experienced some of the fastest growth in total and elderly population in the Nation. Growth in expenditures in these States stemmed, in part, from the large growth in the population 65 years of age or over: In these States, the average annual rate of growth among the elderly population increased from 3.1 to 6.7 percent between 1980-93, compared with 1.9 percent for the Nation. Although the average cost per prescription shows little variation between age categories, the absolute number of prescriptions dispensed was much greater for persons 65 years of age or over, magnifying the effect of large elderly population growth on increases in drug spending.

Vision Products and Other Medical Durables

Expenditures for vision products and other durable medical equipment (DME) cover items such as eyeglasses, hearing aids, surgical appliances and supplies, bulk and cylinder oxygen, and medical equipment rentals. At $12.6 billion in 1993, it is the smallest PHCE category, amounting to 1.6 percent of all spending.

Expenditures for DME in 1993 were largest for the States of California, New York, Texas, and Florida. These States also have a large number of residents over 65 years of age. Florida, ranking fourth in total expenditures, has 2.5 million residents over 65 years of age, representing 18.4 percent of that State's total population. States with low concentrations of those over 65 years of age and small total populations, such as Wyoming and Vermont, contributed the least to total expenditures for DME.

Expenditure growth slowed from 1990-93 for all States, reflecting the overall rate of growth evident in national expenditure estimates. The Southeast experienced the fastest rate of DME expenditure growth of all regions, with rates as high as 11.1 percent in 1990. During the 1980-93 period, however, three out of four States with the highest rate of expenditure growth (Nevada, Hawaii, and Washington) are found in the Far West.

Nursing Home Care

Expenditures for nursing home care are the fourth largest category of spending in SHEA In 1993, spending for nursing home care totaled $66.2 billion, 8.5 percent of all PHCE. These expenditures grew at an average annual rate of 10.7 percent between 1980 and 1993.

Spending for nursing home care covers care provided in freestanding nursing and personal-care facilities. Providers include Medicare- and Medicaid-certified skilled nursing and intermediate care facilities as well as facilities that are not certified. Expenditures for care in facilities that are hospital-based are excluded from this category of spending; such expenditures are captured under hospital care spending.

Average annual growth in regional spending for nursing home care for the 1980-93 period ranged from a high of 12.4 percent in the Southeast region to a low of 9.4 percent in the Plains and the Far West. This trend in the Southeast region is not surprising because the Southeast had faster-than-average growth among the aged population. This population cohort is the most likely to require nursing home care.

Average per capita nursing home expenditures for the 65 years of age or over population were $2,020 in 1993. Regionally, the New England, Mideast, Plains, and Great Lakes regions experienced nursing home care spending per aged person that ranged from 12 to 58 percent higher than the U.S. average. In contrast, spending in the Far West, Southeast, Southwest, and Rocky Mountains ranged from 17 to 31 percent below the U.S. average (Table 6).

Nationwide, nursing home expenditures per aged person increased 8.7 percent annually from 1980 to 1993. Spending in New England, the Southeast, and the Great Lakes, all high-cost regions, grew faster than the United States overall. Spending in the Southwest, Rocky Mountains, and Far West, all low-cost regions, grew slower than the U.S. average. Only the Mideast region grew at about the same rate as the U.S. overall.

Factors that affect regional differences in spending and rates of growth for nursing home care are similar to those for other components of health care spending. The number of people 65 years of age or over, the aged share of the population, health status, and per capita personal income or wealth of the populations influence the demand for nursing home care. Also, traditional societal values may affect the choice of long-term care treatment settings for the disabled elderly, favoring either nursing home care or home health care. Constraints on the supply of nursing home care include nursing home resource costs (Prospective Payment Assessment Commission, 1995) and the availability of beds (Harrington, Swan, and Grant, 1988; Harrington and Estes, 1994). States can control the growth in nursing home bed supply through certificate-of-need programs. By restraining the growth in bed supply, States can constrain their rapidly growing Medicaid spending for nursing home care. Nationwide, Medicaid funded 49.0 percent of nursing home care in 1993; the low Medicare share, at 6.5 percent in 1993, reflected the more stringent requirements for covered services.

Nursing home expenditures in SHEA do not capture all nursing home-type spending. Not only are hospital-based nursing homes excluded, but so are expenditures for nursing care provided in swing beds of acute-care facilities. In addition, long-term care facilities specifically for Alzheimer's patients are out of scope in SHEA because these patients predominantly require custodial rather than medical care.

Other Personal Health Care

Other personal health care (OPHC) expenditures increased from $4.0 billion in 1980 to $18.0 billion in 1993, an annual rate of 12.4 percent OPHC spending amounted to 2.3 percent of PHCE in 1993. Expenditures for OPHC cover spending for publicly and privately funded health care that is not provided through health care establishments and is therefore not captured elsewhere in SHEA OPHC services are provided through non-medical locations such as job sites, schools, military field-stations, or community centers where delivery of medical services is incidental to the function of the site. For the Nation, Medicaid accounted for about 11 percent of OPHC total in 1980, increasing to 45 percent by 1993. The unusually rapid growth in Medicaid OPHC spending stemmed from the introduction and expansion of home and community-based waivers and “other” miscellaneous Medicaid services.

The five States exhibiting the highest average annual growth rates (between 15.9 and 21.2 percent) in OPHC spending were Rhode Island, Oregon, New Hampshire, Maine, and Vermont. These high growths can be traced back to large increases in the OPHC Medicaid expenditures that exhibited increases ranging from 28.9 to 47.3 percent annually. The State with the lowest average annual growth in OPHC expenditures was Ohio, at 8.2 percent.

Medicare

Medicare financed $150.4 billion (19.3 percent) of total U.S. PHCE in 1993. Medicare spending increased at an average annual rate of 11.6 percent from 1980 to 1993.

Medicare primarily funds acute-care (hospital and physician) services for aged and disabled enrollees. In 1993, Medicare funded 29.1 percent of the Nation's expenditures for hospital care and 20.2 percent of total spending for physician services, about 3 percent more than was funded in 1980. From 1980 to 1993, Medicare funding of medical durables increased from 9.4 percent to 29.2 percent, non-hospital nursing home care from 1.7 percent to 6.5 percent, and non-hospital home health care from 26.9 percent to 34.9 percent.

The distribution of Medicare expenditures by type of service differed by region. In 1993, hospital care accounted for $94.2 billion (62.7 percent) of the $150.4 billion spent by Medicare for personal health care in the United States. Four of eight regions had shares higher than the U.S. average for hospital care, ranging from 69.1 percent in the Plains to 65.5 percent in the Mideast (Table 7). Two regions had shares that approximated the U.S. average—New England and the Southwest. The Southeast and Far West exhibited shares lower than the U.S. average. In 1993, the Far West and Plains, more than any other regions, deviated from the national distribution of services. In the Far West, the smallest percent of Medicare expenditures of any region went for hospital care (57.8 percent), while the percent spent on physician services (28.5 percent) was the highest of any region. In the Plains, 69.1 percent of all Medicare spending went for hospital care, offset by lower-than-average percentages spent in all other service sectors. The share of Medicare spending for home health was high in both New England (8.1 percent) and the Southeast (7.9 percent).

Table 7. Number of Medicare Enrollees, Medicare Expenditures for Personal Health Care, and Distribution by Type of Service, by Region: Calendar Year 1993.

Region	Number of Enrollees1 (Thousands)	Total Personal Health Care (Millions)	Type of Service
			Hospital Care	Physician Services	Other Professional Services	Home Health Care	Medical Durables	Nursing Home Care
			Percent
United States	35,557	$150,374	62.7	23.0	3.7	5.3	2.5	2.9
New England	1,988	8,829	63.0	19.2	4.1	8.1	1.4	4.2
Mideast	6,520	30,438	65.5	22.9	3.5	3.1	2.8	2.2
Great Lakes	6,071	23,508	65.7	21.1	3.4	4.2	2.4	3.2
Plains	2,738	9,861	69.1	20.8	3.1	2.7	2.2	2.2
Southeast	9,150	38,805	59.5	23.0	4.1	7.9	3.0	2.6
Southwest	3,211	13,271	62.7	21.8	4.1	7.2	2.3	2.0
Rocky Mountains	898	3,104	65.8	19.8	2.7	5.0	2.8	4.0
Far West	4,955	22,558	57.8	28.5	3.7	4.2	1.7	4.1

¹Number of aged and disabled persons enrolled in the Hospital and/or Supplementary Medical Insurance Programs as of July 1,1993, by area of residence. U.S. total includes enrollees with unknown State of residence.

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

By State, the share of total Medicare expenditures attributable to hospital care ranged from 75.4 percent in Alaska to 51.6 percent in Florida. Physician services accounted for 31.4 percent in Hawaii and 16.6 percent in Alaska. Tennessee had the highest share attributable to home health care but almost the lowest shares for hospital care and physician services.

States that were the most costly to the Medicare program were primarily States where the largest number of Medicare enrollees reside. The age and gender composition and health and disability status of this population contributed to regional variation in aggregate and per enrollee expenditures by affecting the volume and intensity of services used (Helbing, Sangl, and Silverman, 1992). However, many other factors contributed to regional differences, such as provider practice patterns, population density, managed-care penetration, and provider resource costs (Prospective Payment Assessment Commission, 1995). Regional variation in provider resource costs are affected in part by differences in area wages and other costs of operating a business (input prices), State dictated specialized training requirements, and regulations designed by States to control the growth in public program medical care spending. The population density of rural contrasted with urban areas may affect the number of providers willing to serve an area.

Per enrollee Medicare PHCE for the United States grew 9.5 percent annually from $1,300 in 1980 to $4,229 in 1993. Regionally, growth in PHCE per enrollee ranged from 10.7 percent in the Southeast to 8.4 percent in the Great Lakes and Plains. Spending levels by region ranged from 10.4 percent above the U.S. average in the Mideast ($4,668 per enrollee) to 18.3 percent below the U.S. average in the Rocky Mountains ($3,456 per enrollee).

Medicaid

Medicaid expenditures amounted to $112.8 billion in 1993, accounting for 14.5 percent of PHCE. Annual growth from 1980-93 averaged 12.5 percent. However, from 1989 to 1992, the growth rates in total Medicaid expenditures exceeded this 13-year average. The largest growth rates (21.3 percent and 25.5 percent) occurred in 1990 and 1991, as a result of the disproportionate share hospital (DSH) program (see Levit et al., 1994 for further information). The annual rate of growth in total Medicaid expenditures decelerated in 1992 and 1993, primarily due to the deceleration in Medicaid hospital expenditures resulting from DSH program caps. Nationally, the Medicaid expenditure growth rate slowed to 8.7 percent in 1993.

The Federal Government defines minimum services that must be provided to all or specified groups of Medicaid recipients in order for States to receive Federal matching funds. States can also receive Federal assistance for funding if they elect to provide other optional services. The minimum services that must be provided are: inpatient and outpatient hospital services; physician care; rural health clinic services; laboratory and X-ray services; nurse practitioners' and nurse-midwife services; nursing home and home health care; early and periodic screening, diagnosis, and treatment; family planning services and supplies; and services of selected other health professionals. As of October 1994, there were 34 different optional services that States could choose to provide. Examples of these optional services include: podiatrists' services; optometrists' services; chiropractors' services; clinic services; physical therapy services; prosthetic devices; prescribed drugs; transportation services; hospice care services; respiratory care services; and tuberculosis-related services. There is considerable variation among States as to the types of optional services provided. The States offering the most optional services were Wisconsin (31), and Illinois, Indiana, and Minnesota (30). Louisiana and Delaware offered only 15 of the 34 optional services. All States offered prescription drug services, and most States offered transportation services and prosthetic devices; however, relatively few States offered respiratory care services and tuberculosis-related services.

The largest shares of total Medicaid expenditures in 1993 were in New York, California, Texas, Pennsylvania, and Florida, together totaling 40 percent of Medicaid spending nationwide. From a regional perspective, two regions, the Mideast and the Southeast, accounted for 47.7 percent of total Medicaid expenditures in 1993. The share of Medicaid spending in the Mideast region declined from 29.1 percent to 26.5 percent from 1980 to 1993, while the share of spending in the Southeast grew from 16.1 percent in 1980 to 21.2 percent in 1993. The remaining regions maintained relatively constant shares of spending during the last 13 years.

The highest Medicaid spending occurred in New York, with expenditures 91 percent higher per recipient than the U.S. average. California maintained very low costs per recipient—32 percent below the U.S. average. Only Mississippi had relative spending per recipient lower than California (Table 8).

Table 8. Medicaid Recipients, Medicaid Cost-per-Recipient Index, and Medicaid Recipients-per-Population Index, by Region and State: 1993.

Region and State	Medicaid Recipients1 (Thousands)	Cost-per-Recipient Index2	Recipients-per-Population Index3
United States	32,664	1.00	1.00
New England	1,618	1.41	0.97
Connecticut	334	1.73	0.80
Maine	169	1.24	1.07
Massachusetts	765	1.40	1.00
New Hampshire	79	1.63	0.56
Rhode Island	191	1.20	1.51
Vermont	81	0.83	1.10
Mideast	5,393	1.60	0.96
Delaware	69	1.05	0.78
District of Columbia	120	1.63	1.64
Maryland	445	1.25	0.71
New Jersey	794	1.41	0.80
New York	2,742	1.91	1.19
Pennsylvania	1,223	1.21	0.80
Great Lakes	5,094	1.03	0.94
Illinois	1,396	0.96	0.94
Indiana	565	1.42	0.78
Michigan	1,172	0.96	0.98
Ohio	1,491	0.91	1.06
Wisconsin	471	1.31	0.74
Plains	1,863	1.04	0.81
Iowa	289	0.96	0.81
Kansas	243	0.92	0.76
Minnesota	425	1.52	0.74
Missouri	609	0.78	0.92
Nebraska	165	0.99	0.81
North Dakota	62	1.25	0.77
South Dakota	70	1.10	0.77
Southeast	8,635	0.80	1.10
Alabama	522	0.71	0.98
Arkansas	339	0.86	1.10
Florida	1,745	0.78	1.00
Georgia	955	0.83	1.09
Kentucky	618	0.79	1.29
Louisiana	751	1.03	1.38
Mississippi	504	0.60	1.51
North Carolina	898	0.83	1.02
South Carolina	470	0.82	1.02
Tennessee	909	0.70	1.41
Virginia	576	0.82	0.70
West Virginia	347	0.90	1.51
Southwest	3,340	0.76	0.98
Arizona	404	0.91	0.81
New Mexico	241	0.69	1.18
Oklahoma	387	0.76	0.94
Texas	2,308	0.74	1.01
Rocky Mountains	664	0.96	0.67
Colorado	281	1.00	0.62
Idaho	100	0.84	0.71
Montana	89	1.05	0.84
Utah	148	0.93	0.63
Wyoming	46	0.86	0.78
Far West	6,056	0.74	1.12
Alaska	65	1.22	0.86
California	4,834	0.68	1.22
Hawaii	110	0.93	0.74
Nevada	88	1.13	0.50
Oregon	325	0.85	0.85
Washington	633	0.99	0.95

¹Data reported on HCFA Form-2082 for fiscal year 1993.

²Calendar year State health expenditures divided by fiscal year recipient counts.

³Fiscal year recipient counts divided by calendar year population counts.

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

The five States exhibiting the highest annual growth rate for total Medicaid expenditures in 1993 were Alaska, Colorado, Georgia, Hawaii, and Oregon. All five States showed growth rates greater than the U.S. recipient growth rate, although none showed unusually high growth in recipients in fiscal year 1993. Four States experienced declines in Medicaid expenditures in 1993: New Hampshire, Missouri, Massachusetts, and Pennsylvania. In Pennsylvania, the decrease in numbers of Medicaid recipients accounted for the slight decrease in expenditures. In New Hampshire, limits on Medicaid DSH payments largely contributed to the decrease in spending: DSH payments accounted for 33 percent of total Medicaid payments in 1991, nearly 60 percent in 1992, and only 8.8 percent in 1993 (Table 9).

Table 9. State Medicaid Payments to Disproportionate Share Hospitals (DSH) as a Share of Total State Medicaid Expenditures and as a Share of Total Medicaid DSH Payments, by Region and State: Calandar Years 1992-93.

Region and State	1992		1993
	State DSH as a Share of State Medicaid Spending	State DSH as a Share of U.S. DSH	State DSH as a Share of State Medicaid Spending	State DSH as a Share of U.S. DSH
	Percent
United States	16.6	100.0	15.4	100.0
New England	19.1	8.9	16.2	7.3
Connecticut	22.2	2.4	21.5	2.5
Maine	21.0	0.8	24.7	1.0
Massachusetts	12.3	2.8	13.8	2.9
New Hampshire	59.9	2.3	8.8	0.2
Rhode island	11.2	0.5	12.9	0.6
Vermont	10.3	0.1	8.4	0.1
Mideast	18.1	29.3	16.7	28.6
Delaware	2.2	0.0	2.2	0.0
District of Columbia	5.6	0.2	7.1	0.3
Maryland	6.3	0.7	4.2	0.5
New Jersey	31.1	6.4	29.6	6.6
New York	17.0	16.3	15.9	16.4
Pennsylvania	19.0	5.7	16.6	4.9
Great Lakes	9.3	9.0	7.4	7.7
Illinois	7.5	1.8	5.5	1.4
Indiana	8.9	1.2	1.3	0.2
Michigan	15.6	3.2	14.8	3.3
Ohio	10.0	2.6	10.1	2.7
Wisconsin	0.4	0.1	0.4	0.0
Plains	15.5	5.7	14.5	5.6
Iowa	0.5	0.0	0.4	0.0
Kansas	28.0	1.1	25.2	1.1
Minnesota	2.2	0.2	1.5	0.2
Missouri	41.3	4.3	44.8	4.2
Nebraska	0.6	0.0	0.6	0.0
North Dakota	0.0	0.0	0.0	0.0
South Dakota	0.0	0.0	0.0	0.0
Southeast	17.1	21.3	16.2	22.3
Alabama	35.1	2.4	34.5	2.5
Arkansas	0.3	0.0	0.3	0.0
Florida	4.8	1.1	5.4	1.4
Georgia	13.3	1.8	11.8	1.9
Kentucky	16.4	1.5	8.5	0.8
Louisiana	38.3	5.2	38.7	5.9
Mississippi	15.5	0.9	15.3	0.9
North Carolina	14.6	1.9	14.1	2.1
South Carolina	35.6	2.6	34.9	2.7
Tennessee	20.4	2.5	20.7	2.6
Virginia	10.1	0.9	8.5	0.8
West Virginia	9.1	0.5	10.3	0.6
Southwest	19.6	9.1	19.6	9.9
Arizona	0.0	0.0	7.5	0.5
New Mexico	2.4	0.1	1.6	0.1
Oklahoma	2.2	0.1	2.4	0.1
Texas	28.9	8.9	26.9	9.1
Rocky Mountains	16.4	1.8	6.5	0.8
Colorado	38.4	1.8	14.2	0.8
Idaho	0.4	0.0	0.4	0.0
Montana	0.0	0.0	0.2	0.0
Utah	1.1	0.0	1.0	0.0
Wyoming	0.1	0.0	0.1	0.0
Far West	19.2	14.9	20.1	17.8
Alaska	3.6	0.0	5.4	0.1
California	22.5	12.8	23.6	15.3
Hawaii	13.7	0.2	13.0	0.3
Nevada	22.6	0.4	24.5	0.5
Oregon	2.1	0.1	2.3	0.1
Washington	11.6	1.3	12.5	1.5

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

In 1993, 40.9 percent of all Medicaid expenditures in the U.S. were attributable to hospital care, 28.8 percent to nursing home care, 11.1 percent to physician care, 7.2 percent to other personal care, 6.8 percent to drugs, 2.8 percent to freestanding home health care, 1.4 percent to dental care, and 1.2 percent to other professional care. Institutional care in hospitals and nursing homes accounted for nearly 70 percent of Medicaid spending in 1993, while long-term care (nursing home and home health care) accounted for approximately 32 percent of all Medicaid spending. Medicaid hospital care expenditures as a percentage of total Medicaid expenditures in the Far West and the Southwest were above the national share (49.2 percent and 46.1 percent, respectively), while New England showed the lowest share, at 30.9 percent Nursing home care expenditures varied from a high of 39.8 percent of total Medicaid expenditures in New England to a low of 15.9 percent in the Far West; the share of Medicaid spending on physician care was 16 percent in the Southeast but only 7 percent in the Mideast and New England.

In the current State health care reform climate, the Medicaid program is poised to face significant change. Already, increased emphasis on Medicaid managed care has resulted in enrolling nearly one-quarter of all Medicaid recipients in some type of managed-care program and has led to the approval and implementation of statewide 1115 waivers as a part of a larger health care reform effort (Lewin-VHI, Inc., 1995). Section 1115 waivers allow the Secretary of the Department of Health and Human Services to waive Federal Medicaid requirements in the Social Security Act and authorize experimental, pilot, or demonstration projects (such as enrolling recipients in managed-care plans). Prior to 1993, section 1115 waivers principally involved limited research projects. In 1993, however, the Secretary authorized expansion of statewide 1115 waivers, opening the way for approval of statewide demonstrations in Florida, Hawaii, Kentucky, Oregon, Rhode Island, South Carolina, Tennessee, and Ohio. (Arizona has had an approved 1115 waiver for over a decade.) Also, several States have submitted 1115 waiver applications for smaller programs which target specific populations (Lewin-VHI, Inc., 1995). Much of the emphasis of these current statewide 1115 programs is on delivery of health care benefits through lower-cost capitated managed-care plans that would permit expansion of the Medicaid program to more poor people. Additionally, the prospect of block grants will give States more flexibility in program eligibility and covered services. The effect of these programs and proposals on State Medicaid expenditures is yet to be fully realized.

Population

One factor that affected the level and growth in spending across most health care sectors was population. In 1993, California was by far the most populous State, with an estimated 31.2 million residents (Table 3). New York, Texas, and Florida ranked second through fourth, respectively, in population size. Together, these four States accounted for 31 percent of the 257.8 million persons residing in the United States.

Growth in health spending is directly related to population growth. Between 1980 and 1993, the resident population grew at an average annual rate of 1.0 percent nationwide. The fastest growth occurred in Nevada, where population swelled at a 4.2-percent average annual rate. Growth in Alaska, Arizona, and Florida, up 3.0,2.8, and 2.6 percent, respectively, followed close behind. These States also experienced some of the most rapid growths in elderly population. Since die elderly use more health services than other age groups, those States where the elderly population grew more rapidly than the United States experienced more rapidly growing spending, all other factors being equal. Nationwide, the elderly population averaged 1.9 percent growth during this period. In States with high total population growth, the elderly population also grew at a faster average annual rate than the U.S. average rate: 6.7 percent in Nevada, 6.5 percent in Alaska, 4.2 percent in Arizona, and 3.1 percent in Florida. Several areas lost population between 1980 and 1993: the District of Columbia, West Virginia, North Dakota, Iowa, and Wyoming.

The level of health spending is also related to the distribution of the aged population in a State. The 32.8 million persons 65 years of age or over in the United States accounted for 12.7 percent of the population in 1993, up from 11.3 percent in 1980. The elderly share of population was highest in Florida (18.4 percent). Pennsylvania, Rhode Island, Iowa, and West Virginia also showed elderly shares of population greater than 15 percent. At the opposite extreme, the elderly population shares in Alaska and Utah each were less than 9 percent in 1993. All other factors being equal, the level of health spending per person will be higher in States where the elderly comprise a larger share of the total population.

Sources and Methods

The structure of SHEA parallels that of the NHE accounts. SHEA uses the same definitions and, to the extent possible, the same data sources as NHE (Lazenby et al., 1992). This structure clusters health services according to the establishment providing those services; for products, this structure groups retail purchases of medical products according to product classification. For purposes of health expenditure accounting, this establishment-based structure has both strengths and weaknesses. Strength comes from the wealth of uniform State-level information collected by the Federal Government and private organizations on an establishment basis. These data also permit uniformity in concepts, collection methods, and data processing, which allows us to make valid interstate comparisons.

Establishment-based structure eases the collection of data by reducing requirements for providers to disaggregate their revenue according to the specific service provided. The Federal Government has created an establishment-based structure for data collection codified in the Standard Industrial Classification (SIC) Manual (Executive Office of the President, 1987). These SICs form the basis for the service categories used in SHEA (Table 10).

Table 10. Classification of Establishments by Standard Industrial Classification, 1987.

Industry Group Number	Industry
801	Offices and Clinics of Doctors of Medicine
802	Offices and Clinics of Dentists
803	Offices and Clinics of Doctors of Osteopathy
804	Offices and Clinics of Other Health Practitioners
805	Nursing and Personal Care Facilities
806	Hospitals
807	Medical and Dental Laboratories
808	Home Health Agencies
809	Miscellaneous Health and Allied Services, Not Elsewhere Classified

SOURCE: (Executive Office of the President, 1987).

This structure may not meet all the analytical needs of researchers and policymakers because it does not measure spending for narrowly-defined “services,” but for establishment services overall. For example, hospital establishments provide hospital care, but may also provide nursing home care in long-term units and serve as a home health care agency; hospitals also furnish prescription drugs to patients and employ physicians who provide services to patients. We include all revenues received from these billed services and products in hospital expenditures, rather than with other similar services.

Establishment-based expenditures mean that spending is in the State of the provider rather than in the State of residence of the beneficiary of services. People are able to cross borders to receive health care services. Therefore, the population of a State is not necessarily an accurate reflection of persons using the services of providers in that State. Therefore, we do not generally compute per capita health spending using State-of-provider expenditure data. In some services and for regions where net border crossing is small, per capita expenditures are presented.

The next phase of SHEA will estimate border crossing for health care services, adjusting State-of-provider expenditures to a location of beneficiary residence. We will produce per capita expenditures at this point, and interstate comparisons of spending will be made.

Revisions

U.S. expenditure totals presented in the tables in this article will differ occasionally from NHE totals (Levit et al, 1994). First, spending in U.S. territories and by the Department of Defense at foreign military bases are included in the NHE but excluded from the U.S. totals reported in SHEA. Second, U.S. expenditure totals for nursing homes are lower than those published in NHE. In this article, we have removed expenditures for hospital-based nursing home services from nursing home expenditures. This methodological change will be incorporated into the next NHE report. It was necessary to include this revision because hospital-based nursing home spending is greater in some States than others. This would result not only in overstating spending on freestanding nursing home care and PHCE, but in distorting the distribution of this spending across States. Third, home health expenditures are higher than the published NHE. This revision, also methodological in nature, counts revenues received by government agencies in the delivery of health services in the home. As with the nursing home revision, this change will be incorporated into the next NHE report.

We have also made revisions to previously published State expenditures for hospital care, physician services, and prescription drugs (Levit et al., 1993). For hospitals, this estimate remained the same methodologically, but small revisions to spending by State resulted from the receipt of new data. Second, spending by State for physician services was revised to incorporate new levels from the recently released 1992 Census of Service Industries (CSI) (U.S. Bureau of the Census, 1977, 1982, 1987, 1992). Third, a revision was made to prescription drugs to incorporate an age-gender factor into the extrapolation methodology. This minor revision affected 1988-93 expenditure estimates.

Hospital Care

Hospital care expenditure estimates (SIC 805) reflect spending for all hospital services provided to patients for which the hospital bills. Expenditures include revenues received for room and board charges, ancillary charges such as operating room fees, charges for the services of resident physicians, inpatient pharmacy charges, charges for hospital-based nursing home care and care delivered by hospital-based home health agencies, and fees for any other services billed by the hospital. We exclude expenditures for services of physicians who bill independently for services delivered to patients in hospitals.

Non-Federal hospital estimates are measured using American Hospital Association (AHA) Annual Survey data that capture information from registered and non-registered hospitals in the United States. To meet the definitions of SHEA, we modify AHA data in four ways. First, data from each year's survey is combined to create a longitudinal file containing one multiple-year record for each hospital; hospital characteristics contained on this record are edited for consistency. Second, hospital revenues are imputed from expense data using revenue-to-expense ratios provided by AHA Third, individual hospitals' imputed accounting year revenues are converted to a calendar year basis. Finally, when complete calendar year data is not available for a facility through calendar year 1993, the latest available data is extrapolated using patterns of acceleration and deceleration observed in AHA Panel Survey data. Federal hospital estimates are based on data from either the Federal agencies that administer those facilities or AHA.

Physician Services

We estimate expenditures for physician services (SICs 801 and 803) in three pieces: expenditures in private physician offices and clinics; fees of independently-billing laboratories; and professional fees received by physicians from hospitals. Expenditures in private physician offices and clinics are based on business receipts from taxable establishments and revenues from tax-exempt establishments reported in the CSI (U.S. Bureau of the Census, 1977, 1982, 1987, 1992). We use receipt and revenue distributions for these years to estimate spending by State. For taxable establishments, we estimate intervening years using business receipts for sole proprietorships, partnerships, and corporations from the Internal Revenue Services' Business Master File (BMF) (U.S. Internal Revenue Service, 1977-92). Growth in wages and salaries for physicians' offices and clinics (U.S. Bureau of Labor Statistics, 1994) is used to estimate 1993. For tax-exempt physician offices and clinics, estimates for census years are interpolated and extrapolated using civilian population (U.S. Bureau of the Census, 1994). Expenditures in tax-exempt and taxable establishments are separately scaled to national totals.

The distribution of laboratory fees parallels the distribution of physician expenditures. We distribute the U.S. total for laboratory fees to States using total physician expenditures.

We reduce expenditures for State physician services by the amount of professional fees paid by hospitals to physicians. Professional fees are distributed to States based on professional fee expenses from the AHA Annual Survey for 1980,1985, and 1990-93. Expenditures by State for intervening years are estimated by interpolating AHA-based estimates using community hospital revenues by State. We scale the results to U.S. totals.

We have introduced one major revision to State expenditures for physician services since our previous publication (Levit et al., 1993). Since that time, the 1992 CSI has become available. This information is linked to the 1987 CSI, producing revisions to estimates for 1988 and later years.

Dental Services

Expenditures for dental services (SIC 802) are estimated using CSI and BMF data in the same manner as taxable establishments for physician offices and clinics. To estimate 1993 spending, we extrapolate the 1992 CSI-based estimates using growth in wages and salaries in dental offices and clinics (U.S. Bureau of Labor Statistics, 1994).

Other Professional Services

Spending for other professional services (SICs 804 and 809) is estimated in three segments. The first segment, expenditures for the services of licensed professionals such as chiropractors, optometrists, podiatrists, and independently practicing nurses, is estimated using CSI and BMF data in the same manner as taxable establishments for physician offices and clinics. For the second segment, we distribute expenditures in specialty clinics and for miscellaneous professional services to States using data from the CSI for 1977, 1982, 1987, and 1992. CSI-based expenditures for each State are interpolated and extrapolated for intervening years using civilian population. The final piece, spending for Medicare ambulance services, is estimated using the distribution of expenditures for Medicare other professional services. We control State spending for each segment to national totals.

Home Health Care

Like the estimates for professional services, expenditure estimates for freestanding home health care (SIC 808) are based on revenue estimates for taxable businesses and receipt information for tax-exempt businesses collected every 5 years by the CSI. Because the standard industrial classification for home health agencies (SIC 808) was first created with the release of the 1987 Standard Industrial Classification Manual (Executive Office of the President, 1987), collection of separate State data for estimating spending for this service category is available for 1987 and 1992 only. Data from these two surveys are benchmarks for private spending on freestanding home health services by State. We develop separate estimates of spending for government-supplied home health services (not surveyed by the CSI) for 1987 and 1992 using the relationship between Medicare reimbursements to home health agencies for government-owned agencies and all agencies for 1988 and 1992. We sum expenditures for services from government and private home health agencies. The 1987 and 1992 estimates are interpolated and extrapolated for 1980 through 1991 using expenditures for home health services paid by Medicare and Medicaid. For 1993, we extrapolate 1992 CSI-based spending using the growth in private and government wages and salaries paid by home health care establishments (U.S. Bureau of Labor Statistics, 1994). Distributions are controlled to national estimates of freestanding home health expenditures.

Drugs and Other Medical Non-Durables

Prescription and non-prescription drug and sundry expenditure estimates are based on retail sales data reported in the 1977, 1982, and 1987 Census of Retail Trade, Merchandise Line Sales (U.S. Bureau of the Census, 1977, 1982, 1987). Intervening years are interpolated using population data. Estimates for 1988 and after are extrapolated using adjusted State population data. These adjustments measure the variation in drug use and costs due to the age-gender composition of the population within each State. These adjustments are constructed from prescription drug expenditure and use information collected in the 1987 National Medical Expenditure Survey (NMES) (Agency for Health Care Policy and Research, 1987). NMES data show that the average cost per prescription is much greater for males than females in most age categories, and that the number of prescriptions dispensed is much greater for females than males of every age. The data also show an increase in the number of prescriptions dispensed as age increases.

Revisions to previously published prescription drug expenditure estimates by State result from the increase in expenditure levels shown in recently-released national health expenditure estimates (Levit et al., 1994). At that time, we introduced preliminary results from a HCFA-sponsored study conducted by Actuarial Research Corporation (1994). The revised methodology increased spending from 1983 forward. California and Florida, the two States most heavily affected by the revision, showed increases of $0.9 billion and $0.5 billion, respectively. We attribute a small portion of revision for 1988 and later years, however, to the use of an age-gender adjusted population used in deriving our expenditure estimates. Previously, we assumed that State prescription drug costs per capita grew at similar rates, regardless of that States' age and gender composition.

Vision Products and Other Medical Durables

State expenditure estimates for durable medical goods are derived by scaling the distribution of optical goods sales by State to our national expenditure estimates. To measure optical goods sales for retail establishments, State data from the Census of Retail Trade are used for 1977,1982 and 1987. Business receipts for offices of optometrists reported in the 1977, 1982, 1987, and 1992 CSI are used to distribute optical sales that occur in those types of establishments. According to data from the 1992 CSI, these sales represent 23 percent of all retail sales of optical goods nationwide. We rely upon population statistics to extrapolate and interpolate estimates of optical sales for years when actual retail sales are not available.

Nursing Home Care

Expenditures for nursing home care cover services delivered in nursing and personal-care facilities (SIC 805). Estimates are given for four facility types: private nursing homes; State and local nursing homes; nursing homes operated by the Department of Veterans Affairs (DVA); and intermediate care facilities for the mentally retarded (ICFs/MR).

To estimate spending in private facilities, revenues for taxable businesses and receipts for tax-exempt businesses collected by State in the CSI in 1977, 1982, 1987, and 1992 are used. We interpolate and extrapolate revenues and receipts by State using wages and salaries paid in private nursing home establishments (U.S. Bureau of Labor Statistics, 1994). To estimate expenditures in government nursing homes, we inflate wages and salaries for State and local government nursing facilities to revenues. We estimate spending for nursing home care in DVA facilities from State-specific data furnished by the Department. Medicaid expenditures for nursing home care in ICFs/MR from data reported by Medicaid State agencies on HCFA Form-64 are used to estimate spending for this facility type.

We have revised national expenditure estimates for nursing home care since the latest publication of NHE (Levit et al., 1994). This revision eliminates expenditures for nursing home care provided in long-term care units of hospitals from nursing home spending, removing duplication in expenditures between the hospital and nursing home components of NHE.

Other Personal Health Care

Privately funded OPHC consists of industrial inplant services provided by employers for the health care needs of their employees. These services may be provided either onsite or offsite. We estimate expenditures for industrial inplant services using the number of occupational health nurses (American Nurses' Association, 1979; U.S. Public Health Service, 1986, 1994) and average annual wages in the health services sector (U.S. Bureau of Economic Analysis, 1969-93).

Public expenditures include Medicaid and States' general medical assistance spending for health screening services, certain home and community-based waivers, case management, and transportation services. Expenses for shipboard facilities and field stations operated by the Department of Defense and expenditures for certain services funded through State and local maternal and child health programs, school health programs, and Federal agency programs targeting veterans, military personnel, Native Americans, and persons with drug- and alcohol-dependency and mental health-related problems are also covered in this category. We use agency-supplied data to estimate government spending for each OPHC program.

Medicare

We estimate 1991 Medicare spending by State of provider from payments recorded in Medicare's National Claims History (NCH) files. These detailed claim records permit us to assemble expenditures for each SHEA service category. Because of the detail available, 1991 Medicare expenditures can be estimated more precisely than any other year. Payments for each type of service from 1980-90 and from 1992-93 were extrapolated using unpublished tabulations of Medicare reimbursements by program service category and State. When State-of-provider data was unavailable, extrapolations were performed using State-of-beneficiary reimbursement information. We adjusted distributions for each year to equal NHE expenditure estimates.

Medicare payments for services provided to enrollees in Medicare managed-care plans are separately estimated. We allocate national totals by type of service to States based on payments to managed-care organizations by State of beneficiary residence.

Medicaid

Medicaid estimates are based on financial information reports (HCFA Form-64) filed by State Medicaid agencies. These reports show total and service-specific program expenditures. However, we adjusted reported program data to fit the estimates into the framework of SHEA.

The first adjustment splits home health spending into expenditures flowing to hospital-based and freestanding home health care establishments based on ratios supplied from Medicare program data. We add estimates of hospital-based home health care spending to Medicaid hospital care expenditures and subtract it from Medicaid home health care expenditures. A similar adjustment is made for nursing homes. The second adjustment counts that portion of reported program expenditure for ICFs/MR estimated to cover services in hospital-based facilities as hospital care rather than nursing home care.

Additionally, for the purposes of SHEA, we exclude certain Medicaid disproportionate share payments to hospitals that are offset by donations and taxes paid by the same facilities because these payments net out and do not contribute to overall hospital operation (Levit et al, 1994).

Table 12. Hospital Care Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	101,510	166,545	254,239	303,461	323,919	9.4
New England	6,467	10,332	15,540	17,855	19,056	8.7
Connecticut	1,396	2,328	3,664	4,193	4,380	9.2
Maine	460	735	1,119	1,280	1,376	8.8
Massachusetts	3,646	5,628	8,159	9,380	10,034	8.1
New Hampshire	313	590	1,056	1,233	1,388	12.2
Rhode Island	481	760	1,095	1,237	1,314	8.1
Vermont	174	290	447	532	562	9.5
Mideast	21,568	34,346	52,968	62,586	67,330	9.2
Delaware	259	434	709	854	937	10.4
District of Columbia	913	1,469	2,133	2,437	2,612	8.4
Maryland	2,034	2,980	4,655	5,516	5,926	8.6
New Jersey	2,763	4,751	7,857	9,406	10,312	10.7
New York	9,582	14,585	22,739	26,387	28,001	8.6
Pennsylvania	6,017	10,126	14,876	17,987	19,540	9.5
Great Lakes	19,590	30,093	42,984	50,835	54,172	8.2
Illinois	6,217	8,998	12,400	14,744	15,621	7.4
Indiana	2,125	3,399	5,288	6,473	6,998	9.7
Michigan	4,482	6,882	9,500	11,008	11,711	7.7
Ohio	4,808	8,026	11,419	13,394	14,305	8.8
Wisconsin	1,959	2,788	4,377	5,216	5,537	8.4
Plains	7,810	12,261	18,012	21,116	22,252	8.4
Iowa	1,179	1,733	2,634	2,996	3,111	7.8
Kansas	1,090	1,607	2,300	2,771	2,868	7.8
Minnesota	1,740	2,716	4,094	4,674	4,796	8.2
Missouri	2,532	4,172	5,986	7,077	7,652	8.9
Nebraska	681	1,060	1,587	1,881	2,003	8.8
North Dakota	313	524	717	853	903	8.5
South Dakota	275	450	694	863	920	9.8
Southeast	20,585	36,181	58,466	71,001	75,835	10.6
Alabama	1,590	2,606	4,015	5,028	5,301	9.8
Arkansas	746	1,313	2,109	2,546	2,723	10.6
Florida	4,385	8,404	13,462	15,992	17,131	11.1
Georgia	2,148	3,885	6,685	8,092	8,704	11.4
Kentucky	1,230	2,157	3,437	4,268	4,515	10.6
Louisiana	1,744	3,155	4,627	5,575	5,956	10.0
Mississippi	867	1,427	2,187	2,658	2,897	9.8
North Carolina	1,963	3,250	5,901	7,311	7,801	11.3
South Carolina	978	1,753	3,108	3,962	4,221	12.0
Tennessee	2,027	3,483	5,511	6,761	7,208	10.3
Virginia	2,077	3,530	5,661	6,618	7,031	.9.9
West Virginia	831	1,219	1,763	2,190	2,346	8.4
Southwest	8,264	14,738	23,191	28,583	30,768	10.7
Arizona	1,093	2,103	3,218	3,765	3,999	10.5
New Mexico	451	873	1,364	1,703	1,848	11.5
Oklahoma	1,177	1,896	2,674	3,182	3,329	8.5
Texas	5,543	9,866	15,935	19,932	21,592	11.1
Rocky Mountains	2,325	4,010	6,123	7,488	7,886	9.9
Colorado	1,218	2,087	3,101	3,776	3,932	9.5
Idaho	243	419	665	844	900	10.7
Montana	264	438	679	841	894	9.9
Utah	453	816	1,325	1,631	1,743	11.0
Wyoming	146	248	353	396	417	8.5
Far West	14,901	24,584	36,955	43,998	46,621	9.2
Alaska	199	385	557	690	701	10.2
California	11,632	18,883	27,949	32,880	34,827	8.8
Hawaii	360	648	1,148	1,358	1,460	11.5
Nevada	387	667	1,043	1,267	1,362	10.3
Oregon	928	1,486	2,297	2,714	2,966	9.4
Washington	1,396	2,516	3,961	5,090	5,305	10.9

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 13. Physician Service Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	45,245	83,636	140,499	161,783	171,226	10.8
New England	2,072	4,010	7,656	8,678	9,250	12.2
Connecticut	589	1,127	2,185	2,468	2,587	12.1
Maine	142	275	480	570	601	11.7
Massachusetts	978	1,890	3,766	4,130	4,442	12.3
New Hampshire	130	281	491	719	780	14.8
Rhode Island	166	304	514	543	575	10.0
Vermont	68	131	221	248	265	11.1
Mideast	7,827	14,532	24,472	28,631	30,080	10.9
Delaware	120	214	377	439	466	11.0
Dist. of Columbia	237	362	657	651	672	8.4
Maryland	835	1,702	2,968	3,498	3,704	12.1
New Jersey	1,353	2,533	4,519	5,526	5,776	11.8
New York	3,332	5,822	9,697	11,287	12,003	10.4
Pennsylvania	1,950	3,901	6,254	7,230	7,460	10.9
Great Lakes	8,078	13,646	21,823	24,837	26,275	9.5
Illinois	2,118	3,672	5,864	6,707	6,970	9.6
Indiana	891	1,607	2,680	3,061	3,263	10.5
Michigan	2,002	3,080	4,668	5,224	5,562	8.2
Ohio	2,130	3,692	6,048	6,786	7,118	9.7
Wisconsin	938	1,595	2,564	3,059	3,362	10.3
Plains	3,286	5,739	9,125	10,395	10,987	9.7
Iowa	488	769	1,142	1,294	1,376	8.3
Kansas	461	774	1,211	1,362	1,425	9.1
Minnesota	944	1,765	2,957	3,322	3,617	10.9
Missouri	877	1,537	2,485	2,879	2,958	9.8
Nebraska	276	433	688	785	825	8.8
North Dakota	139	288	368	433	445	9.4
South Dakota	102	173	274	319	342	9.8
Southeast	9,428	18,184	32,089	36,086	37,893	11.3
Alabama	632	1,167	2,247	2,466	2,631	11.6
Arkansas	374	680	1,134	1,217	1,244	9.7
Florida	2,482	5,272	9,444	10,131	10,498	11.7
Georgia	987	1,930	3,645	4,321	4,543	12.5
Kentucky	562	955	1,639	1,950	2,038	10.4
Louisiana	743	1,424	2,129	2,450	2,537	9.9
Mississippi	327	568	925	1,015	1,107	9.8
North Carolina	866	1,543	3,005	3,458	3,717	11.9
South Carolina	399	734	1,325	1,552	1,685	11.7
Tennessee	841	1,499	2,569	2,988	3,137	10.7
Virginia	886	1,772	3,172	3,565	3,769	11.8
West Virginia	330	642	856	973	988	8.8
Southwest	4,350	8,218	13,377	15,008	15,680	10.4
Arizona	635	1,287	2,500	2,676	2,799	12.1
New Mexico	182	368	574	665	716	11.1
Oklahoma	536	972	1,382	1,558	1,640	9.0
Texas	2,996	5,590	8,920	10,108	10,526	10.1
Rocky Mountains	1,187	2,260	3,461	4,029	4,354	10.5
Colorado	600	1,230	1,891	2,242	2,452	11.4
Idaho	140	235	374	453	486	10.1
Montana	138	205	311	350	392	8.4
Utah	244	472	739	832	864	10.2
Wyoming	64	118	146	152	160	7.3
Far West	9,018	17,047	28,494	34,120	36,706	11.4
Alaska	97	214	258	276	301	9.1
California	6,959	13,311	22,365	26,903	28,981	11.6
Hawaii	249	444	629	742	771	9.1
Nevada	207	421	812	988	1,029	13.1
Oregon	596	990	1,597	1,798	1,904	9.3
Washington	909	1,667	2,834	3,413	3,720	11.4

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 14. Dental Service Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	13,323	21,650	30,395	34,719	37,383	8.3
New England	757	1,192	1,973	2,158	2,274	8.8
Connecticut	228	361	616	654	685	8.8
Maine	45	77	129	147	157	10.1
Massachusetts	362	544	870	970	1,022	8.3
New Hampshire	49	85	149	164	177	10.4
Rhode Island	47	85	140	145	150	9.3
Vermont	26	40	69	77	84	9.5
Mideast	2,497	4,036	5,866	6,533	6,903	8.1
Delaware	35	60	79	100	104	8.8
District of Columbia	42	74	96	109	119	8.4
Maryland	242	396	604	697	749	9.1
New Jersey	491	897	1,217	1,384	1,460	8.7
New York	1,081	1,646	2,407	2,707	2,837	7.7
Pennsylvania	606	964	1,464	1,536	1,634	7.9
Great Lakes	2,476	3,689	4,887	5,553	5,973	7.0
Illinois	662	962	1,333	1,476	1,588	7.0
Indiana	258	416	524	626	692	7.9
Michigan	682	996	1,288	1,442	1,531	6.4
Ohio	569	857	1,147	1,307	1,398	7.2
Wisconsin	306	458	595	702	765	7.3
Plains	918	1,394	1,906	2,168	2,366	7.6
Iowa	150	210	265	313	341	6.5
Kansas	124	201	261	299	325	7.7
Minnesota	274	426	608	671	741	7.9
Missouri	230	353	494	557	602	7.7
Nebraska	80	113	153	181	191	7.0
North Dakota	31	46	61	69	78	7.4
South Dakota	28	45	64	78	87	9.1
Southeast	2,407	4,101	5,927	6,859	7,492	9.1
Alabama	161	248	355	414	456	8.3
Arkansas	84	145	198	221	242	8.5
Florida	588	1,133	1,622	1,850	2,029	10.0
Georgia	270	474	723	826	898	9.7
Kentucky	128	195	270	331	369	8.5
Louisiana	179	269	344	400	432	7.0
Mississippi	80	120	167	194	214	7.9
North Carolina	261	429	639	744	810	9.1
South Carolina	114	209	308	356	387	9.8
Tennessee	208	316	485	559	609	8.6
Virginia	267	465	692	794	863	9.4
West Virginia	67	99	124	170	182	7.9
Southwest	1,061	1,971	2,449	2,858	3,164	8.8
Arizona	165	313	430	495	551	9.7
New Mexico	59	105	134	156	175	8.7
Oklahoma	142	253	288	330	356	7.3
Texas	695	1,301	1,597	1,876	2,081	8.8
Rocky Mountains	391	717	939	1,087	1,204	9.0
Colorado	192	375	470	543	605	9.2
Idaho	52	84	120	147	163	9.2
Montana	44	71	80	94	103	6.8
Utah	79	143	223	252	276	10.1
Wyoming	24	43	47	52	57	7.0
Far West	2,816	4,552	6,448	7,503	8,005	8.4
Alaska	34	72	92	112	124	10.6
California	2,065	3,299	4,670	5,399	5,664	8.1
Hawaii	80	129	188	215	235	8.6
Nevada	62	115	163	199	215	10.0
Oregon	201	304	449	514	578	8.5
Washington	375	632	887	1,064	1,189	9.3

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 15. Other Professional Service Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	6,353	16,639	36,010	46,401	51,220	17.4
New England	349	974	2,269	2,847	3,134	18.4
Connecticut	82	224	554	701	769	18.7
Maine	29	70	159	192	210	16.4
Massachusetts	163	472	1,096	1,383	1,524	18.7
New Hampshire	28	86	194	243	269	18.9
Rhode Island	30	79	175	218	239	17.3
Vermont	15	42	91	110	122	17.2
Mideast	1,146	3,087	6,838	9,044	9,956	18.1
Delaware	14	46	104	141	156	20.6
Dist. of Columbia	39	90	183	244	267	15.9
Maryland	90	257	629	855	942	19.8
New Jersey	186	542	1,282	1,701	1,870	19.4
New York	474	1,248	2,634	3,374	3,717	17.2
Pennsylvania	344	904	2,006	2,728	3,005	18.2
Great Lakes	1,176	2,797	5,481	7,033	7,744	15.6
Illinois	329	748	1,464	1,873	2,063	15.2
Indiana	149	349	728	899	993	15.7
Michigan	286	704	1,287	1,676	1,844	15.4
Ohio	299	718	1,379	1,790	1,969	15.6
Wisconsin	113	278	623	795	875	17.0
Plains	504	1,171	2,455	2,978	3,283	15.5
Iowa	88	159	330	393	431	13.0
Kansas	72	164	330	427	470	15.5
Minnesota	151	391	723	845	933	15.0
Missouri	125	303	770	916	1,013	17.4
Nebraska	35	78	151	205	225	15.5
North Dakota	15	31	63	85	93	14.9
South Dakota	18	45	87	106	117	15.6
Southeast	1,205	3,330	7,848	10,344	11,455	18.9
Alabama	70	207	446	578	641	18.6
Arkansas	52	120	230	301	332	15.3
Florida	343	998	2,422	3,163	3,505	19.6
Georgia	111	356	858	1,106	1,226	20.3
Kentucky	85	182	430	623	691	17.5
Louisiana	82	240	527	667	736	18.4
Mississippi	42	108	219	260	288	16.0
North Carolina	105	268	722	996	1,102	19.8
South Carolina	56	142	327	428	472	17.8
Tennessee	114	324	785	1,049	1,166	19.6
Virginia	99	281	669	878	970	19.2
West Virginia	46	105	213	295	326	16.3
Southwest	544	1,505	3,399	4,655	5,170	18.9
Arizona	85	253	558	736	821	19.1
New Mexico	36	88	178	230	254	16.3
Oklahoma	77	180	335	458	504	15.6
Texas	347	984	2,328	3,231	3,591	19.7
Rocky Mountains	171	476	939	1,199	1,331	17.1
Colorado	81	247	534	675	751	18.7
Idaho	26	59	92	115	126	13.1
Montana	25	63	108	149	166	15.6
Utah	25	75	156	198	220	18.1
Wyoming	14	31	49	62	68	13.2
Far West	1,259	3,300	6,781	8,301	9,147	16.5
Alaska	18	51	93	115	127	16.3
California	969	2,548	5,173	6,232	6,859	16.2
Hawaii	22	60	146	202	222	19.4
Nevada	25	69	208	277	307	21.3
Oregon	70	184	376	481	530	16.9
Washington	155	389	785	994	1,102	16.3

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 16. Home Health Care Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	2,376	5,642	13,232	20,348	22,982	19.1
New England	175	377	932	1,358	1,555	18.3
Connecticut	42	97	240	347	391	18.7
Maine	13	27	60	92	104	17.3
Massachusetts	85	193	501	718	835	19.2
New Hampshire	11	20	46	67	71	15.7
Rhode Island	16	29	58	90	103	15.2
Vermont	8	11	27	45	52	16.0
Mideast	896	2,041	4,177	5,141	5,486	15.0
Delaware	4	16	30	45	51	20.7
District of Columbia	11	21	37	40	45	11.7
Maryland	39	109	189	298	314	17.5
New Jersey	182	290	479	631	718	11.1
New York	536	1,270	2,937	3,409	3,562	15.7
Pennsylvania	124	334	505	718	796	15.4
Great Lakes	326	805	1,750	2,561	2,789	18.0
Illinois	112	195	418	791	853	16.9
Indiana	25	57	141	269	308	21.5
Michigan	73	268	562	638	714	19.2
Ohio	80	162	368	578	649	17.5
Wisconsin	37	123	261	286	265	16.3
Plains	114	267	644	1,021	1,155	19.5
Iowa	15	28	82	127	137	18.7
Kansas	10	24	76	140	152	23.3
Minnesota	27	79	243	369	414	23.5
Missouri	55	118	191	291	347	15.2
Nebraska	5	14	34	69	74	22.8
North Dakota	1	3	12	15	16	21.5
South Dakota	1	2	6	10	16	20.2
Southeast	409	1,041	3,336	6,149	7,042	24.5
Alabama	30	72	267	489	602	26.0
Arkansas	13	29	75	128	145	20.4
Florida	170	361	1,153	2,208	2,323	22.3
Georgia	39	104	343	606	729	25.2
Kentucky	16	44	183	326	357	26.8
Louisiana	17	43	125	279	410	27.7
Mississippi	21	48	168	262	300	22.8
North Carolina	20	58	273	483	541	29.1
South Carolina	18	43	83	175	216	21.2
Tennessee	26	124	396	756	899	31.2
Virginia	30	94	206	324	368	21.2
West Virginia	9	21	63	114	150	24.4
Southwest	138	421	1,035	1,791	2,234	23.9
Arizona	10	56	148	245	317	30.5
New Mexico	6	14	30	56	62	20.2
Oklahoma	29	43	87	167	273	18.7
Texas	93	308	770	1,323	1,583	24.3
Rocky Mountains	40	87	190	325	422	19.8
Colorado	25	47	105	156	195	17.0
Idaho	7	17	16	36	49	16.0
Montana	4	10	29	43	50	20.9
Utah	2	9	33	74	100	33.9
Wyoming	1	4	7	17	29	25.7
Far West	277	603	1,167	2,001	2,299	17.7
Alaska	0	1	2	4	5	31.8
California	200	449	847	1,438	1,640	17.6
Hawaii	4	8	16	23	32	16.7
Nevada	2	9	44	101	120	35.2
Oregon	19	39	52	105	122	15.3
Washington	52	98	207	329	380	16.6

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 17. Drug and Other Medical Non-Durable Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	21,621	37,363	61,217	70,750	74,956	10.0
New England	1,095	2,041	3,497	3,901	4,079	10.6
Connecticut	295	525	860	957	996	9.8
Maine	83	156	282	318	333	11.3
Massachusetts	521	986	1,682	1,873	1,961	10.7
New Hampshire	76	145	269	302	319	11.7
Rhode Island	81	156	269	299	310	10.9
Vermont	39	73	134	153	161	11.6
Mideast	3,804	6,776	11,127	12,583	13,189	10.0
Delaware	55	100	172	201	214	10.9
District of Columbia	60	103	161	171	175	8.6
Maryland	416	789	1,425	1,654	1,749	11.7
New Jersey	694	1,255	2,062	2,334	2,452	10.2
New York	1,503	2,675	4,337	4,861	5,081	9.8
Pennsylvania	1,076	1,854	2,970	3,361	3,519	9.5
Great Lakes	3,874	6,367	10,213	11,689	12,302	9.3
Illinois	1,037	1,718	2,716	3,102	3,263	9.2
Indiana	523	820	1,307	1,506	1,594	9.0
Michigan	907	1,490	2,446	2,799	2,937	9.5
Ohio	1,036	1,712	2,689	3,064	3,218	9.1
Wisconsin	371	628	1,054	1,218	1,290	10.1
Plains	1,532	2,504	3,941	4,502	4,746	9.1
Iowa	252	402	622	708	743	8.7
Kansas	222	368	578	660	695	9.2
Minnesota	341	575	939	1,081	1,146	9.8
Missouri	477	760	1,180	1,346	1,420	8.8
Nebraska	138	224	350	400	421	9.0
North Dakota	51	90	137	153	160	9.2
South Dakota	51	85	135	154	163	9.3
Southeast	5,136	8,974	15,193	17,750	18,912	10.5
Alabama	365	614	1,011	1,173	1,247	9.9
Arkansas	232	359	559	643	684	8.7
Florida	1,010	1,924	3,535	4,170	4,450	12.1
Georgia	523	940	1,654	1,967	2,117	11.4
Kentucky	357	612	978	1,127	1,196	9.7
Louisiana	436	742	1,059	1,208	1,269	8.6
Mississippi	227	381	595	680	720	9.3
North Carolina	565	939	1,616	1,892	2,027	10.3
South Carolina	274	454	786	922	978	10.3
Tennessee	460	791	1,308	1,532	1,635	10.2
Virginia	503	905	1,614	1,890	2,015	11.3
West Virginia	184	314	479	545	574	9.1
Southwest	2,194	3,861	5,954	7,013	7,538	10.0
Arizona	262	484	863	1,031	1,124	11.9
New Mexico	103	192	319	379	409	11.2
Oklahoma	307	508	721	829	874	8.4
Texas	1,522	2,677	4,052	4,773	5,131	9.8
Rocky Mountains	562	978	1,496	1,789	1,945	10.0
Colorado	255	459	704	843	919	10.4
Idaho	83	130	198	242	265	9.3
Montana	64	113	168	195	209	9.5
Utah	118	205	334	404	439	10.7
Wyoming	42	71	92	106	113	7.8
Far West	3,424	5,862	9,796	11,523	12,243	10.3
Alaska	44	84	126	154	165	10.8
California	2,514	4,341	7,294	8,527	9,017	10.3
Hawaii	109	211	339	393	416	10.9
Nevada	87	146	288	369	408	12.6
Oregon	264	392	602	710	762	8.5
Washington	406	688	1,146	1,370	1,474	10.4

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 18. Prescription Drug Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	12,049	21,405	38,198	45,730	48,840	11.4
New England	625	1,217	2,250	2,578	2,710	11.9
Connecticut	174	312	544	622	650	10.7
Maine	51	93	174	202	213	11.6
Massachusetts	290	596	1,113	1,270	1,337	12.5
New Hampshire	39	77	160	185	197	13.3
Rhode Island	48	96	174	198	206	11.8
Vermont	22	43	86	101	108	13.0
Mideast	2,100	3,884	6,990	8,148	8,590	11.4
Delaware	25	49	98	120	129	13.3
District of Columbia	32	57	93	101	103	9.5
Maryland	226	443	888	1,069	1,140	13.3
New Jersey	381	723	1,298	1,515	1,601	11.7
New York	820	1,506	2,665	3,077	3,232	11.1
Pennsylvania	616	1,105	1,948	2,267	2,386	11.0
Great Lakes	2,219	3,850	6,691	7,895	8,360	10.7
Illinois	561	1,006	1,771	2,084	2,206	11.1
Indiana	305	508	874	1,038	1,106	10.4
Michigan	527	939	1,654	1,947	2,054	11.0
Ohio	607	1,010	1,684	1,982	2,095	10.0
Wisconsin	218	387	708	844	899	11.5
Plains	887	1,495	2,557	3,012	3,195	10.4
Iowa	156	255	419	490	516	9.6
Kansas	128	218	373	439	465	10.5
Minnesota	191	324	580	691	739	11.0
Missouri	274	461	783	919	975	10.2
Nebraska	80	136	235	277	293	10.5
North Dakota	28	51	86	98	103	10.6
South Dakota	30	50	82	97	104	10.0
Southeast	3,011	5,356	9,811	11,872	12,759	11.7
Alabama	235	404	707	845	904	10.9
Arkansas	153	235	382	452	484	9.3
Florida	536	1,041	2,135	2,627	2,832	13.7
Georgia	294	540	1,035	1,283	1,397	12.7
Kentucky	225	392	667	791	846	10.7
Louisiana	254	440	668	788	832	9.5
Mississippi	142	241	399	468	499	10.1
North Carolina	340	569	1,061	1,287	1,392	11.5
South Carolina	154	268	511	622	665	11.9
Tennessee	288	500	886	1,072	1,153	11.2
Virginia	275	522	1,026	1,248	1,343	13.0
West Virginia	116	204	333	389	412	10.3
Southwest	1,198	2,116	3,512	4,326	4,709	11.1
Arizona	123	250	526	659	728	14.7
New Mexico	52	101	190	237	259	13.2
Oklahoma	175	299	450	535	569	9.5
Texas	848	1,467	2,346	2,896	3,153	10.6
Rocky Mountains	279	498	865	1,089	1,203	11.9
Colorado	127	223	379	481	534	11.7
Idaho	44	74	129	164	182	11.6
Montana	31	54	90	110	120	11.0
Utah	54	110	218	274	302	14.2
Wyoming	23	37	49	59	64	8.2
Far West	1,730	2,988	5,523	6,810	7,313	11.7
Alaska	16	34	58	77	85	13.7
California	1,296	2,274	4,222	5,155	5,501	11.8
Hawaii	44	87	148	184	197	12.2
Nevada	36	67	158	218	246	15.8
Oregon	125	187	318	396	431	10.0
Washington	212	340	618	781	853	11.3

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 19. Vision Products and Other Medical Durable Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	4,495	7,067	10,511	11,997	12,636	8.3
New England	206	340	525	582	608	8.7
Connecticut	67	107	165	184	192	8.5
Maine	16	26	40	44	46	8.4
Massachusetts	91	153	233	258	269	8.7
New Hampshire	12	22	37	41	43	10.3
Rhode Island	12	19	29	32	33	8.2
Vermont	8	13	20	23	24	8.9
Mideast	916	1,433	2,107	2,394	2,505	8.0
Delaware	14	19	28	33	35	7.4
District of Columbia	19	24	30	33	34	4.6
Maryland	95	147	226	259	272	8.4
New Jersey	155	249	384	436	457	8.7
New York	398	636	919	1,043	1,090	8.1
Pennsylvania	235	358	520	590	617	7.7
Great Lakes	818	1,247	1,790	2,005	2,103	7.5
Illinois	228	350	510	576	604	7.8
Indiana	100	159	228	257	270	7.9
Michigan	180	267	393	437	457	7.4
Ohio	223	328	455	507	531	6.9
Wisconsin	88	143	203	228	240	8.0
Plains	373	547	769	870	914	7.1
Iowa	61	93	127	141	148	7.0
Kansas	44	67	91	102	107	7.0
Minnesota	104	156	229	263	277	7.8
Missouri	100	144	205	232	244	7.1
Nebraska	39	50	67	77	80	5.7
North Dakota	12	19	25	27	28	7.1
South Dakota	12	19	26	28	30	7.0
Southeast	879	1,440	2,246	2,608	2,756	9.2
Alabama	52	82	125	147	155	8.7
Arkansas	21	33	48	53	56	8.0
Florida	256	430	705	824	872	9.9
Georgia	103	169	267	311	331	9.4
Kentucky	50	77	115	134	141	8.3
Louisiana	69	102	134	153	160	6.7
Mississippi	26	35	49	57	60	6.8
North Carolina	77	133	217	253	268	10.1
South Carolina	33	59	95	109	115	10.2
Tennessee	69	116	186	216	228	9.6
Virginia	98	160	244	280	295	8.8
West Virginia	27	44	63	70	74	8.1
Southwest	493	738	1,053	1,222	1,299	7.7
Arizona	62	108	181	212	227	10.5
New Mexico	22	37	56	65	69	9.3
Oklahoma	50	76	101	115	121	7.0
Texas	359	517	716	830	883	7.2
Rocky Mountains	149	239	341	402	430	8.5
Colorado	75	121	178	210	226	8.9
Idaho	14	21	28	33	35	7.1
Montana	15	24	30	34	36	6.8
Utah	36	60	91	109	117	9.4
Wyoming	9	13	14	16	17	5.1
Far West	660	1,083	1,679	1,914	2,021	9.0
Alaska	13	19	21	25	26	5.3
California	473	807	1,274	1,446	1,522	9.4
Hawaii	23	34	51	61	64	8.1
Nevada	21	34	58	70	76	10.2
Oregon	40	58	79	85	91	6.4
Washington	89	131	196	228	242	8.0

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 20. Nursing Home Care Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	17,649	30,679	50,923	62,297	66,201	10.7
New England	1,407	2,542	4,932	5,640	5,839	11.6
Connecticut	373	703	1,408	1,646	1,749	12.6
Maine	120	196	361	440	453	10.8
Massachusetts	675	1,208	2,455	2,716	2,737	11.4
New Hampshire	66	126	204	240	268	11.4
Rhode Island	124	246	376	456	485	11.1
Vermont	49	63	130	143	148	8.9
Mideast	4,818	8,437	13,269	15,960	17,021	10.2
Delaware	46	93	173	203	217	12.8
District of Columbia	26	73	142	213	231	18.3
Maryland	254	549	920	1,092	1,185	12.6
New Jersey	497	915	1,731	2,056	2,128	11.8
New York	2,796	4,677	7,013	8,502	9,106	9.5
Pennsylvania	1,200	2,130	3,289	3,894	4,153	10.0
Great Lakes	3,182	5,666	9,503	11,886	12,526	11.1
Illinois	830	1,480	2,311	3,006	3,148	10.8
Indiana	406	738	1,472	1,914	2,018	13.1
Michigan	607	920	1,502	1,765	1,849	8.9
Ohio	793	1,689	2,828	3,563	3,758	12.7
Wisconsin	545	840	1,389	1,639	1,752	9.4
Plains	1,816	3,110	4,632	5,523	5,844	9.4
Iowa	334	480	735	878	927	8.2
Kansas	213	342	576	682	721	9.8
Minnesota	589	1,053	1,477	1,776	1,884	9.4
Missouri	361	705	1,096	1,302	1,368	10.8
Nebraska	184	279	379	449	482	7.7
North Dakota	58	135	201	237	246	11.8
South Dakota	78	116	169	199	216	8.2
Southeast	2,746	5,111	8,988	11,558	12,509	12.4
Alabama	186	347	495	658	703	10.8
Arkansas	192	286	430	531	558	8.5
Florida	414	1,109	2,244	2,855	3,089	16.7
Georgia	285	448	776	961	1,038	10.5
Kentucky	243	421	623	782	850	10.1
Louisiana	246	426	786	1,070	1,186	12.9
Mississippi	134	192	310	419	460	10.0
North Carolina	271	548	1,080	1,409	1,562	14.4
South Carolina	161	241	474	596	638	11.2
Tennessee	258	453	768	1,000	1,085	11.7
Virginia	295	510	736	937	976	9.7
West Virginia	61	130	265	342	365	14.7
Southwest	1,262	2,063	3,476	4,321	4,633	10.5
Arizona	83	179	448	515	567	15.9
New Mexico	33	77	162	200	215	15.6
Oklahoma	218	365	593	713	748	10.0
Texas	929	1,442	2,273	2,893	3,104	9.7
Rocky Mountains	406	662	1,059	1,262	1,378	9.9
Colorado	210	338	513	614	661	9.2
Idaho	51	80	131	175	197	10.9
Montana	49	87	153	167	178	10.5
Utah	75	120	207	237	260	10.0
Wyoming	21	37	54	69	83	11.3
Far West	2,011	3,087	5,065	6,145	6,451	9.4
Alaska	22	32	45	54	56	7.3
California	1,344	2,014	3,320	3,939	4,103	9.0
Hawaii	46	95	139	174	181	11.2
Nevada	31	54	111	145	164	13.7
Oregon	198	319	527	642	656	9.7
Washington	371	573	922	1,192	1,291	10.1

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 21. Other Personal Health Care Expenditures and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	3,953	6,015	11,220	15,622	17,988	12.4
New England	276	406	958	1,408	1,654	14.8
Connecticut	78	115	282	422	467	14.7
Maine	21	26	72	113	153	16.7
Massachusetts	131	186	408	542	597	12.4
New Hampshire	17	33	77	108	136	17.4
Rhode Island	18	26	76	152	219	21.2
Vermont	12	19	43	70	82	15.9
Mideast	916	1,380	2,348	3,040	3,524	10.9
Delaware	13	19	38	66	79	15.2
District of Columbia	43	66	96	120	130	8.9
Maryland	73	104	222	301	312	11.9
New Jersey	137	208	420	504	570	11.6
New York	440	672	1,035	1,358	1,635	10.6
Pennsylvania	210	311	537	692	798	10.8
Great Lakes	665	895	1,516	2,138	2,358	10.2
Illinois	174	240	405	582	636	10.5
Indiana	91	133	181	254	264	8.5
Michigan	140	172	325	470	532	10.8
Ohio	184	222	349	444	511	8.2
Wisconsin	76	128	256	389	415	13.9
Plains	241	383	736	1,035	1,213	13.2
Iowa	32	47	83	112	127	11.3
Kansas	27	41	85	118	140	13.5
Minnesota	70	127	240	325	386	14.0
Missouri	66	99	186	291	346	13.6
Nebraska	22	28	68	88	99	12.2
North Dakota	10	18	35	48	52	13.6
South Dakota	15	24	38	53	63	11.8
Southeast	838	1,326	2,489	3,486	4,128	13.0
Alabama	71	104	197	274	323	12.4
Arkansas	31	39	66	111	127	11.5
Florida	146	265	540	764	912	15.1
Georgia	105	167	336	431	516	13.1
Kentucky	45	79	152	206	228	13.2
Louisiana	61	93	157	265	328	13.8
Mississippi	46	57	95	120	141	9.0
North Carolina	85	134	247	343	413	12.9
South Carolina	59	92	194	262	317	13.8
Tennessee	66	105	170	225	235	10.2
Virginia	91	147	261	350	395	12.0
West Virginia	31	45	77	133	192	15.0
Southwest	333	516	988	1,628	1,883	14.3
Arizona	56	74	134	220	230	11.4
New Mexico	29	38	78	113	131	12.4
Oklahoma	43	55	98	170	196	12.4
Texas	204	348	677	1,125	1,325	15.5
Rocky Mountains	142	225	402	552	610	11.9
Colorado	79	130	228	299	327	11.5
Idaho	11	14	34	48	55	13.2
Montana	17	28	48	66	74	11.7
Utah	18	27	62	91	99	13.8
Wyoming	16	26	31	48	55	10.2
Far West	543	884	1,782	2,335	2,619	12.9
Alaska	20	29	45	61	68	9.9
California	369	616	1,225	1,451	1,565	11.7
Hawaii	26	42	77	92	104	11.3
Nevada	14	21	40	60	67	12.9
Oregon	39	72	157	299	391	19.4
Washington	75	105	238	371	425	14.3

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 22. Medicare Expenditures for Personal Health Care and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	36,249	70,063	109,123	134,804	150,374	11.6
New England	2,195	4,124	6,162	7,837	8,829	11.3
Connecticut	513	929	1,550	1,928	2,134	11.6
Maine	177	301	442	533	605	9.9
Massachusetts	1,144	2,247	3,203	4,116	4,712	11.5
New Hampshire	113	209	329	435	473	11.6
Rhode Island	178	331	470	604	664	10.7
Vermont	71	108	168	220	241	9.9
Mideast	7,602	14,809	22,741	27,223	30,438	11.3
Delaware	86	155	268	333	377	12.0
District of Columbia	207	334	512	568	603	8.6
Maryland	555	1,112	2,024	2,463	2,692	12.9
New Jersey	1,075	2,337	3,365	4,390	4,838	12.3
New York	3,358	5,902	9,206	10,642	11,872	10.2
Pennsylvania	2,320	4,969	7,366	8,828	10,056	11.9
Great Lakes	6,740	12,199	17,702	21,445	23,508	10.1
Illinois	2,018	3,619	4,769	5,865	6,404	9.3
Indiana	682	1,395	2,232	2,836	3,126	12.4
Michigan	1,710	2,906	4,136	4,817	5,405	9.3
Ohio	1,630	3,018	4,692	5,758	6,177	10.8
Wisconsin	700	1,260	1,873	2,170	2,397	9.9
Plains	2,981	5,252	7,619	9,059	9,861	9.6
Iowa	458	772	1,136	1,310	1,447	9.3
Kansas	388	661	985	1,210	1,326	9.9
Minnesota	680	1,148	1,751	2,042	2,164	9.3
Missouri	1,006	1,889	2,595	3,128	3,439	9.9
Nebraska	241	386	576	685	746	9.1
North Dakota	115	216	304	351	374	9.5
South Dakota	93	178	272	332	364	11.0
Southeast	7,687	15,975	26,995	34,770	38,805	13.3
Alabama	526	1,048	1,794	2,354	2,625	13.2
Arkansas	326	656	1,068	1,347	1,422	12.0
Florida	2,416	5,095	8,728	10,950	12,484	13.5
Georgia	642	1,340	2,320	3,243	3,549	14.1
Kentucky	425	850	1,543	1,917	2,143	13.3
Louisiana	499	1,171	1,958	2,448	2,730	14.0
Mississippi	290	572	981	1,244	1,367	12.7
North Carolina	690	1,424	2,384	3,231	3,553	13.4
South Carolina	294	618	1,001	1,348	1,541	13.6
Tennessee	697	1,447	2,409	3,151	3,549	13.3
Virginia	617	1,207	1,986	2,483	2,736	12.1
West Virginia	266	547	824	1,053	1,106	11.6
Southwest	2,837	5,677	9,437	11,873	13,271	12.6
Arizona	424	985	1,720	2,134	2,276	13.8
New Mexico	128	277	442	514	565	12.1
Oklahoma	436	764	1,205	1,521	1,665	10.9
Texas	1,849	3,650	6,071	7,704	8,765	12.7
Rocky Mountains	683	1,359	2,134	2,699	3,104	12.4
Colorado	353	682	1,082	1,352	1,556	12.1
Idaho	85	173	246	340	384	12.3
Montana	91	172	279	346	391	11.8
Utah	117	261	421	532	624	13.8
Wyoming	37	72	106	129	150	11.4
Far West	5,525	10,668	16,332	19,899	22,558	11.4
Alaska	17	38	71	93	101	14.9
California	4,360	8,355	12,514	15,200	17,347	11.2
Hawaii	99	199	351	433	496	13.2
Nevada	136	278	499	605	732	13.8
Oregon	389	713	1,124	1,362	1,521	11.1
Washington	523	1,085	1,775	2,206	2,360	12.3

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 23. Medicaid Expenditures for Personal Health Care and Average Annual Percent Growth, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993	Average Annual Percent Growth 1980-93
			Millions of Dollars
United States	24,743	39,024	71,561	103,731	112,776	12.5
New England	1,875	2,884	6,088	8,068	7,880	11.9
Connecticut	346	626	1,277	1,857	1,998	14.7
Maine	148	246	449	669	722	13.1
Massachusetts	1,083	1,546	3,464	3,923	3,689	10.3
New Hampshire	75	122	260	661	446	17.0
Rhode Island	160	257	480	731	793	13.3
Vermont	63	87	159	227	232	10.9
Mideast	7,205	11,766	19,952	27,875	29,865	11.6
Delaware	47	73	137	220	249	14.2
District of Columbia	164	304	416	595	678	12.0
Maryland	439	640	1,199	1,807	1,924	12.3
New Jersey	756	1,178	2,473	3,555	3,857	13.6
New York	4,504	7,636	12,550	16,546	18,041	11.3
Pennsylvania	1,294	1,934	3,177	5,153	5,116	11.5
Great Lakes	4,513	7,010	11,454	16,693	18,054	11.4
Illinois	1,294	1,707	2,401	4,205	4,609	10.8
Indiana	394	770	1,525	2,410	2,777	16.3
Michigan	1,199	1,694	2,710	3,522	3,865	9.6
Ohio	873	1,827	3,326	4,558	4,665	14.0
Wisconsin	753	1,013	1,493	1,999	2,138	8.5
Plains	1,593	2,603	4,437	6,314	6,700	11.9
Iowa	244	367	654	907	960	11.3
Kansas	199	267	505	682	769	11.2
Minnesota	611	1,027	1,488	1,948	2,229	10.6
Missouri	314	552	1,087	1,790	1,648	14.2
Nebraska	113	172	330	495	561	13.3
North Dakota	51	123	201	253	269	14.3
South Dakota	61	95	172	240	264	12.1
Southeast	3,975	6,502	14,228	21,478	23,891	15.0
Alabama	294	434	812	1,201	1,276	12.6
Arkansas	249	376	612	919	1,007	11.6
Florida	418	953	2,576	4,056	4,697	20.6
Georgia	483	773	1,593	2,288	2,753	14.5
Kentucky	321	541	1,087	1,624	1,683	13.9
Louisiana	420	745	1,460	2,329	2,664	15.5
Mississippi	222	284	632	962	1,043	13.1
North Carolina	431	677	1,577	2,297	2,564	14.9
South Carolina	265	354	919	1,248	1,324	13.8
Tennessee	384	621	1,474	2,133	2,183	14.6
Virginia	376	564	1,047	1,485	1,621	12.1
West Virginia	112	181	439	935	1,075	19.9
Southwest	1,379	2,290	4,840	7,992	8,775	15.7
Arizona	0	101	568	1,189	1,270	51.4
New Mexico	75	154	300	507	577	17.3
Oklahoma	290	461	722	1,007	1,013	10.3
Texas	1,014	1,573	3,250	5,289	5,914	15.0
Rocky Mountains	406	667	1,289	1,897	2,193	14.1
Colorado	191	306	570	795	967	13.6
Idaho	53	75	164	270	290	14.5
Montana	69	104	198	279	322	13.1
Utah	78	152	285	431	477	15.2
Wyoming	15	29	72	123	137	18.9
Far West	3,797	5,303	9,273	13,414	15,418	11.7
Alaska	39	69	155	218	273	16.2
California	3,047	4,143	6,941	9,834	11,330	10.9
Hawaii	97	141	212	296	354	10.8
Nevada	49	70	153	329	344	17.3
Oregon	186	262	547	820	955	13.7
Washington	379	618	1,265	1,917	2,161	14.6

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 24. Number of Medicare Enrollees and Medicare Expenditures for Personal Health Care, by Type of Service, by Region and State: Calendar Year 1993.

Region and State	Number of Enrollees1 (Thousands)	Total Personal Health Care	Hospital Care	Physician Services	Other Professional Services	Home Health Care	Medical Durables	Nursing Home Care
				Millions of Dollars
United States	35,557	150,374	94,226	34,555	5,559	8,023	3,696	4,315
New England	1,988	8,829	5,559	1,698	359	718	123	372
Connecticut	490	2,134	1,258	477	88	167	29	115
Maine	194	605	391	116	22	58	12	7
Massachusetts	911	4,712	3,017	834	199	378	69	215
New Hampshire	149	473	309	91	16	39	7	11
Rhode Island	165	664	425	139	28	47	4	22
Vermont	79	241	160	42	7	28	2	3
Mideast	6,520	30,438	19,933	6,973	1,064	956	848	665
Delaware	96	377	240	85	16	16	12	8
District of Columbia	79	603	445	111	20	15	3	9
Maryland	580	2,692	1,778	611	95	79	73	56
New Jersey	1,142	4,838	2,944	1,347	144	118	205	80
New York	2,583	11,872	7,907	2,717	427	375	207	240
Pennsylvania	2,041	10,056	6,619	2,102	362	353	348	271
Great Lakes	6,071	23,508	15,441	4,953	811	986	573	744
Illinois	1,592	6,404	4,219	1,332	228	284	210	131
Indiana	803	3,126	2,105	601	70	147	41	162
Michigan	1,306	5,405	3,449	1,197	224	257	152	127
Ohio	1,626	6,177	4,066	1,329	223	223	125	210
Wisconsin	745	2,397	1,603	494	66	74	45	114
Plains	2,738	9,861	6,815	2,049	303	263	214	216
Iowa	469	1,447	1,043	287	47	33	29	8
Kansas	377	1,326	887	276	55	43	43	21
Minnesota	616	2,164	1,430	481	57	53	52	90
Missouri	815	3,439	2,395	691	105	113	64	71
Nebraska	245	746	527	159	20	13	16	11
North Dakota	102	374	269	81	10	5	4	6
South Dakota	114	364	264	75	8	2	7	8
Southeast	9,150	38,805	23,075	8,943	1,574	3,056	1,156	1,002
Alabama	619	2,625	1,613	508	101	272	67	64
Arkansas	411	1,422	962	281	53	64	40	22
Florida	2,519	12,484	6,438	3,674	547	801	542	482
Georgia	793	3,549	2,187	698	143	348	94	79
Kentucky	565	2,143	1,376	472	86	115	45	50
Louisiana	562	2,730	1,749	497	113	303	55	13
Mississippi	384	1,367	839	264	59	166	25	14
North Carolina	973	3,553	2,252	784	162	210	55	89
South Carolina	482	1,541	978	290	77	110	50	36
Tennessee	739	3,549	2,107	618	100	528	113	82
Virginia	781	2,736	1,817	609	101	101	52	55
West Virginia	322	1,106	756	247	33	37	17	15
Southwest	3,211	13,271	8,318	2,888	541	949	307	268
Arizona	561	2,276	1,298	664	99	94	44	78
New Mexico	199	565	354	130	23	29	13	16
Oklahoma	474	1,665	1,108	317	49	146	30	16
Texas	1,977	8,765	5,558	1,777	371	681	220	158
Rocky Mountains	898	3,104	2,042	615	82	156	87	123
Colorado	396	1,556	1,013	319	49	63	50	61
Idaho	143	384	257	73	10	17	8	19
Montana	125	391	271	78	8	13	9	11
Utah	177	624	399	119	13	55	13	26
Wyoming	57	150	101	25	3	9	6	5
Far West	4,955	22,558	13,044	6,437	824	940	389	924
Alaska	30	101	76	17	3	2	2	1
California	3,499	17,347	9,895	5,093	641	735	292	691
Hawaii	141	496	306	156	11	12	6	6
Nevada	172	732	411	215	22	44	18	22
Oregon	454	1,521	932	392	50	50	27	70
Washington	659	2,360	1,425	563	97	97	44	134

¹Number of aged and disabled persons enrolled in the Hospital and/or Supplementary Medical Insurance programs as of July 1, 1993, by State of residence. U.S. total includes enrollees with unknown State of residence.

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 25. Medicaid Recipients and Expenditures for Personal Health Care, by Type of Service, by Region and State: 1993.

Region and State	Number of Medicaid Recipients1 (Thousands)	Total Personal Health Care	Hospital Care	Physician Services	Dental Services	Other Professional Services	Home Health Care	Prescription Drugs	Nursing Home Care	Other Personal Health Care
				Millions of Dollars
United States	32,664	112,776	46,108	12,471	1,541	1,320	3,166	7,647	32,427	8,096
New England	1,618	7,880	2,431	555	72	35	276	419	3,139	953
Connecticut	334	1,998	546	102	13	10	64	97	929	238
Maine	169	722	204	54	6	6	14	50	284	104
Massachusetts	765	3,689	1,308	297	40	13	187	195	1,354	294
New Hampshire	79	446	85	57	4	3	4	26	173	93
Rhode Island	191	793	240	16	4	2	3	31	327	170
Vermont	81	232	48	28	4	1	4	19	72	54
Mideast	5,393	29,865	12,320	2,090	177	544	1,803	1,525	9,776	1,631
Delaware	69	249	84	17	1	2	10	13	83	40
District of Columbia	120	678	337	67	2	2	18	23	213	17
Maryland	445	1,924	935	227	4	2	47	110	473	126
New Jersey	794	3,857	1,719	198	35	11	107	262	1,266	260
New York	2,742	18,041	7,298	1,273	103	512	1,587	709	5,701	859
Pennsylvania	1,223	5,116	1,948	308	33	16	35	408	2,040	328
Great Lakes	5,094	18,054	7,244	1,900	167	158	315	1,276	5,873	1,120
Illinois	1,396	4,609	2,165	347	36	35	8	299	1,431	289
Indiana	565	2,777	1,024	384	35	38	34	229	937	95
Michigan	1,172	3,865	1,559	555	41	16	173	227	1,023	271
Ohio	1,491	4,665	1,967	430	40	54	23	333	1,639	178
Wisconsin	471	2,138	529	183	16	15	77	188	843	286
Plains	1,863	6,700	2,429	615	83	54	136	491	2,293	599
Iowa	289	960	392	106	21	9	14	78	304	37
Kansas	243	769	289	93	8	5	8	55	246	64
Minnesota	425	2,229	758	171	25	22	91	112	821	228
Missouri	609	1,648	640	116	15	9	16	176	517	160
Nebraska	165	561	188	73	8	4	6	44	191	48
North Dakota	62	269	86	26	4	3	1	13	106	31
South Dakota	70	264	76	30	3	2	1	14	109	30
Southeast	8,635	23,891	9,188	3,815	306	183	371	1,965	6,361	1,700
Alabama	522	1,276	393	157	8	10	17	125	408	159
Arkansas	339	1,007	410	183	7	8	32	65	245	56
Florida	1,745	4,697	1,875	631	46	55	73	414	1,217	387
Georgia	955	2,753	1,153	478	32	29	33	212	633	183
Kentucky	618	1,683	590	361	40	20	47	163	369	94
Louisiana	751	2,664	1,077	323	23	0	17	196	832	195
Mississippi	504	1,043	449	173	2	1	7	115	249	47
North Carolina	898	2,564	954	382	37	18	76	163	806	130
South Carolina	470	1,324	495	210	13	8	7	91	358	142
Tennessee	909	2,183	858	404	23	12	15	193	612	66
Virginia	576	1,621	643	242	12	9	6	155	429	125
West Virginia	347	1,075	292	271	62	14	42	74	202	117
Southwest	3,340	8,775	4,044	1,043	77	102	186	491	1,987	845
Arizona	404	1,270	1,035	171	1	2	3	7	8	44
New Mexico	241	577	259	89	6	27	4	31	103	58
Oklahoma	387	1,013	350	101	8	7	20	75	362	90
Texas	2,308	5,914	2,401	683	62	66	159	378	1,513	652
Rocky Mountains	664	2,193	863	332	27	19	26	132	545	249
Colorado	281	967	426	144	5	1	6	51	213	120
Idaho	100	290	103	38	7	7	7	20	82	25
Montana	89	322	100	40	5	6	9	21	102	40
Utah	148	477	179	90	7	5	3	32	116	45
Wyoming	46	137	54	20	2	0	1	8	32	19
Far West	6,056	15,418	7,589	2,120	632	224	52	1,348	2,453	999
Alaska	65	273	125	56	8	2	1	12	48	21
California	4,834	11,330	6,300	1,503	555	143	15	1,096	1,316	402
Hawaii	110	354	141	49	10	3	1	25	99	27
Nevada	88	344	143	52	7	5	6	13	97	21
Oregon	325	955	243	87	7	3	8	72	239	297
Washington	633	2,161	638	373	46	69	21	130	654	231

¹Medicaid recipient data from the Health Care Financing Administration, Medicaid Bureau, as reported on HCFA Form-2082 for fiscal year 1993.

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 26. Medicare and Medicaid Personal Health Care Expenditures as a Share of Total Personal Health Care Expenditures, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993
	Percent
United States	28.2	29.1	29.7	32.8	33.8
New England	31.8	31.5	32.0	35.8	35.2
Connecticut	27.3	27.8	28.3	32.7	33.8
Maine	35.0	34.4	33.0	37.6	38.6
Massachusetts	33.5	33.7	34.8	36.6	35.9
New Hampshire	26.9	23.8	23.4	35.2	26.6
Rhode Island	34.6	34.5	34.8	42.1	42.5
Vermont	33.6	28.6	27.7	32.0	31.6
Mideast	33.4	34.9	34.7	37.8	38.7
Delaware	23.9	22.8	23.7	26.5	27.7
District of Columbia	26.7	27.9	26.3	28.9	29.9
Maryland	24.4	24.9	27.2	30.1	30.5
New Jersey	28.4	30.2	29.3	33.1	33.8
New York	39.0	40.7	40.5	43.2	44.6
Pennsylvania	30.7	33.1	32.5	36.1	36.5
Great Lakes	28.0	29.5	29.2	32.2	32.9
Illinois	28.3	29.0	26.1	30.6	31.7
Indiana	23.5	28.2	29.9	34.4	36.0
Michigan	31.1	31.1	31.2	32.8	34.2
Ohio	24.7	27.8	30.0	32.8	32.4
Wisconsin	32.8	32.6	29.7	30.8	31.3
Plains	27.6	28.7	28.6	31.0	31.4
Iowa	27.0	29.1	29.7	31.8	32.8
Kansas	25.9	25.9	27.0	28.8	30.4
Minnesota	30.5	29.8	28.1	29.9	31.0
Missouri	27.4	29.8	29.2	33.0	31.9
Nebraska	24.2	24.5	26.1	28.5	29.7
North Dakota	26.4	29.4	31.2	31.4	31.8
South Dakota	26.5	28.5	29.8	31.6	32.1
Southeast	26.7	28.2	30.2	33.9	35.2
Alabama	26.0	27.2	28.5	31.7	32.3
Arkansas	32.9	34.4	34.7	39.4	39.7
Florida	28.9	30.4	32.2	35.8	38.3
Georgia	24.6	24.9	25.6	29.7	31.3
Kentucky	27.5	29.5	33.6	36.3	36.8
Louisiana	25.7	29.5	34.6	39.6	41.4
Mississippi	29.0	29.2	34.2	39.0	39.0
North Carolina	26.6	28.8	28.9	32.7	33.5
South Carolina	26.7	26.1	28.7	31.0	31.7
Tennessee	26.6	28.7	31.9	35.0	35.4
Virginia	22.9	22.5	22.9	25.4	26.1
West Virginia	23.8	27.8	32.4	41.1	42.0
Southwest	22.6	23.4	26.0	29.6	30.5
Arizona	17.3	22.4	27.0	33.6	33.3
New Mexico	22.1	24.1	25.6	28.6	29.4
Oklahoma	28.1	28.2	30.7	33.6	33.3
Texas	22.6	22.7	25.0	28.2	29.5
Rocky Mountains	20.3	21.0	22.9	25.3	27.1
Colorado	19.9	19.6	21.4	22.9	25.1
Idaho	21.9	23.4	24.8	29.1	29.6
Montana	25.7	26.5	29.7	32.3	33.9
Utah	18.6	21.4	22.3	25.2	26.7
Wyoming	15.4	17.1	22.4	27.4	28.7
Far West	26.7	26.2	26.1	28.3	30.1
Alaska	12.6	12.1	18.3	20.9	23.8
California	27.9	27.0	26.2	28.4	30.4
Hawaii	21.4	20.4	20.6	22.4	24.4
Nevada	22.1	22.6	23.5	26.9	28.7
Oregon	24.4	25.4	27.2	29.7	31.0
Washington	23.6	25.0	27.2	29.3	29.9

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.

Table 27. Medicare Personal Health Care Expenditures as a Share of Total Personal Health Care Expenditures, by Region and State: Selected Calendar Years 1980-93.

Region and State of Provider	1980	1985	1990	1992	1993
	Percent
United States	16.7	18.7	17.9	18.5	19.3
New England	17.1	18.6	16.1	17.6	18.6
Connecticut	16.3	16.6	15.5	16.7	17.5
Maine	19.0	18.9	16.4	16.7	17.6
Massachusetts	17.2	20.0	16.7	18.7	20.1
New Hampshire	16.2	15.0	13.0	14.0	13.7
Rhode Island	18.2	19.4	17.2	19.0	19.4
Vermont	17.9	15.8	14.2	15.8	16.1
Mideast	17.1	19.5	18.5	18.7	19.5
Delaware	15.5	15.5	15.7	16.0	16.7
District of Columbia	14.9	14.6	14.5	14.1	14.1
Maryland	13.6	15.8	17.1	17.4	17.8
New Jersey	16.6	20.1	16.9	18.3	18.8
New York	16.7	17.8	17.1	16.9	17.7
Pennsylvania	19.7	23.8	22.7	22.8	24.2
Great Lakes	16.8	18.7	17.7	18.1	18.6
Illinois	17.2	19.7	17.4	17.8	18.4
Indiana	14.9	18.2	17.8	18.6	19.1
Michigan	18.3	19.7	18.8	18.9	19.9
Ohio	16.1	17.3	17.6	18.3	18.5
Wisconsin	15.8	18.1	16.5	16.0	16.5
Plains	18.0	19.2	18.0	18.3	18.7
Iowa	17.6	19.7	18.9	18.8	19.7
Kansas	17.2	18.4	17.9	18.4	19.2
Minnesota	16.0	15.8	15.2	15.3	15.2
Missouri	20.9	23.1	20.6	21.0	21.6
Nebraska	16.5	17.0	16.6	16.6	17.0
North Dakota	18.3	18.7	18.8	18.3	18.5
South Dakota	16.1	18.6	18.2	18.4	18.6
Southeast	17.6	20.0	19.8	21.0	21.8
Alabama	16.7	19.2	19.6	21.0	21.8
Arkansas	18.7	21.8	22.0	23.4	23.3
Florida	24.7	25.6	24.8	26.1	27.9
Georgia	14.0	15.8	15.2	17.4	17.7
Kentucky	15.6	18.0	19.7	19.7	20.6
Louisiana	13.9	18.0	19.8	20.3	21.0
Mississippi	16.4	19.5	20.8	22.0	22.1
North Carolina	16.4	19.5	17.4	19.1	19.5
South Carolina	14.1	16.6	14.9	16.1	17.1
Tennessee	17.1	20.1	19.8	20.9	21.9
Virginia	14.2	15.3	15.0	15.9	16.4
West Virginia	16.8	20.9	21.1	21.8	21.3
Southwest	15.2	16.7	17.2	17.7	18.3
Arizona	17.3	20.3	20.3	21.6	21.4
New Mexico	13.9	15.5	15.3	14.4	14.6
Oklahoma	16.9	17.6	19.2	20.2	20.7
Texas	14.6	15.8	16.3	16.7	17.6
Rocky Mountains	12.7	14.1	14.3	14.9	15.9
Colorado	12.9	13.5	14.0	14.5	15.5
Idaho	13.6	16.4	14.9	16.2	16.9
Montana	14.7	16.5	17.4	17.9	18.6
Utah	11.1	13.5	13.3	13.9	15.2
Wyoming	10.9	12.1	13.4	14.0	15.0
Far West	15.8	17.5	16.6	16.9	17.9
Alaska	3.7	4.3	5.7	6.3	6.4
California	16.4	18.1	16.9	17.2	18.4
Hawaii	10.8	11.9	12.8	13.3	14.2
Nevada	16.2	18.1	18.0	17.4	19.5
Oregon	16.5	18.6	18.3	18.5	19.0
Washington	13.7	16.0	15.9	15.7	15.6

SOURCE: Health Care Financing Administration, Office of the Actuary: Estimates prepared by the Office of National Health Statistics.