APPENDIX C. NATIONAL AND INTERNATIONAL HEALTH CARE EXPENDITURES AND
HEALTH INSURANCE COVERAGE
CONTENTS
National Health Expenditures
Expenditures for Hospital Care
Trends in Hospital Utilization
Admissions
Average Length of Stay
Hospital Occupancy
Hospital Employment
Expenditures for Physicians' Services
Supply of Hospital Beds
Supply of Physicians
Health Insurance Status in 1995
Health Insurance Coverage and Selected Population
Characteristics
Characteristics of the Uninsured Population Under Age 65
Trends in Health Insurance Coverage
Uncompensated Care Costs in PPS Hospitals, 1980-95
International Health Spending
References
NATIONAL HEALTH EXPENDITURES
In 1965, the year prior to the beginning of the Medicare
and Medicaid Programs, national health expenditures were only
$41.1 billion. After adjusting for inflation, this spending
figure represented $199.1 billion, or $975.60 per capita in
constant 1995 dollars. Health care expenditures increased
substantially over the next 30 years. In 1995, the Nation's
health care bill was $3,621.20 per capita, or $988.5 billion
for the 273 million persons residing in the United States (see
tables C-1 and C-2).
The annual rate of increase in inflation-adjusted per
capita expenditures was 4.8 percent from 1980 to 1985 and 5.0
percent from 1985 to 1990 (table C-3). After increasing by 5.8
percent between 1991 and 1992, however, health expenditure
growth per capita decelerated to 2.8 percent for 1992 to 1993
and 1.5 percent for 1993 to 1994. This figure increased
slightly to 1.6 for 1994-95. Growth in spending between 1993
and 1995, however, remains the slowest in more than three
decades.
TABLE C-1.--NATIONAL HEALTH EXPENDITURES, SELECTED CALENDAR YEARS 1960-95
[Dollar amounts in billions]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Spending category 1960 1965 1970 1975 1980 1985 1990 1991 1992 1993 1994 1995
--------------------------------------------------------------------------------------------------------------------------------------------------------
Health services and supplies.................. $25.2 $37.7 $67.9 $122.3 $235.6 $411.8 $672.9 $736.3 $806.7 $863.1 $906.7 $957.8
Personal health care...................... 23.6 35.2 63.8 114.5 217.0 376.4 614.7 676.6 740.5 786.9 827.9 878.8
Hospital care......................... 9.3 14.0 28.0 52.6 102.7 168.3 256.4 282.3 305.4 323.3 335.0 350.1
Physicians' services.................. 5.3 8.2 13.6 23.9 45.2 83.6 146.3 159.2 175.7 182.7 190.6 201.6
Dentists' services.................... 2.0 2.8 4.7 8.0 13.3 21.7 31.6 33.3 37.0 39.2 42.1 45.8
Other professional services........... 0.6 0.9 1.4 2.7 6.4 16.6 34.7 38.3 42.1 46.3 49.1 52.6
Home health care...................... 0.1 0.1 0.2 0.6 2.4 5.6 13.1 16.1 19.6 23.0 26.3 28.6
Drugs and other medical nondurables... 4.2 5.9 8.8 13.0 21.6 37.1 59.9 65.6 71.2 75.0 77.7 83.4
Vision products and other medical
durables............................. 0.6 1.0 1.6 2.5 3.8 6.7 10.5 11.2 11.9 12.5 12.9 13.8
Nursing home care..................... 0.8 1.5 4.2 8.7 17.6 30.7 50.9 57.2 62.3 67.0 72.4 77.9
Other personal health care............ 0.7 0.8 1.3 2.5 4.0 6.1 11.2 13.6 15.4 17.9 21.7 25.0
Program administration and net cost of
private health insurance................. 1.2 1.9 2.7 4.9 11.8 23.8 38.6 38.8 42.7 50.9 50.6 47.7
Government public health activities....... 0.4 0.6 1.3 2.9 6.7 11.6 19.6 21.4 23.4 25.3 28.2 31.4
Research and construction of medical
facilities................................... 1.7 3.4 5.3 8.4 11.6 16.4 24.5 24.9 27.5 29.0 30.4 30.7
---------------------------------------------------------------------------------------------------------
Total................................... 26.9 41.1 73.2 130.7 247.2 428.2 697.5 761.7 834.2 892.1 937.1 988.5
=========================================================================================================
Percent of GDP.......................... 5.1 5.7 7.1 8.0 8.9 10.2 12.1 12.9 13.4 13.6 13.5 13.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note.--Numbers may not add to totals due to rounding.
Source: Health Care Financing Administration, Office of the Actuary: Data from the Office of National Health Statistics.
TABLE C-2.--NATIONAL HEALTH EXPENDITURES IN CONSTANT 1995 DOLLARS, SELECTED CALENDAR YEARS 1960-95
[Dollar amounts in billions]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Spending category 1960 1965 1970 1975 1980 1985 1990 1991 1992 1993 1994 1995
--------------------------------------------------------------------------------------------------------------------------------------------------------
Health services and supplies................ $129.6 $182.4 $266.7 $346.6 $435.8 $583.3 $784.7 $824.4 $876.3 $910.3 $932.4 $957.8
Personal health care.................... 121.7 170.1 250.7 324.4 401.4 533.2 716.7 757.0 804.4 829.9 851.4 878.8
Hospital care....................... 47.8 67.9 110.0 148.9 189.9 238.4 299.0 315.8 331.7 340.9 344.5 350.1
Physicians' services................ 27.2 39.6 53.3 67.7 83.7 118.4 170.6 178.1 190.9 192.6 196.0 201.6
Dentists' services.................. 10.1 13.5 18.3 22.5 24.6 30.7 36.8 37.3 40.2 41.4 43.3 45.8
Other professional services......... 3.1 4.2 5.5 7.7 11.7 23.6 40.4 42.8 45.7 48.9 50.5 52.6
Home health care.................... 0.3 0.4 0.9 1.8 4.4 8.0 15.3 18.0 21.3 24.2 27.0 28.6
Drugs and other medical nondurables. 21.9 28.5 34.6 36.9 40.0 52.5 69.9 73.4 77.3 79.1 79.9 83.4
Visions products and other medical
durables........................... 3.3 4.8 6.4 7.2 7.0 9.6 12.2 12.5 12.9 13.2 13.2 13.8
Nursing home care................... 4.4 7.1 16.6 24.6 32.6 43.5 59.4 64.0 67.7 70.7 74.5 77.9
Other personal health care.......... 3.6 4.0 5.1 7.0 7.4 8.7 13.1 15.2 16.7 18.9 22.4 25.0
Program administration and net cost of
private health insurance............... 6.0 9.3 10.7 13.9 21.9 33.7 45.1 43.4 46.4 53.7 52.0 47.7
Government public health activities..... 1.9 3.0 5.3 8.3 12.5 16.5 22.9 24.0 25.4 26.7 29.0 31.4
Research and construction of medical
facilities................................. 8.8 16.6 21.0 23.7 21.5 23.2 28.6 27.9 29.9 30.6 31.3 30.7
-----------------------------------------------------------------------------------------------------------
Total................................. 138.4 199.1 287.7 370.3 457.3 606.5 813.3 852.3 906.2 940.8 963.7 988.5
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note.--Constant dollar expenditures are calculated using the Consumer Price Index for all Urban Consumers (CPI-U). Totals may not equal sum of rounded
components.
Source: Health Care Financing Administration, Office of the Actuary. Data from the Office of National Health Statistics.
TABLE C-3.--NATIONAL HEALTH EXPENDITURES: PER CAPITA AMOUNTS IN CONSTANT 1995 DOLLARS AND AVERAGE ANNUAL PERCENTAGE INCREASES, SELECTED CALENDAR YEARS
1960-95
[Dollar amounts per capita]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Spending category 1960 1965 1970 1975 1980 1985 1990 1991 1992 1993 1994 1995
--------------------------------------------------------------------------------------------------------------------------------------------------------
Health services and supplies...... $682.1 $894.1 $1241.6 $1543.4 $1853.3 $2360.1 $3018.3 $3139.7 $3303.7 $3398.3 $3447.9 $3508.9
Personal health care.............. 640.5 833.8 1167.2 1444.5 1707.2 2157.3 2757.0 2883.2 3032.8 3098.4 3148.2 3219.3
Hospital care................. 251.5 332.9 512.1 663.2 807.8 964.4 1150.2 1202.9 1250.6 1272.9 1273.7 1282.6
Physicians' services.......... 143.3 194.2 248.3 301.6 355.8 479.2 656.4 678.3 719.6 719.2 724.9 738.6
Dentists' services............ 53.2 66.2 85.4 100.4 104.8 124.1 141.6 142.1 151.6 154.5 160.0 167.9
Other professional services... 16.4 20.5 25.7 34.4 50.0 95.4 155.5 163.1 172.4 182.4 186.9 192.7
Home health care.............. 1.5 2.1 4.0 7.8 18.7 32.3 58.8 68.4 80.4 90.5 100.0 104.7
Drugs and other medical
nondurables.................. 115.2 139.7 161.1 164.3 170.1 212.4 268.7 279.4 291.5 295.4 295.5 305.5
Vision products and other
medical durables............. 17.6 23.7 29.7 32.2 29.6 38.7 46.9 47.7 48.7 49.2 48.9 50.5
Nursing home care............. 23.0 34.9 77.1 109.3 138.8 175.8 228.4 243.6 255.1 263.9 275.5 285.3
Other personal health care.... 18.8 19.5 23.7 31.3 31.6 35.1 50.4 57.8 62.9 70.4 82.7 91.5
Program administration and net
cost of private health insurance. 31.6 45.7 49.8 61.9 93.1 136.2 173.3 165.2 175.0 200.3 192.4 174.6
Government public health
activities....................... 10.0 14.6 24.6 36.9 53.0 66.6 88.0 91.3 95.9 99.5 107.2 115.0
Research and construction of
medical facilities............... 46.1 81.5 97.8 105.8 91.5 93.8 110.0 106.2 112.8 114.2 115.7 112.3
---------------------------------------------------------------------------------------------------------------------
Total....................... 728.1 975.6 1,339.5 1,649.1 1,944.8 2,454.0 3,128.3 3,246.0 3,416.5 3,512.5 3,563.6 3,621.2
---------------------------------------------------------------------------------------------------------------------
Average annual percentage increase
---------------------------------------------------------------------------------------------------------------------
60-65 65-70 70-75 75-80 80-85 85-90 91-92 92-93 93-94 94-95
---------------------------------------------------------------------------------------------------------------------
Health services and supplies...... 5.6 6.8 4.4 3.7 5.0 5.0 5.2 2.9 1.5 1.8
Personal health care.............. 5.4 7.0 4.4 3.4 4.8 5.0 5.2 2.2 1.6 2.3
Hospital care................. 5.8 9.0 5.3 4.0 3.6 3.6 4.0 1.8 0.1 0.7
Physicians' services.......... 6.3 5.0 4.0 3.4 6.1 6.5 6.1 -0.1 0.8 1.9
---------------------------------------------------------------------------------------------------------------------
Total....................... 6.0 6.5 4.2 3.4 4.8 5.0 5.3 2.8 1.5 1.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note.--Constant dollar expenditures are calculated using the Consumer Price Index for all Urban Consumers (CPI-U). Totals may not equal sum of rounded
components.
Source: Health Care Financing Administration, Office of the Actuary. Data from the Office of National Health Statistics.
The majority of health spending is for personal health care
services that treat or prevent illness and disease in
individuals. In 1995, 88.9 percent of all health spending
($878.8 billion) was for personal health care. The remaining
11.1 percent ($109.7 billion) was spent on health program
administration; administrative costs and profits earned by
private health insurers; public health activities;
noncommercial health research; and new construction of health
facilities.
Hospital care ($350.1 billion) and physician services
($201.6 billion) are the two largest categories of personal
health care spending. They accounted for 35.4 percent and 20.4
percent of total national health expenditures. Two other major
service areas, prescription drugs and other medical
nondurables, and nursing home care, each added approximately 8
percent.
The private sector, including private health insurance,
out-of-pocket spending, and philanthropy, continues to finance
the majority of personal health care expenditures (55.4
percent) with combined expenditures of $486.7 billion. Public
sources, however, are responsible for an increasing portion of
spending. Government's share has grown from 20.6 percent in
1965 to 44.6 percent in 1995 (see table C-4). The Federal
Government is now the single largest contributor, accounting
for 34.5 percent ($303.6 billion) of personal health spending
in 1995. State and local governments funded another 10.1
percent ($88.5 billion).
The initial growth in Federal Government spending is
attributed to the beginning of the Medicare and Medicaid
Programs and the expansion of Medicare to cover the disabled
population in 1973. In 1965, before the enactment of these
programs, the Federal Government contribution represented 8.4
percent of personal health spending. By 1970, the Federal
Government's share had increased to 23 percent and to 27
percent by 1975. Between 1980 and 1990 the portion remained
steady at approximately 29 percent, but since 1990, this figure
has gradually increased to 34.5 percent in 1995.
In contrast, while the share paid by private sources also
remained stable at about 60 percent from 1980 to 1990, this
portion declined to 55.4 percent in 1995, reflecting the
influence of increased enrollment in managed care plans (Levit,
Lazenby & Braden, 1996).
EXPENDITURES FOR HOSPITAL CARE
In 1995, hospitals accounted for 35 percent of total
national health expenditures, down from 42 percent in 1980.
Table C-5 shows several measures of costs incurred by community
hospitals, which include all non-Federal short-term general
hospitals. These hospitals' total expenses (including inpatient
and outpatient acute and postacute care, as well as nonpatient
care activities) reached $320.8 billion in 1996. This was up
4.0 percent from the previous year, the smallest rise in
hospital costs in at least 30 years. With the increases of 5.0
percent in 1994 and 5.3 percent in 1995, hospital costs have
been growing more slowly than in any previous 3-year period.
That inpatient expenses increased more slowly than total
expenses reflects the growing share of activity in the hospital
outpatient setting.
TABLE C-4.--PERSONAL HEALTH CARE EXPENDITURES: AGGREGATE AMOUNTS AND PERCENTAGE DISTRIBUTION, SELECTED CALENDAR YEARS 1960-95
--------------------------------------------------------------------------------------------------------------------------------------------------------
Spending source 1960 1965 1970 1975 1980 1985 1990 1991 1992 1993 1994 1995
--------------------------------------------------------------------------------------------------------------------------------------------------------
Amount in billions of dollars
----------------------------------------------------------------------------------------------------------------
Private................................ $18.5 $27.9 $41.3 $69.2 $130.0 $228.4 $371.7 $400.0 $433.4 $453.0 $466.7 $486.7
Private health insurance........... 5.0 8.7 14.8 28.4 62.0 113.8 201.8 221.6 243.2 255.4 264.5 276.8
Out-of-pocket payments............. 13.1 18.5 24.9 38.1 60.3 100.6 148.4 155.0 165.8 171.6 176.0 182.6
Other private sources of funds..... 0.4 0.7 1.6 2.7 7.8 14.1 21.5 23.4 24.4 26.1 26.2 27.3
Public................................. 5.1 7.3 22.5 45.3 87.3 148.0 243.0 276.6 307.1 333.9 361.2 392.1
Federal............................ 2.1 3.0 14.7 30.9 63.4 111.3 178.1 205.8 233.5 255.9 278.1 303.6
State and local.................... 3.0 4.3 7.8 14.4 23.6 36.7 64.9 70.8 73.6 78.0 83.1 88.5
----------------------------------------------------------------------------------------------------------------
Total.......................... 23.6 35.2 63.8 114.5 217.0 376.4 614.7 676.6 740.5 786.9 827.9 878.8
----------------------------------------------------------------------------------------------------------------
Percentage distribution
----------------------------------------------------------------------------------------------------------------
Private................................ 78.3 79.4 64.7 60.4 59.9 60.7 60.5 59.1 58.5 57.6 56.4 55.4
Private health insurance........... 21.2 24.7 23.2 24.8 28.6 30.2 32.8 32.8 32.8 32.5 31.9 31.5
Out-of-pocket payments............. 55.3 52.7 39.0 33.3 27.8 26.7 24.1 22.9 22.4 21.8 21.3 20.8
Other private sources of funds..... 1.8 2.0 2.6 2.4 3.6 3.7 3.5 3.5 3.3 3.3 3.2 3.1
Public................................. 21.7 20.6 35.3 39.6 40.1 39.3 39.5 40.9 41.5 42.4 43.6 44.6
Federal............................ 9.0 8.4 23.0 27.0 29.2 29.6 29.0 30.4 31.5 32.5 33.6 34.5
State and local.................... 12.6 12.2 12.2 12.5 10.9 9.7 10.6 10.5 9.9 9.9 10.0 10.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note.--Totals may not equal sum of rounded components. Percentage amounts are calculated on unrounded numbers.
Source: Health Care Financing Administration, Office of the Actuary. Data from the Office of National Health Statistics.
TABLE C-5.--SELECTED DATA ON COMMUNITY HOSPITAL EXPENSES, 1965-96
----------------------------------------------------------------------------------------------------------------
Total expenses Expenses per Expenses per Inpatient expenses
-------------------- adjusted adjusted \1\
inpatient day admission -------------------
Year Amount Percent ------------------------------------ Amount
(in change Percent Percent (in Percent
billions) Amount change Amount change billions) change
----------------------------------------------------------------------------------------------------------------
1965................................ $9.220 8.6 $41 7.5 $315 8.1 $8.414 8.7
1966................................ 10.497 13.8 46 11.4 356 13.1 9.611 14.2
1967................................ 12.624 20.3 53 15.3 425 19.1 11.551 20.2
1968................................ 14.720 16.6 59 11.5 482 13.4 13.372 15.8
1969................................ 17.247 17.2 68 15.4 551 14.5 15.636 16.9
1970................................ 20.261 17.5 78 13.8 608 10.3 18.329 17.2
1971................................ 22.496 11.0 87 12.3 670 10.1 20.269 10.6
1972................................ 25.223 12.1 96 10.3 729 8.8 22.622 11.6
1973................................ 28.248 12.0 105 9.2 784 7.5 25.173 11.3
1974................................ 32.759 16.0 118 12.3 873 11.4 29.077 15.5
1975................................ 38.492 17.5 138 16.4 1,017 16.5 33.971 16.8
1976................................ 45.842 19.1 158 15.0 1,168 14.8 40.321 18.7
1977................................ 53.006 15.6 181 14.3 1,312 12.3 46.437 15.2
1978................................ 59.802 12.8 203 12.1 1,466 11.8 52.131 12.3
1979................................ 67.833 13.4 226 11.5 1,618 10.4 59.060 13.3
1980................................ 79.340 17.0 256 12.9 1,836 13.5 68.962 16.8
1981................................ 94.187 18.7 299 16.9 2,155 17.4 81.634 18.4
1982................................ 109.091 15.8 348 16.2 2,489 15.5 94.346 15.6
1983................................ 120.220 10.2 391 12.4 2,742 10.2 103.361 9.6
1984................................ 126.028 4.8 443 13.3 2,947 7.5 107.005 3.5
1985................................ 134.043 6.4 493 11.3 3,226 9.5 111.416 4.1
1986................................ 146.032 8.9 535 8.6 3,527 9.3 119.286 7.1
1987................................ 161.322 10.5 581 8.6 3,860 9.5 129.824 8.8
1988................................ 177.770 10.2 632 8.8 4.194 8.7 140.482 8.2
1989................................ 195.378 9.9 690 9.3 4,586 9.3 152.147 8.3
1990................................ 217.113 11.1 765 10.7 5,021 9.5 165.792 9.0
1991................................ 238.633 9.9 844 10.3 5,461 8.8 178.401 7.6
1992................................ 260.994 9.4 927 9.9 5,905 8.1 191.401 7.3
1993................................ 278.880 6.9 1,000 7.8 6,188 4.8 202.055 5.6
1994................................ 292.801 5.0 1,060 6.0 6,312 2.0 207.918 2.9
1995................................ 308.411 5.3 1,127 6.3 6,427 1.8 214.594 3.2
1996................................ 320.789 4.0 1,188 5.4 6,553 2.0 218.013 1.6
----------------------------------------------------------------------------------------------------------------
\1\ Inpatient expenses estimated from total expenses, based on the proportion of inpatient to total revenues.
Note.--Admissions and inpatient days are adjusted to reflect the volume of outpatient visits as well as
inpatient admissions and days.
Source: Prospective Payment Assessment Commission analysis of data from the American Hospital Association
National Hospital Panel Survey.
The average cost of a day of hospital care (adjusted to
reflect outpatient services) rose by 5.4 percent to $1,188 in
1996. The higher rate of growth in expenses per day reflects a
decrease in the number of hospital days (see the discussion of
average length of stay below). However, combined with the 6.0-
percent increase in 1994 and 6.3 percent in 1995, this also
produced the smallest 3 year growth rate in more than 3
decades.
The average cost per case (also adjusted to reflect
outpatient care) rose to $6,553 in 1996, an increase of only
2.0 percent. From 1994 through 1996, the increase in costs per
case averaged 1.9 percent per year, compared with 9.1 percent
from 1985 through 1992 and 14.0 percent from 1975 through 1982.
Chart C-1 presents the real annual growth in expenses per
adjusted admission. This chart provides a clearer picture of
the actual rate of increase in costs per case by removing the
effects of general inflation. Even after taking inflation into
account, the recent trend in hospital costs differs sharply
from previous years. In 1994, hospital costs per case rose more
slowly than inflation for the first time since 1979. In 1995
and 1996, costs per case grew even more slowly relative to
inflation.
CHART C-1. REAL ANNUAL CHANGES IN HOSPITAL EXPENSES PER ADJUSTED
ADMISSION (IN PERCENT), 1965-96
Source: Prospective Payment Assessment Commission analysis
of data from the American Hospital Association National
Hospital Panel Survey.
A variety of factors other than general inflation
contribute to aggregate changes in hospital costs, and the
roles of these factors may vary widely over time. Chart C-2
displays the contributions of five factors: general inflation,
hospital input prices, population growth, utilization, and
intensity. Between 1985 and 1992, total hospital expenses rose
at an annual rate of 10 percent. The largest contributor to
this increase was the intensity of hospital care; that is, the
resources used per patient. During this period, general
inflation also accounted for a large share of the increase in
hospital expenses. Hospital input prices rose faster than the
general price level, and hospital utilization per person
actually fell (as the number of adjusted admissions grew more
slowly than the population).
CHART C-2. FACTORS CONTRIBUTING TO GROWTH OF TOTAL HOSPITAL EXPENSES,
1985-92 AND 1992-96
Note._Hospital expenses grew at an annual rate of 10.0
percent between 1985 and 1992 and 5.3 percent between 1992 and
1996.
Source: Prospective Payment Assessment Commission.
Between 1992 and 1996, the increase in total hospital
expenses was only 5.3 percent per year. Because of this,
although it slowed from 3.9 percent between 1985 and 1992 to
2.8 percent between 1992 and 1996, general inflation accounted
for more than half of the hospital cost increase in the latter
period. Hospital utilization per person, which had fallen in
the earlier period, rose substantially between 1992 and 1996,
accounting for a large share of the growth in hospital
expenses. Finally, intensity, which had been the major
contributor to cost growth in the earlier period, was almost
level between 1992 and 1996.
Expenditures for hospital care are financed primarily by
third parties, as shown in table C-6. In 1995, private health
insurers paid 32.3 percent of the total, Medicare 32.2 percent,
and Medicaid (including both the Federal and State shares) 14.8
percent. The share financed by out-of-pocket payments from
individuals was only 3.3 percent in 1995, down from 5.2 percent
in 1980.
TABLE C-6.--NATIONAL EXPENDITURES FOR HOSPITAL CARE BY SOURCE OF FUNDS, SELECTED YEARS 1980-95
[Amounts in billions]
----------------------------------------------------------------------------------------------------------------
1980 1985 1990 1995
Source of payment -----------------------------------------------------------------------
Amount Percent Amount Percent Amount Percent Amount Percent
----------------------------------------------------------------------------------------------------------------
Out of pocket........................... $5.3 5.2 $8.8 5.2 $9.8 3.8 $11.4 3.3
Third-party payments.................... 97.4 94.8 159.4 94.8 246.8 96.2 338.7 96.7
Private health insurance.............. 38.7 37.7 61.0 36.3 95.7 37.3 113.1 32.3
Other private funds................... 5.0 4.9 8.3 4.9 13.8 5.4 11.3 3.2
Government............................ 53.7 52.3 90.1 53.6 137.3 53.5 214.3 61.2
Federal............................. 40.9 39.8 71.1 42.3 103.4 40.3 175.4 50.1
Medicare.......................... 26.3 25.6 48.9 29.1 68.5 26.7 112.6 32.2
Medicaid\1\....................... 4.6 4.4 7.4 4.4 14.9 5.8 37.2 10.6
Other Federal..................... 9.9 9.7 14.8 8.8 20.0 7.8 25.5 7.3
State and local..................... 12.8 12.5 19.0 11.3 33.9 13.2 39.0 11.1
Medicaid\2\....................... 3.9 3.8 6.3 3.7 11.6 4.5 14.8 4.2
Other State and local............. 8.9 8.7 12.8 7.6 22.3 8.7 24.2 6.9
-----------------------------------------------------------------------
Total........................... $102.7 100.0 $168.2 100.0 $256.5 100.0 $350.1 100.0
----------------------------------------------------------------------------------------------------------------
\1\ Federal share only.
\2\ State and local share only.
Source: Prospective Payment Assessment Commission analysis of data from the Health Care Financing
Administration, Office of the Actuary.
TRENDS IN HOSPITAL UTILIZATION
Admissions
From 1978 through 1983, total inpatient admissions
increased at an annual rate of 1.0 percent, and admissions for
persons 65 and over increased an average of 4.8 percent per
year, as shown in table C-7.
TABLE C-7.--ANNUAL CHANGE IN HOSPITAL ADMISSIONS BY AGE GROUP, 1978-96
------------------------------------------------------------------------
Percent change in admissions
--------------------------------
Year 65 and
All Under 65 over
------------------------------------------------------------------------
1978................................... 0.4 -1.0 4.9
1979................................... 2.7 1.7 5.3
1980................................... 2.9 1.5 6.7
1981................................... 0.9 0.0 3.0
1982................................... 0.0 -1.6 4.1
1983................................... -0.5 -2.8 4.7
1984................................... -3.7 -4.2 -2.6
1985................................... -4.9 -4.7 -5.2
1986................................... -2.1 -2.5 -1.0
1987................................... -0.6 -1.0 0.4
1988................................... -0.4 -1.6 2.0
1989................................... -1.0 -2.0 1.2
1990................................... -0.5 -1.6 1.7
1991................................... -1.1 -2.9 2.5
1992................................... -0.8 -2.2 1.7
1993................................... 0.7 -0.5 2.9
1994................................... 0.9 0.2 2.0
1995................................... 1.4 0.4 2.9
1996................................... -0.4 -0.8 0.4
--------------------------------
Average annual percent change
--------------------------------
1978-83................................ 1.0 -0.4 4.8
1984-86................................ -3.5 -3.8 -3.0
1987-92................................ -0.7 -1.9 1.6
1993-96................................ 0.7 -0.2 2.1
------------------------------------------------------------------------
Source: Prospective Payment Assessment Commission analysis of data from
the American Hospital Association National Hospital Panel Survey.
With the introduction of Medicare's prospective payment
system (PPS) in 1983, the number of elderly patients declined
sharply, contrary to most expectations. Admissions of patients
under 65, however, fell even more during the first few years of
PPS and had been decreasing for several years before that. From
1987 through 1992, total admissions continued to decrease, but
at a slower rate, due to an increase among the older
population. In 1993, overall admissions increased for the first
time in 12 years, due to a slower rate of decline in younger
patients and a continuing increase in those 65 and over. This
trend continued until 1995 when total admissions increased 1.4
percent over the previous year, the largest increase in 15
years. In 1996, however, total admissions decreased 0.4 percent
from the previous year due to fewer admissions in the under 65
population and only a small increase in the number of
admissions among the elderly.
Average Length of Stay
Before the implementation of PPS, the average length of
stay for all patients was relatively constant between 7.0 and
7.2 days, as shown in table C-8. With the introduction of PPS,
however, there was a significant drop in length of stay. From
1982 to 1984, the average stay fell from 7.2 days to 6.7 days
for all patients and from 10.1 days to 8.9 days for patients 65
and over. Average length of stay stabilized at these levels
throughout the rest of the 1980s, but has declined again in the
1990s. Hospital stays for elderly patients were 2.0 days
shorter, on average, in 1996 than in 1990, and for patients
under 65 the average stay was 0.6 days shorter. This decline
was even steeper than in the first years of PPS.
TABLE C-8.--AVERAGE LENGTH OF STAY AND ANNUAL CHANGE BY AGE GROUP, 1978-96
----------------------------------------------------------------------------------------------------------------
All Under 65 65 and over
-----------------------------------------------------------------
Average Average Average
Year length of Percent length of Percent length of Percent
stay (in change stay (in change stay (in change
days) days) days)
----------------------------------------------------------------------------------------------------------------
1978.......................................... 7.2 -0.3 6.0 -0.9 10.6 -1.2
1979.......................................... 7.1 -1.0 5.9 -1.2 10.4 -1.9
1980.......................................... 7.2 0.5 5.9 -0.2 10.4 -0.1
1981.......................................... 7.2 0.4 5.9 0.1 10.4 -0.1
1982.......................................... 7.2 -0.6 5.9 -0.6 10.1 -2.3
1983.......................................... 7.0 -2.0 5.8 -1.7 9.7 -4.4
1984.......................................... 6.7 -5.1 5.6 -3.5 8.9 -7.5
1985.......................................... 6.5 -1.7 5.5 -1.3 8.8 -2.1
1986.......................................... 6.6 0.6 5.6 0.5 8.8 0.4
1987.......................................... 6.6 0.8 5.6 0.4 8.9 1.0
1988.......................................... 6.6 -0.1 5.6 -0.3 8.8 -0.7
1989.......................................... 6.6 0.1 5.5 -0.7 8.8 0.2
1990.......................................... 6.6 -1.1 5.4 -1.5 8.7 -1.5
1991.......................................... 6.5 -1.4 5.3 -2.1 8.5 -2.0
1992.......................................... 6.4 -1.6 5.2 -1.9 8.3 -2.2
1993.......................................... 6.2 -2.8 5.1 -1.8 7.9 -4.7
1994.......................................... 6.0 -3.8 4.9 -3.8 7.6 -4.2
1995.......................................... 5.7 -4.2 4.8 -2.4 7.1 -6.6
1996.......................................... 5.5 -3.3 4.8 -1.3 6.7 -5.6
-----------------------------------------------------------------
Average annual percent change
-----------------------------------------------------------------
1978-83....................................... ........... -0.5 ........... -0.8 ........... -1.7
1984-86....................................... ........... -2.1 ........... -1.4 ........... -3.1
1987-92....................................... ........... -0.6 ........... -1.0 ........... -0.9
1993-96....................................... ........... -3.5 ........... -2.3 ........... -5.3
----------------------------------------------------------------------------------------------------------------
Source: Prospective Payment Assessment Commission analysis of data from the American Hospital Association
National Hospital Panel Survey.
Hospital Occupancy
Table C-9 shows that, with slight increases in admissions
and stable average length of stay, occupancy rates were over 70
percent in the early 1980s. The number of hospital beds was
increasing, exceeding 1 million by 1983. During the early years
of PPS, however, occupancy rates decreased dramatically. From
1983 to 1986, the aggregate occupancy rate fell from 72.2
percent to 63.4 percent. There was a slight increase in
occupancy rates in the late 1980s, but the sharp reduction in
average length of stay lowered the occupancy rate below 60
percent by 1995, despite almost 130,000 fewer beds than in
1983. In 1996, occupancy rates decreased 1.3 percent from the
previous year, to 58.9 percent.
TABLE C-9.--INPATIENT HOSPITAL OCCUPANCY RATE AND NUMBER OF BEDS, 1978-96
----------------------------------------------------------------------------------------------------------------
Occupancy
Year Inpatient days rate (in Percent Number of Percent
percent) change beds change
----------------------------------------------------------------------------------------------------------------
1978................................................ 256,708,259 73.7 -0.8 954,001 0.9
1979................................................ 260,791,942 74.5 1.0 959,269 0.6
1980................................................ 269,615,111 76.1 2.2 970,456 1.2
1981................................................ 272,956,933 75.8 -0.4 986,917 1.7
1982................................................ 271,422,385 74.5 -1.6 997,720 1.1
1983................................................ 264,504,444 72.2 -3.1 1,003,658 0.6
1984................................................ 241,779,724 66.7 -7.6 992,616 -1.1
1985................................................ 226,128,547 63.6 -4.7 974,559 -1.8
1986................................................ 222,903,834 63.4 -0.3 963,133 -1.2
1987................................................ 223,441,342 64.1 1.2 954,458 -0.9
1988................................................ 222,312,614 64.6 0.8 942,306 -1.3
1989................................................ 220,360,991 64.8 0.3 930,994 -1.2
1990................................................ 216,836,360 64.5 -0.6 921,447 -1.0
1991................................................ 211,474,700 63.5 -1.4 911,781 -1.0
1992................................................ 206,440,330 62.3 -1.9 907,661 -0.5
1993................................................ 202,077,589 61.4 -1.5 901,669 -0.7
1994................................................ 196,116,784 60.3 -1.7 890,575 -1.2
1995................................................ 190,377,347 59.7 -1.1 874,250 -1.8
1996................................................ 183,495,155 58.9 -1.3 853,561 -2.4
-----------------------------------------------------------
Average annual percent change
-----------------------------------------------------------
1978-83............................................. ................ ......... -0.5 ........... 1.0
1984-86............................................. ................ ......... -4.2 ........... -1.4
1987-92............................................. ................ ......... -0.3 ........... -1.0
1993-96............................................. ................ ......... -1.4 ........... -1.5
----------------------------------------------------------------------------------------------------------------
Source: Prospective Payment Assessment Commission analysis of data from American Hospital Association National
Hospital Panel Survey.
Hospital Employment
Hospitals experienced a significant downturn in total
employment levels at the time PPS was introduced, as shown in
table C-10. During 1984 and 1985, full-time equivalent
employees declined by 2.3 percent. From 1986 through 1993,
however, hospital employment increased. During the late 1970s
and through the 1980s, growth in the number of part-time
personnel exceeded growth in the number of full-time personnel
in every year. In 1992, however, the number of full-time
personnel grew faster than the number of part-time personnel
for the first time in more than 20 years. This trend continued
in 1993, but the increase in both types of personnel slowed
dramatically. In 1994 hospital employment declined for the
first time since the early years of PPS. This was only the
second such period in the past three decades. The number of
hospital employees has continued to decrease; part-time
employees decreased 1.1 percent in 1996 compared to the
previous year, while full-time employees held constant.
TABLE C-10.--ANNUAL PERCENT CHANGE IN HOSPITAL EMPLOYMENT, 1978-96
------------------------------------------------------------------------
Personnel
Year Total --------------------------------
FTEs Total Full time Part time
------------------------------------------------------------------------
1978........................ 3.7 4.1 3.3 6.8
1979........................ 3.5 3.9 2.9 6.7
1980........................ 4.7 5.2 4.0 9.1
1981........................ 5.4 6.0 4.8 9.4
1982........................ 3.7 3.7 3.6 4.1
1983........................ 1.4 1.5 1.2 2.3
1984........................ -2.3 -2.1 -2.6 -0.8
1985........................ -2.3 -2.0 -2.7 -0.1
1986........................ 0.3 0.4 0.2 0.9
1987........................ 0.7 0.9 0.4 2.3
1988........................ 1.1 1.4 0.7 3.3
1989........................ 1.6 1.9 1.2 3.6
1990........................ 2.1 2.3 1.8 3.6
1991........................ 0.6 0.7 0.6 1.0
1992........................ 1.6 1.5 1.7 0.9
1993........................ 0.7 0.6 0.8 0.2
1994........................ -0.8 -0.8 -0.7 -0.9
1995........................ -1.4 -1.4 -1.5 -0.9
1996........................ -0.2 -0.3 0.0 -1.1
-------------------------------------------
Average annual percent change
-------------------------------------------
1978-83..................... 3.7 4.1 3.3 6.4
1984-86..................... -1.4 -1.2 -1.7 0.0
1987-92..................... 1.3 1.5 1.1 2.4
1993-96..................... -0.4 -0.5 -0.4 -0.7
------------------------------------------------------------------------
Source: Prospective Payment Assessment Commission analysis of data from
the American Hospital Association National Hospital Panel Survey.
EXPENDITURES FOR PHYSICIANS' SERVICES
Health care expenditures for physicians' services were
$201.6 billion in 1995, an increase of 5.8 percent from 1994.
This amounted to 20.4 percent of national health expenditures.
Third-party (public expenditures and private insurance)
payments financed over 80 percent of physicians' services. In
1995 private health insurance, the single largest payer, was
responsible for 48.1 percent of these expenditures ($97
billion). In 1980, this portion was only 37.9 percent. Public
expenditures in this area have grown much more slowly, rising
from 28.9 percent in 1980 to 31.7 percent ($64 billion) in
1995. Of this last figure, $40 billion was for Federal Medicare
payments. In contrast, out-of-pocket payments by individuals
for physicians' services have decreased from 32.4 percent in
1980 to 18.3 percent ($6.9 billion) in 1995 (see table C-11).
Inflation in physicians' fees has outpaced that of the U.S.
economy as a whole since 1981 as measured by the Consumer Price
Index (CPI). The inflation rate of 3.6 for 1996, however, is
the lowest since 1973 (see table C-12).
The American Medical Association reports that, over the 10
years from 1984 to 1994, physician income rose an average 5
percent a year. In 1994, however, the average physician net
income experienced the first decrease ever recorded by the AMA.
After expenses but before taxes, average physician income was
$182,400, a 3.6 percent decrease from $189,300 in 1993. In
1995, average physician net income rebounded 7.2 percent to
$195,500. The 2-year change in income, however, amounts to an
average annual increase of only 1.6 percent from 1993 to 1995.
When adjusted for inflation, this represents an average annual
loss of 1.04 percent, with real incomes remaining below those
for 1993.
Changes in the health care market appear to be affecting
the conditions of employment for many physicians (Physician
Payment Review Commission). In 1995, the percentage of
physicians who were self-employed declined from 58 to 55
percent. These doctors, who were more likely to have additional
years of experience and be board certified, earned an average
income of $230,800. This was over 50 percent higher than
employee-doctors whose average net income was only $152,500,
but the difference would be less if noncash benefits received
by employee physicians were included. The share of physicians
who were employees increased from 36 to 39 percent in the same
time period.
Growth in average net income for physicians in the Middle
Atlantic and Pacific areas was well above average in 1995. The
West North Central, Mountain, and New England census regions
saw the least increase in income from 1994 to 1995. Physicians
in the New England States continue to report the lowest average
net income of $161,000; the East South Central region remained
the highest at $216,000 (see table C-13).
TABLE C-11.--EXPENDITURES FOR PHYSICIAN SERVICES \1\ BY SOURCE OF FUNDS, SELECTED YEARS 1980-95
[Amounts in billions]
--------------------------------------------------------------------------------------------------------------------------------------------------------
1980 1985 1990 1993 1994 1995
Source of payment -----------------------------------------------------------------------------------------------------------
Amount Percent Amount Percent Amount Percent Amount Percent Amount Percent Amount Percent
--------------------------------------------------------------------------------------------------------------------------------------------------------
Out-of-pocket payments...................... $14.8 32.4 $24.3 29.1 $35.4 24.2 $37.5 20.6 $37.3 19.6 $36.9 18.3
Third-party payments........................ 30.6 67.6 59.3 70.9 110.9 75.8 145.1 79.4 153.3 80.4 164.8 81.7
Private health insurance.................... 17.1 37.9 23.4 36.9 63.3 43.2 86.5 47.3 91.1 47.8 97.0 48.1
Other private funds......................... 0.4 0.8 1.4 1.6 2.7 1.8 3.1 1.7 3.1 1.6 3.7 1.9
Government.................................. 13.1 28.9 24.5 29.3 45.0 30.7 55.6 30.4 59.1 31.0 64.0 31.7
Federal................................. 10.0 22.1 19.5 23.4 35.9 24.5 43.5 23.8 46.7 24.5 50.9 25.3
Medicare.............................. 8.0 17.6 16.5 19.7 29.5 20.2 33.4 18.3 36.2 19.0 40.0 19.8
Medicaid.............................. 1.4 3.1 2.0 2.4 4.2 2.8 7.6 4.2 8.0 4.2 8.4 4.2
Other Federal programs................ 0.6 1.4 1.1 1.3 2.2 1.5 2.6 1.4 2.5 1.3 2.6 1.3
State and local......................... 3.1 6.9 4.9 5.9 9.1 6.2 12.0 6.6 12.5 6.5 13.1 6.5
Medicaid.............................. 1.1 2.5 1.5 1.9 2.9 2.0 5.0 2.7 5.5 2.9 5.9 2.9
Other State and local programs........ 2.0 4.3 3.4 4.0 6.2 4.2 7.0 3.8 7.0 3.7 7.1 3.5
-----------------------------------------------------------------------------------------------------------
Total............................... 45.2 100.0 83.6 100.0 146.3 100.0 182.7 100.0 190.6 100.0 201.6 100.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Encompasses the cost of all services and supplies provided in physicians' offices, the cost for services of privately billing physicians in
hospitals and other institutions, and the cost of diagnostic work performed in independent clinical laboratories. The salaries of staff physicians are
counted with expenditures for the services of the employing institution.
Note.--Totals may not equal sum of rounded components.
Source: Health Care Financing Administration, Office of the Actuary. Data from the Office of National Health Statistics.
TABLE C-12.--ANNUAL PERCENTAGE CHANGE IN SELECTED COMPONENTS OF THE CONSUMER PRICE INDEX (CPI-U), \1\ 1965-96
----------------------------------------------------------------------------------------------------------------
All items
less Medical Physicians'
Year All items medical care total services
care
----------------------------------------------------------------------------------------------------------------
1965........................................................... 1.6 1.6 2.4 3.6
1966........................................................... 2.9 3.1 4.4 5.6
1967........................................................... 3.1 2.1 7.2 7.2
1968........................................................... 4.2 4.2 6.0 5.6
1969........................................................... 5.5 5.4 6.7 7.0
1970........................................................... 5.7 5.9 6.6 7.5
1971........................................................... 4.4 4.1 6.2 7.0
1972........................................................... 3.2 3.2 3.3 3.0
1973........................................................... 6.2 6.4 4.0 3.4
1974........................................................... 11.0 11.2 9.3 9.2
1975........................................................... 9.1 9.0 12.0 12.1
1976........................................................... 5.8 5.3 9.5 11.4
1977........................................................... 6.5 6.3 9.6 9.1
1978........................................................... 7.6 7.6 8.4 8.4
1979........................................................... 11.3 11.5 9.2 9.1
1980........................................................... 13.5 13.6 11.0 10.5
1981........................................................... 10.3 10.4 10.7 11.0
1982........................................................... 6.2 5.9 11.6 9.4
1983........................................................... 3.2 2.9 8.8 7.8
1984........................................................... 4.3 4.1 6.2 6.9
1985........................................................... 3.6 3.4 6.3 5.9
1986........................................................... 1.9 1.5 7.5 7.2
1987........................................................... 3.6 3.5 6.6 7.3
1988........................................................... 4.1 3.9 6.5 7.2
1989........................................................... 4.8 4.6 7.7 7.4
1990........................................................... 5.4 5.2 9.0 7.1
1991........................................................... 4.2 3.9 8.7 6.0
1992........................................................... 3.0 2.8 7.4 6.3
1993........................................................... 3.0 2.7 5.9 5.6
1994........................................................... 2.6 2.5 4.8 4.4
1995........................................................... 2.8 2.7 4.5 4.5
1996........................................................... 3.0 2.8 3.5 3.6
----------------------------------------------------------------------------------------------------------------
\1\ Consumer Price Index for all Urban Consumers (CPI-U), changes in annual averages.
Source: U.S. Department of Labor, Bureau of Labor Statistics.
Physician net income varies more by specialty than across
geographic areas. Surgeons had the highest average net incomes
in 1995 ($269,400) and general and family practitioners the
lowest ($131,200). Incomes for general and family
practitioners, however, continue to increase at a healthy rate,
with gains from 1993 to 1994 of 3.9 percent and from 1994 to
1995 of 8.1 percent. The largest gain from 1994 to 1995 was by
obstetricians and gynecologists with an increase of 21.9
percent to $244,300. This followed a 9.7 percent decrease in
average net income for this specialty in 1994. Growth in income
for surgeons was below the all-physician average, declining 2.9
percent from 1993 to 1994 and increasing only 5.6 percent from
1994 to 1995 (see table C-13).
TABLE C-13.--PHYSICIANS' AVERAGE NET INCOME AFTER EXPENSES BUT BEFORE TAXES, 1983-95
[Average net income \1\ in thousands of dollars]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Percent
Category 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 change
1994-95
--------------------------------------------------------------------------------------------------------------------------------------------------------
Specialty:
General/family practice........... 68.5 71.1 77.9 80.3 91.5 94.6 95.9 102.7 111.5 114.4 116.8 121.4 131.2 8.1
Internal medicine................. 93.3 103.2 101.0 109.4 121.8 130.9 146.5 152.5 149.6 162.1 180.8 174.9 185.7 6.2
Surgery........................... 145.5 151.8 155.4 162.4 187.9 207.5 220.5 236.4 233.8 250.5 262.7 255.2 269.4 5.6
Pediatrics........................ 70.7 74.5 77.1 81.8 85.3 94.9 104.7 106.5 119.3 123.9 135.4 126.2 140.5 11.3
Obstetrics/gynecology............. 119.9 116.2 122.7 135.9 163.2 180.7 194.3 207.3 221.8 220.7 221.9 200.4 244.3 21.9
Radiology......................... 148.0 139.8 150.8 168.8 180.7 188.5 210.5 219.4 229.8 257.3 259.8 237.4 244.4 2.9
Psychiatry........................ 80.0 85.5 88.6 91.5 102.7 111.4 111.7 116.5 127.6 132.1 131.3 128.5 137.2 6.8
Anesthesiology.................... 144.7 145.4 140.2 150.2 163.1 194.5 185.8 207.4 221.1 231.1 224.1 218.1 215.1 -1.4
Census division:
New England....................... 84.5 87.3 108.3 107.1 110.6 132.9 128.3 142.5 143.8 171.2 171.5 156.1 161.0 3.1
Middle Atlantic................... 98.6 98.4 107.9 114.6 126.1 135.0 152.5 156.1 171.0 172.4 185.3 177.8 207.0 16.4
East North Central................ 114.3 109.4 118.9 126.6 137.6 147.0 155.6 172.4 174.1 187.1 199.2 191.9 198.8 3.6
West North Central................ 110.5 110.7 113.7 120.7 133.9 138.0 159.2 151.4 164.2 187.5 198.2 183.8 184.6 0.4
South Atlantic.................... 106.7 114.5 112.6 119.6 133.8 156.0 165.6 169.0 168.8 186.4 192.5 189.3 198.8 5.0
East South Central................ 114.9 122.2 115.0 122.6 141.2 164.8 173.0 169.0 179.4 180.0 195.0 199.2 216.0 8.4
West South Central................ 124.4 119.1 123.3 129.0 140.4 160.7 170.5 178.8 193.3 193.8 189.1 195.5 205.9 5.3
Mountain.......................... 91.4 102.3 97.5 108.5 125.5 132.1 142.6 170.9 155.0 175.7 193.2 175.4 178.8 1.9
Pacific........................... 103.1 109.4 113.6 119.0 135.4 136.0 148.1 162.5 172.4 178.1 181.2 171.8 189.9 10.5
Location:
Nonmetropolitan................... 87.2 90.9 94.2 107.7 117.9 120.9 129.4 130.5 150.4 159.2 160.0 171.4 157.5 -8.1
Metropolitan:
Less than 1,000,000........... 111.0 115.1 118.1 124.5 140.4 154.1 164.1 172.7 174.8 185.6 195.2 193.0 204.1 5.8
1,000,000 and over............ 106.3 106.4 112.8 117.5 127.9 140.7 153.4 163.3 170.4 181.5 188.5 175.1 193.5 10.5
Employment status:
Self-employed..................... 115.9 118.6 124.5 131.1 146.2 160.0 175.3 185.6 191.0 202.3 218.0 210.2 230.8 9.8
Employee.......................... 77.6 80.4 83.8 91.7 99.6 113.0 119.2 119.8 134.0 136.1 150.7 148.2 152.5 2.9
-----------------------------------------------------------------------------------------------------------------
All physicians \2\............ 104.1 108.4 112.2 119.5 132.3 144.7 155.8 164.3 170.6 181.7 189.3 182.4 195.5 7.2
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Average net income after expenses but before taxes. These figures include contributions made into pension, profit-sharing, and deferred compensation
plans.
\2\ Includes physicians in specialties not reported separately.
Source: American Medical Association (1997a and b).
Table C-14 shows median net income for physicians, the
level below and above which lie half of all earnings. In the
decade from 1985 to 1995, the median income for all physicians
increased each year by an average 5.5 percent. After adjusting
for inflation, this represents a real growth of 1.9 percent
yearly. Pediatrics had the largest yearly increase of 6.3
percent (nominal) or 2.7 percent (real or constant dollars).
Anesthesiology grew only 4.3 percent (nominal) or 0.8 percent
(real or constant dollars) over this same time.
TABLE C-14.--MEDIAN PHYSICIAN NET INCOME AFTER EXPENSES BUT BEFORE TAXES, 1985 AND 1995
[In thousands of dollars]
----------------------------------------------------------------------------------------------------------------
Median net income Average annual
------------------------------ percent change
Category 1995 1995 -------------------
1985 nominal real \1\ Nominal Real \1\
----------------------------------------------------------------------------------------------------------------
Specialty:
General/family practice................................... $70 $124 $88 5.9 2.3
Internal medicine......................................... 90 150 106 5.2 1.6
Surgery................................................... 129 225 159 5.7 2.1
Pediatrics................................................ 70 129 91 6.3 2.7
Obstetrics/gynecology..................................... 120 200 141 5.2 1.6
Radiology................................................. 135 230 162 5.5 1.9
Psychiatry................................................ 80 124 88 4.5 0.9
Anesthesiology............................................ 133 203 143 4.3 0.8
Pathology................................................. 115 185 131 4.9 1.3
Census division:
New England............................................... 94 140 99 4.1 0.5
Middle Atlantic........................................... 90 173 122 6.8 3.1
East North Central........................................ 100 164 116 5.1 1.5
West North Central........................................ 85 160 113 6.5 2.9
South Atlantic............................................ 94 164 116 5.7 2.1
East South Central........................................ 92 175 124 6.6 3.0
West South Central........................................ 100 173 122 5.6 2.0
Mountain.................................................. 85 151 107 5.9 2.3
Pacific................................................... 97 165 116 5.5 1.8
-------------------------------------------------
All physicians \2\.................................... 94 160 113 5.5 1.9
----------------------------------------------------------------------------------------------------------------
\1\ In 1985 dollars.
\2\ Includes physicians in specialties not listed separately.
Source: American Medical Association (1997b).
Table C-15 shows average physician net income in nominal
and real (or constant) dollars. Physicians' average net income
increased 74 percent between 1985 and 1995, but real income,
expressed in 1995 dollars, increased only 23 percent (from
$158,900 to $195,500) over the 10 year period.
TABLE C-15.--AVERAGE PHYSICIAN NET INCOME AFTER EXPENSES BUT BEFORE
TAXES, 1977-95
[Dollars in thousands]
------------------------------------------------------------------------
Year Nominal Real
------------------------------------------------------------------------
1977.............................................. $60.4 $151.9
1978.............................................. 64.6 151.0
1979.............................................. 77.4 162.5
1980.............................................. NA NA
1981.............................................. 89.9 150.7
1982.............................................. 97.7 154.3
1983.............................................. 104.1 159.3
1984.............................................. 108.4 159.0
1985.............................................. 112.2 158.9
1986.............................................. 119.5 166.2
1987.............................................. 132.3 177.5
1988.............................................. 144.7 186.4
1989.............................................. 155.8 191.5
1990.............................................. 164.3 191.6
1991.............................................. 170.6 190.9
1992.............................................. 181.7 197.4
1993.............................................. 189.3 199.6
1994.............................................. 182.4 187.6
1995.............................................. 195.5 195.5
------------------------------------------------------------------------
NA--Not available.
Note.--Real (1995 dollars) incomes are calculated using the Consumer
Price Index for all Urban Consumers.
Source: CRS analysis of data from American Medical Association (1997a
and b).
Table C-16 shows the distribution of physicians' net
incomes in 1995 for all physicians and selected specialties.
While the average net income of all physicians was $195,500,
the median income may be more representative of the typical
physician's earnings. Half of all physicians earned $160,000 or
less. One-fourth of all physicians earned $115,000 or less,
while one-fourth earned $238,000 or more. Median incomes across
all physician specialties remain far apart, with the median
income for gastroenterology at $244,000 in 1995, followed by
surgery at $225,000. On the lower side, general and family
practice and psychiatry reported median incomes of $124,000.
TABLE C-16.--DISTRIBUTION OF PHYSICIAN NET INCOME AFTER EXPENSES BUT
BEFORE TAXES BY SPECIALTY AND CENSUS DIVISION, 1995
[In thousands of dollars]
------------------------------------------------------------------------
25th 75th
Category Mean percentile Median percentile
------------------------------------------------------------------------
Specialty:
General/family practice. $131.2 $90.0 $124.0 $159.0
Internal medicine....... 185.7 110.0 150.0 214.0
General internal
medicine........... 159.5 101.0 138.0 190.0
Cardiovascular
diseases........... 292.3 150.0 210.0 388.0
Gastroenterology.... 256.5 145.0 244.0 315.0
Surgery................. 269.4 160.0 225.0 316.0
General surgery..... 244.4 150.0 203.0 302.0
Otolaryngology...... 232.3 148.0 206.0 282.0
Orthopedic surgery.. 323.2 200.0 250.0 350.0
Ophthalmology....... 240.8 125.0 194.0 260.0
Urological surgery.. 243.4 175.0 220.0 293.0
Pediatrics.............. 140.5 95.0 129.0 175.0
Obstetrics/gynecology... 244.3 150.0 200.0 296.0
Radiology............... 244.4 160.0 230.0 310.0
Psychiatry.............. 137.2 95.0 124.0 160.0
Anesthesiology.......... 215.1 150.0 203.0 262.0
Pathology............... 209.4 130.0 185.0 230.0
Other specialty......... 188.5 127.0 170.0 222.0
Emergency medicine.. 184.4 145.0 170.0 225.0
Neurology........... 197.8 130.0 160.0 225.0
Dermatology......... 214.9 125.0 190.0 238.0
Geographic area:
New England............. 161.0 100.0 140.0 200.0
Middle Atlantic......... 207.0 119.0 173.0 250.0
East North Central...... 198.8 119.0 164.0 250.0
West North Central...... 184.6 108.0 160.0 221.0
South Atlantic.......... 198.8 113.0 164.0 240.0
East South Central...... 216.0 120.0 175.0 282.0
West South Central...... 205.9 124.0 173.0 240.0
Mountain................ 178.8 108.0 151.0 220.0
Pacific................. 189.9 120.0 165.0 220.0
-------------------------------------------
All physicians \1\.. 195.5 115.0 160.0 238.0
------------------------------------------------------------------------
\1\ Includes physicians in specialties not listed separately.
Source: American Medical Association (1997a).
The AMA's Physician Marketplace Statistics 1996 reported
that, on average, nonfederal patient care physicians received
42.9 percent of their incomes from private insurers. Medicare
payments were 27.4 percent; Medicaid was a source of another
11.8 percent of doctor revenue. Patient out-of-pocket payments
accounted for 17.9 percent (see table C-17). The importance of
each source varied by specialty, with physicians specializing
in internal medicine receiving the highest percentage of
revenue from Medicare. Pediatricians, on average, received only
1.3 percent of their income from Medicare, but received the
highest percentage of income from Medicaid (23.6 percent).
TABLE C-17.--PERCENT OF NONFEDERAL PHYSICIAN REVENUE BY SOURCE OF PAYMENT, 1996
----------------------------------------------------------------------------------------------------------------
Private Patient out
Category Medicare Medicaid insurance of pocket
----------------------------------------------------------------------------------------------------------------
Specialty:
General/family practice................................. 23.6 12.9 40.8 22.7
Internal medicine....................................... 40.2 8.8 37.9 13.2
Surgery................................................. 34.9 8.1 43.2 13.8
Pediatrics.............................................. 1.3 23.6 48.8 26.3
Obstetrics/gynecology................................... 8.7 17.9 58.2 15.1
Radiology............................................... 34.9 10.5 39.9 14.8
Psychiatry.............................................. 13.7 11.8 35.9 38.6
Anesthesiology.......................................... 27.4 13.0 46.4 13.3
Pathology............................................... 30.4 10.7 42.2 16.6
Census:
New England............................................. 26.6 11.7 44.6 17.1
Middle Atlantic......................................... 30.2 8.8 43.9 17.1
East North Central...................................... 28.1 11.9 42.3 17.7
West North Central...................................... 28.5 10.2 43.8 17.4
South Atlantic.......................................... 27.9 11.8 42.1 18.2
East South Central...................................... 29.0 15.2 38.5 17.3
West South Central...................................... 27.8 12.0 40.8 19.4
Mountain................................................ 23.9 11.8 46.2 18.1
Pacific................................................. 23.9 13.8 43.8 18.5
---------------------------------------------------
All physicians \1\.................................. 27.4 11.8 42.9 17.9
----------------------------------------------------------------------------------------------------------------
Source: American Medical Association (1997a).
A Medical Economics Continuing Survey addressed physician
gross income from HMOs, PPOs, and the amount in the form of
capitation payments (see table C-18). According to the survey,
there was a small increase between 1994 and 1995 in the portion
of physicians participating in capitated plans from 36 to 38
percent. Physicians with prepaid contracts earned a median
$40,000 in capitation payments in 1995, only 5 percent more
than in 1994.
The rise in the number of doctors who take HMO patients,
however, jumped from a median 69 percent of survey respondents
in 1994 to 77 percent in 1995. The median gross income in 1995
for these physicians was $63,770, an increase of 17 percent
from 1994. PPO participation by physicians also rose from 69 to
75 percent, with earnings increasing 13 percent to $48,660
(Terry, 1996).
TABLE C-18.--PHYSICIAN GROSS INCOME FROM MANAGED CARE AND CAPITATION BY SPECIALTY, 1995
----------------------------------------------------------------------------------------------------------------
Median 1995 gross income \1\ Percent of 1995 gross
from: income \1\ from:
Physician specialty -----------------------------------------------------------
HMOs PPOs Capitation HMOs PPOs Capitation
----------------------------------------------------------------------------------------------------------------
Anesthesiologists................................... $58,680 $39,720 $32,500 20 15 10
Cardiologists....................................... 50,880 44,600 47,500 12 10 10
Cardio/thoracic surgeons............................ 87,670 50,000 50,000 20 10 10
Emergency physicians................................ 49,750 46,790 45,000 20 20 20
Family practitioners................................ 69,080 63,600 27,500 20 15 10
Gastroenterologists................................. 52,210 23,730 32,000 25 10 15
General practitioners............................... 62,660 54,410 53,200 20 15 15
General surgeons.................................... 57,610 33,200 45,000 25 15 20
Internist........................................... 115,860 64,640 60,000 20 10 10
Neurosurgeons....................................... 114,230 79,060 40,000 30 20 15
OBG specialists..................................... 51,710 42,320 22,500 10 9 10
Orthopedic surgeons................................. 74,790 70,000 50,000 15 15 10
Pediatricians....................................... 68,820 63,870 42,500 30 25 17
Plastic surgeons.................................... 73,980 55,580 42,500 15 15 10
Psychiatrists....................................... 46,120 37,880 24,000 20 20 10
Radiologists........................................ (\2\) (\2\) 36,000 20 (\2\) 10
-----------------------------------------------------------
All surgical specialists........................ 78,200 58,960 40,000 20 15 10
All nonsurgeons \2\............................. 56,780 43,630 40,000 20 15 15
All fields...................................... 63,770 48,660 40,000 20 15 15
----------------------------------------------------------------------------------------------------------------
\1\ Gross is the individual physician's share of 1994 practice receipts before professional expenses and income
taxes.
\2\ Insufficient sample. Figures exclude physicians with no HMO, preferred provider organizations, or capitation
contracts.
Source: Terry (1996).
SUPPLY OF HOSPITAL BEDS
The national supply of community hospital beds per 1,000
population steadily increased from the 1940s, reaching a peak
of 4.6 beds per 1,000 population in 1975. By 1994, the number
of beds dropped to 3.5 per 1,000 population. Among the 9 Census
regions, the East South Central experienced the largest
increase from 1.7 per 1,000 population in 1940 to 4.7 in 1980.
By 1994, this number had declined to 4.3, but was still more
than twice that of the 1940 figure. In contrast, the New
England, Mountain, and Pacific regions had fewer beds per 1,000
in 1994 than in 1940 (see table C-19).
TABLE C-19.--COMMUNITY HOSPITAL BEDS PER 1,000 POPULATION AND AVERAGE ANNUAL PERCENT CHANGE BY REGION AND STATE, SELECTED YEARS 1940-1994
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Beds per 1,000 civilian population Average annual percent change
Region and State -----------------------------------------------------------------------------------------------------------------------------------
1940 \1\ 1950 \1\ 1960 \2\ 1970 1980 1990 \3\ 1994 \3\ 1940-60 \1\ \2\ 1960-70 \2\ 1970-80 1980-90 \3\ 1990-94 \3\
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
New England................................................. 4.4 4.2 3.9 4.1 4.1 3.4 3.1 -0.6 0.5 0.0 -1.9 -2.3
Maine..................................................... 3.0 3.2 3.4 4.7 4.7 3.7 3.4 0.6 3.3 0.0 -2.1 -2.1
New Hampshire............................................. 4.2 4.2 4.4 4.0 3.9 3.1 2.9 0.2 -0.9 -0.3 -2.3 -1.7
Vermont................................................... 3.3 4.0 4.5 4.5 4.4 3.0 3.3 1.6 0.0 -0.2 -3.4 2.4
Massachusetts............................................. 5.1 4.8 4.2 4.4 4.4 3.6 3.3 -1.0 0.5 0.0 -2.0 -2.2
Rhode Island.............................................. 3.9 3.8 3.7 4.0 3.8 3.2 2.8 -0.3 0.8 -0.5 -1.7 -3.3
Connecticut............................................... 3.7 3.6 3.4 3.4 3.5 2.9 2.8 -0.4 0.0 0.3 -1.9 -0.9
Middle Atlantic............................................. 3.9 3.8 4.0 4.4 4.6 4.1 4.1 0.1 1.0 0.4 -0.9 0.0
New York.................................................. 4.3 4.1 4.3 4.6 4.5 4.1 4.2 0.0 0.7 -0.2 -0.7 0.6
New Jersey................................................ 3.5 3.2 3.1 3.6 4.2 3.7 3.9 -0.6 1.5 1.6 -1.3 1.3
Pennsylvania.............................................. 3.5 3.8 4.1 4.7 4.8 4.4 4.2 0.8 1.4 0.2 -0.9 -1.2
East North Central.......................................... 3.2 3.2 3.6 4.4 4.7 3.9 3.5 0.6 2.0 0.7 -1.8 -2.7
Ohio...................................................... 2.7 2.9 3.4 4.2 4.7 4.0 3.6 1.2 2.1 1.1 -1.8 -2.6
Indiana................................................... 2.3 2.6 3.1 4.0 4.5 3.9 3.5 1.5 2.6 1.2 -1.4 -2.7
Illinois.................................................. 3.4 3.6 4.0 4.7 6.1 4.0 3.7 0.8 1.6 0.8 -2.4 -1.9
Michigan.................................................. 4.0 3.3 3.3 4.3 4.4 3.7 3.3 -1.0 2.7 0.2 -1.7 -2.8
Wisconsin................................................. 3.4 3.7 4.3 5.2 4.9 3.8 3.4 1.2 1.9 -0.8 -2.5 -2.7
West North Central.......................................... 3.1 3.7 4.3 6.7 6.8 4.9 4.5 1.6 2.9 0.2 -1.7 -2.1
Minnesota................................................. 3.9 4.4 4.8 6.1 5.7 4.4 4.0 1.0 2.4 -0.7 -2.6 -2.4
Iowa...................................................... 2.7 3.2 3.9 5.6 5.7 5.1 4.6 1.9 3.7 0.2 -1.1 -2.5
Missouri.................................................. 2.9 3.3 3.9 5.1 5.7 4.8 4.4 1.5 2.7 1.1 -1.7 -2.2
North Dakota.............................................. 3.5 4.3 5.2 6.8 7.4 7.0 7.0 2.0 2.7 0.8 -0.6 0.0
South Dakota.............................................. 2.8 4.4 4.5 5.6 5.5 6.1 6.1 2.4 2.2 -0.2 1.0 0.0
Nebraska.................................................. 3.4 4.2 4.4 6.2 6.0 5.5 5.2 1.3 3.5 -0.3 -1.0 -1.4
Kansas.................................................... 2.8 3.4 4.2 5.4 5.8 4.8 4.4 2.0 2.5 0.7 -1.9 -2.2
South Atlantic.............................................. 2.5 2.8 3.3 4.0 4.5 3.7 3.5 1.4 1.9 1.2 -1.9 -1.4
Delaware.................................................. 4.4 3.9 3.7 3.7 3.6 3.0 2.6 -0.9 0.0 -0.3 -1.8 -3.5
Maryland.................................................. 3.9 3.6 3.3 3.1 3.6 2.8 2.6 -0.8 -0.6 1.5 -2.1 -1.8
District of Columbia...................................... 5.5 5.5 5.9 7.4 7.3 7.6 7.2 0.4 2.3 -0.1 0.3 -1.3
Virginia.................................................. 2.2 2.5 3.0 3.7 4.1 3.3 3.0 1.6 2.1 1.0 -2.1 -2.4
West Virginia............................................. 2.7 3.1 4.1 5.4 5.5 4.7 4.5 2.1 2.8 0.2 -1.6 -1.1
North Carolina............................................ 2.2 2.6 3.4 3.8 4.2 3.3 3.3 2.2 1.1 1.0 -2.1 0.0
South Carolina............................................ 1.8 2.4 2.9 3.7 3.9 3.3 3.2 2.4 2.5 0.5 -1.7 -0.8
Georgia................................................... 1.7 2.0 2.8 3.8 4.6 4.0 3.8 2.5 3.1 1.9 -1.4 -1.3
Florida................................................... 2.8 2.9 3.1 4.4 5.1 3.9 3.7 0.5 3.6 1.5 -2.4 -1.3
East South Central.......................................... 1.7 2.1 3.0 4.4 4.7 4.3 4.3 3.9 1.5 -0.6 -2.2 -2.4
Kentucky.................................................. 1.8 2.2 3.0 4.0 4.5 4.3 4.1 2.6 2.9 1.2 -0.2 -1.2
Tennessee................................................. 1.9 2.3 3.4 4.7 5.5 4.8 4.3 3.0 3.3 1.6 -1.1 -2.7
Alabama................................................... 1.5 2.0 2.8 4.3 5.1 4.6 4.3 3.2 4.4 1.7 -1.0 -1.7
Mississippi............................................... 1.4 1.7 2.9 4.4 5.3 5.0 4.7 3.7 4.3 1.9 0.0 -1.5
West South Central.......................................... 2.1 2.7 3.3 4.3 4.7 3.8 3.5 2.3 2.7 0.9 -1.8 -2.0
Arkansas.................................................. 1.4 1.6 2.9 4.2 5.0 4.6 4.2 3.7 3.6 1.8 -0.6 -2.2
Louisiana................................................. 3.1 3.8 3.9 4.2 4.8 4.6 4.4 1.2 0.7 1.3 -0.4 -1.1
Oklahoma.................................................. 1.9 2.5 3.2 4.5 4.6 4.0 3.6 2.6 3.5 0.2 -1.4 -2.6
Texas..................................................... 2.0 2.7 3.3 4.3 4.7 3.5 3.2 2.5 2.7 0.9 -2.9 -2.2
Mountain.................................................... 3.6 3.8 3.5 4.3 3.8 3.1 2.7 -0.1 2.1 -1.2 -2.0 -3.4
Montana................................................... 4.9 5.3 5.1 5.8 5.9 5.8 5.0 0.2 1.3 0.2 -0.2 -3.6
Idaho..................................................... 2.6 3.4 3.2 4.0 3.7 3.2 3.0 1.0 2.3 -0.8 -1.4 -1.6
Wyoming................................................... 3.5 3.9 4.6 5.5 3.6 4.8 4.6 1.4 1.8 -4.1 3.1 -1.1
Colorado.................................................. 3.9 4.2 3.8 4.6 4.2 3.2 2.7 -0.1 1.9 -0.9 -2.7 -4.2
New Mexico................................................ 2.7 2.2 2.9 3.5 3.1 2.8 2.5 0.4 1.9 -1.2 -0.7 -2.8
Arizona................................................... 3.4 4.0 3.0 4.1 3.6 2.7 2.4 -0.6 3.2 1.3 -2.8 -2.9
Utah...................................................... 3.2 2.9 2.8 3.6 3.1 2.6 2.3 -0.7 2.5 -1.5 -1.7 -3.0
Nevada.................................................... 5.0 4.4 3.9 4.2 4.2 2.8 2.5 -1.2 0.7 0.0 -3.6 -2.8
Pacific..................................................... 4.1 3.2 3.1 3.7 3.5 2.7 2.4 -1.4 1.8 -0.6 -2.6 -2.9
Washington................................................ 3.4 3.6 3.3 3.5 3.1 2.5 2.2 -0.1 0.6 -1.2 -2.1 -3.1
Oregon.................................................... 3.5 3.1 3.5 4.0 3.5 2.8 2.3 0.0 1.3 -1.3 -1.9 -4.8
California................................................ 4.4 3.3 3.0 3.8 3.6 2.7 2.5 -1.9 2.4 -0.5 -2.8 -1.9
Alaska.................................................... ........ ........ 2.4 2.3 2.7 2.3 2.2 ............... -0.4 1.6 -1.6 -1.1
Hawaii.................................................... ........ ........ 3.7 3.4 3.1 2.7 2.6 ............... -0.8 -0.9 -1.0 -0.9
-----------------------------------------------------------------------------------------------------------------------------------
United States......................................... 3.2 3.3 3.6 4.3 4.5 3.7 3.5 0.6 1.8 0.5 -1.7 -1.4
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ 1940 and 1950 data are estimated based on published figures.
\2\ 1960 includes hospital units of institutions.
\3\ Starting with 1990, excludes hospital units of institutions.
Note.--Data for 1990 has been revised.
Source: U.S. Public Health Service (1997).
SUPPLY OF PHYSICIANS
Physician shortages in the 1950s and 1960s led to Federal
and State initiatives to increase the supply of physicians.
Since that time, however, the number of physicians in the
United States has grown rapidly from 334,028 in 1970 to 720,325
in 1995, a rate over four times faster than that of the total
population. Today, the concern is now focused on a possible
oversupply of physicians and its effect on efforts to control
health care spending.
Table C-20 indicates that between 1970 and 1995, the number
of all physicians per 100,000 civilians grew from 161 to 274, a
70 percent increase. Table C-21 shows variations in the supply
of non-Federal physicians relative to population by State. In
1996, the District of Columbia had the highest ratio (714
physicians per 100,000 population) while Mississippi had the
lowest ratio (155 physicians per 100,000 population).
There are also questions as to whether there are too many
specialists and too few primary care physicians to meet the
Nation's future health care needs and whether a competitive
health care market alone will be able to resolve the imbalance.
In 1995, about 39 percent of physicians were in primary care
specialties, defined as general and family practice, internal
medicine, obstetrics/gynecology, and pediatrics (see table C-22
for number of physicians by specialty). The Physician Payment
Review Commission's 1997 Annual Report to Congress indicates a
moderate trend toward generalism. The National Resident
Matching Program also announced in March 1997 that 56 percent
of U.S. medical school seniors plan to spend at least their
first year of residency training in general practice. This rate
has been on the rise since 1991, when only 44.3 percent of
graduates pursued generalist training (Association of American
Medical Colleges).
TABLE C-20.--PHYSICIAN SUPPLY BY MAJOR CATEGORIES, SELECTED YEARS 1970-95
----------------------------------------------------------------------------------------------------------------
1970 1980 1990 1995
Category -------------------------------------------------------------------------------
Number Percent Number Percent Number Percent Number Percent
----------------------------------------------------------------------------------------------------------------
Federal......................... 29,501 9 17,787 4 20,475 3 21,079 3
Non-Federal..................... 301,323 91 443,502 96 592,166 97 697,269 97
Metropolitan (non-Federal
only)...................... 258,265 86 385,365 87 521,668 88 616,436 86
Nonmetropolitan (non-Federal
only)...................... 43,058 14 58,137 13 70,498 12 80,833 11
Patient care.................... 278,535 83 376,512 80 503,870 82 582,131 81
Nonpatient care................. 32,310 10 38,404 9 43,440 8 43,312 6
Male............................ 308,627 92 413,395 88 511,227 83 570,921 79
Female.......................... 25,401 8 54,284 12 104,194 17 149,404 21
International medical graduates. 57,217 17 97,726 21 131,764 21 165,498 23
-------------------------------------------------------------------------------
Total physicians \1\.... 334,028 100 467,679 100 615,421 100 720,325 100
===============================================================================
Total physician-
population ratio (per
100,000 persons)....... 161 202 240 274
----------------------------------------------------------------------------------------------------------------
\1\ Address unknown excluded from all Federal/non-Federal categories, not-classified, inactive, and address
unknown are excluded from patient care/nonpatient care categories.
Note.--Totals may not equal sum of rounded components.
Source: American Medical Association (1997c).
TABLE C-21.--NON-FEDERAL PHYSICIAN/POPULATION RATIOS \1\ AND RANK BY
STATE, SELECTED YEARS 1970-95
------------------------------------------------------------------------
1995
State 1970 1975 1985 1990 1995 rank
------------------------------------------------------------------------
Alabama....................... 90 103 152 170 202 41
Alaska........................ 74 95 137 155 164 49
Arizona....................... 144 185 220 233 239 25
Arkansas...................... 92 103 150 165 192 43
California.................... 194 219 266 272 275 11
Colorado...................... 178 186 216 232 257 16
Connecticut................... 192 224 302 332 372 5
Delaware...................... 134 155 203 217 246 21
District of Columbia.......... 390 467 607 658 714 1
Florida....................... 155 185 236 251 269 12
Georgia....................... 108 126 172 187 214 36
Hawaii........................ 160 185 239 266 283 10
Idaho......................... 94 104 133 142 162 50
Illinois...................... 138 164 217 229 265 14
Indiana....................... 102 116 156 171 200 42
Iowa.......................... 103 113 149 167 189 44
Kansas........................ 118 137 179 195 223 32
Kentucky...................... 102 122 162 181 211 39
Louisiana..................... 120 131 187 200 241 23
Maine......................... 111 133 193 208 235 28
Maryland...................... 183 217 334 360 384 4
Massachusetts................. 207 237 331 364 420 2
Michigan...................... 125 145 190 201 232 29
Minnesota..................... 151 172 223 240 267 13
Mississippi................... 84 94 126 144 155 51
Missouri...................... 129 148 195 209 236 27
Montana....................... 104 116 155 181 214 37
Nebraska...................... 116 134 170 185 220 33
Nevada........................ 114 129 173 175 178 46
New Hampshire................. 140 162 207 227 248 19
New Jersey.................... 146 174 243 267 302 8
New Mexico.................... 113 130 184 206 229 30
New York...................... 236 258 318 339 391 3
North Carolina................ 111 132 185 209 239 24
North Dakota.................. 96 106 168 184 224 31
Ohio.......................... 133 147 199 213 242 22
Oklahoma...................... 103 113 149 160 177 47
Oregon........................ 144 171 215 233 250 18
Pennsylvania.................. 152 169 234 256 301 9
Rhode Island.................. 160 194 248 277 328 6
South Carolina................ 93 114 161 177 212 38
South Dakota.................. 81 90 143 154 187 45
Tennessee..................... 119 139 189 210 247 20
Texas......................... 117 135 174 188 206 40
Utah.......................... 138 155 185 200 216 35
Vermont....................... 187 207 268 288 316 7
Virginia...................... 125 149 214 233 253 17
Washington.................... 149 168 223 241 259 15
West Virginia................. 104 124 171 183 216 34
Wisconsin..................... 120 137 188 207 239 26
Wyoming....................... 101 108 140 156 176 48
-----------------------------------------
United States \1\......... 148 169 220 237 264 .....
------------------------------------------------------------------------
\1\ The ratios are for nonfederal physicians per 100,000 civilian
population.
\2\ Excludes counts of physicians in U.S. possessions and with unknown
addresses.
Source: American Medical Association (1997c).
TABLE C-22.--FEDERAL AND NON-FEDERAL PHYSICIANS: TOTAL AND OFFICE-BASED ACTIVITY BY SPECIALTY, 1980, 1990, AND
1995
----------------------------------------------------------------------------------------------------------------
Federal and non-Federal physicians
-----------------------------------------------------------
1980 1990 1995
Specialty -----------------------------------------------------------
Office Office Office
Total based Total based Total based
----------------------------------------------------------------------------------------------------------------
Allergy immunology.................................. 1,518 1,371 3,388 2,453 3,775 2,843
Anesthesiology...................................... 15,958 11,338 25,981 17,803 32,853 23,770
Cardiovascular diseases............................. 9,823 6,729 15,862 10,680 18,998 13,739
Child psychiatry.................................... 3,217 1,961 4,343 2,615 5,542 3,673
Dermatology......................................... 5,660 4,378 7,557 6,006 8,563 6,959
Diagnostic radiology................................ 7,048 4,191 15,412 9,815 19,808 12,751
Emergency medicine.................................. 5,699 3,362 14,243 8,420 19,112 11,700
Family practice..................................... 27,530 18,378 47,639 37,476 59,345 45,272
Gastroenterology.................................... 4,046 2,737 7,493 5,200 9,551 7,300
General practice.................................... 32,519 29,642 22,841 20,517 16,867 14,660
General surgery..................................... 34,034 22,426 38,376 24,520 37,569 24,086
Internal medicine................................... 71,531 40,617 98,349 57,950 115,168 72,612
Neurology........................................... 5,685 3,253 9,237 5,595 11,397 7,623
Neurological surgery................................ 3,341 2,468 4,358 3,092 4,888 3,567
Obstetrics/gynecology............................... 26,305 19,513 33,697 25,485 37,652 29,111
Ophthalmology....................................... 12,974 10,603 16,073 13,068 17,464 14,596
Orthopedic surgery.................................. 13,996 10,728 19,138 14,199 22,037 17,136
Otolaryngology...................................... 6,553 5,266 8,138 6,367 9,086 7,139
Pathology \1\....................................... 13,642 6,081 16,584 7,494 18,320 9,306
Pediatrics \2\...................................... 29,462 18,210 41,899 27,073 51,956 34,656
Physical medicine/rehabilitation.................... 2,146 1,014 4,105 2,183 5,565 3,400
Plastic surgery..................................... 2,980 2,438 4,590 3,835 5,493 4,612
Psychiatry.......................................... 27,481 16,004 35,163 20,146 38,098 23,334
Pulmonary diseases.................................. 3,715 2,048 6,080 3,662 7,453 4,964
Radiology........................................... 11,653 7,802 8,492 6,060 8,038 5,994
Radiation oncology.................................. 1,581 1,027 2,821 1,968 3,630 2,633
Urological surgery.................................. 7,743 6,228 9,372 7,398 9,886 7,991
Other specialty..................................... 5,810 2,418 7,254 2,656 7,307 3,014
Other surgical specialties \3\...................... 2,852 2,261 2,945 2,389 3,300 2,529
Other remaining specialties \4\..................... 6,071 2,549 7,822 3,316 8,249 3,693
Unspecified......................................... 12,289 4,959 8,058 1,554 8,473 2,612
Not classified...................................... 20,629 ........ 12,678 ........ 20,579 ........
Other categories \5\................................ 32,134 ........ 55,433 ........ 74,303 ........
-----------------------------------------------------------
Total physicians................................ 467,679 272,000 615,421 360,995 720,325 427,275
----------------------------------------------------------------------------------------------------------------
\1\ Includes pathology and forensic pathology.
\2\ Includes pediatrics, pediatric cardiology, and pediatric allergy.
\3\ Includes colon and rectal surgery and thoracic surgery.
\4\ Includes aerospace medicine, general preventive medicine, nuclear medicine, occupational medicine, medical
genetics, and public health.
\5\ Includes inactive and address unknown; these categories are included in total physicians only, not in office-
based practice.
Note.--Data for 1990 and 1995 are as of January 1. Data for 1980 are as of December 31.
Source: American Medical Association (1997c).
In 1995, there were 98,035 residents in training. The
number of U.S. medical school graduates, which rose rapidly in
the late 1960s and early 1970s, has been relatively stable
since 1980 (see table C-23).
TABLE C-23.--MEDICAL SCHOOL GRADUATES, FIRST-YEAR RESIDENTS AND TOTAL
RESIDENTS, 1965-95
------------------------------------------------------------------------
Medical First-
Year school year Total
graduates residents residents
------------------------------------------------------------------------
1965................................... 7,409 9,670 31,898
1966................................... 7,574 10,316 31,898
1967................................... 7,743 10,419 33,743
1968................................... 7,973 10,464 35,047
1969................................... 8,059 10,808 37,139
1970................................... 8,367 11,552 39,463
1971................................... 8,974 12,066 42,512
1972................................... 9,551 11,500 45,081
1973................................... 10,391 11,031 49,082
1974................................... 11,613 11,628 52,685
1975................................... 12,714 13,200 54,500
1976................................... (\1\) 14,258 56,872
1977................................... 13,607 15,900 59,000
1978................................... 14,393 16,800 63,163
1979................................... 14,966 17,600 64,615
1980................................... 15,135 18,702 61,465
1981................................... 15,667 18,389 69,738
1982................................... 15,985 18,976 69,142
1983................................... 15,824 18,794 73,000
1984................................... 16,327 19,539 75,125
1985................................... 16,319 19,168 75,514
1986................................... 16,125 18,183 76,815
1987................................... 15,836 18,067 81,410
1988................................... 15,887 17,941 81,093
1989................................... 15,620 18,131 82,000
1990................................... 15,336 18,322 82,902
1991................................... 15,481 19,497 86,217
1992................................... 15,386 19,794 88,620
1993................................... 15,512 21,616 96,469
1994................................... 15,579 19,293 97,832
1995................................... 15,911 21,372 98,035
------------------------------------------------------------------------
\1\ Not available.
Source: American Medical Association (various years).
The number of residency positions occupied by international
medical graduates (IMGs) has fluctuated over the period 1971-
95. Due to stricter immigration laws and more rigorous
competency requirements, IMGs dropped from over 40 percent of
all residents in 1971 to about 17 percent in 1985. Since then,
however, the percentage of IMGs in training in the United
States has almost doubled, from 12,509 in 1985 to 24,983 in
1995 and is now at 25 percent of all residents in training (see
table C-24).
TABLE C-24.--INTERNATIONAL MEDICAL GRADUATE RESIDENTS \1\ BY
CITIZENSHIP, SELECTED YEARS 1971-95
------------------------------------------------------------------------
Percent
Total of all U.S. Foreign
residents citizens nationals
------------------------------------------------------------------------
1971........................ 17,515 41 1,063 16,452
1976........................ 16,634 29 1,783 14,851
1981........................ 11,596 17 2,908 8,688
1983........................ 14,084 19 4,961 9,123
1985........................ 12,509 17 6,868 5,609
1991........................ 17,017 20 5,107 11,910
1992........................ 19,084 22 5,015 \2\ 14,06
9
1993........................ 22,706 24 5,056 17,650
1994........................ 23,499 24 4,285 19,214
1995........................ 24,982 25 4,030 20,952
------------------------------------------------------------------------
\1\ IMGs are defined by location of education.
\2\ Includes 6,192 permanent resident aliens.
Source: American Medical Association (various years).
HEALTH INSURANCE STATUS IN 1995
Most people have some form of health insurance. In 1995, an
estimated 84.6 percent of the total noninstitutionalized
population had public or private coverage during at least part
of the year. However, an estimated 40.6 million Americans, or
15.4 percent of the population, were without coverage in 1995.
Almost all of the uninsured were under age 65; consequently,
17.3 percent of the nonelderly population were uninsured. This
section examines characteristics of both the insured and the
uninsured populations in 1995, and reviews trends in health
insurance coverage over the 1979-95 period (see Smith 1996).
Estimates of health insurance coverage in 1995 are based on
analysis of the March 1996 Current Population Survey (CPS), a
household survey by the Department of Commerce's Census Bureau.
Each year's March CPS asks whether individuals had coverage
from selected sources of health insurance at any time during
the preceding calendar year. Thus, the March 1996 CPS reflects
respondents' recollections of coverage during all of 1995. \1\
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\1\ Some analysts have suggested that respondents may actually be
reporting their coverage status at the time of the survey, rather than
for the previous year.
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Health Insurance Coverage and Selected Population Characteristics
Age
Table C-25 provides a breakdown of health insurance
coverage by type of insurance and age. In 1995, young adults
ages 18 to 24 were the least likely to have health insurance.
While 51 percent of this group were covered under an
employment-based plan, over one-fourth (28 percent) had no
health insurance. These young adults comprised 9 percent of the
U.S. population, but 17 percent of the uninsured population.
These individuals are often too old to be covered as dependents
on their parents' policies, and as entry-level workers they do
not have strong ties to the work force; some may choose to
remain uninsured and spend their money on other items. After
age 25, the percentage of people with health insurance
increases. Of those age 65 and over, 96 percent were covered by
Medicare and/or Medicaid, and 1 percent were uninsured. The
remainder of this section focuses on the population under age
65.
TABLE C-25.--HEALTH INSURANCE COVERAGE BY TYPE OF INSURANCE AND AGE, 1995
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Type of insurance \1\
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Population Medicare and/
Age (in Employment or Medicaid Private Military \3\ Uninsured
millions) based \2\ \3\ nongroup (percent) (percent)
(percent) (percent) (percent)
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Under 5............................... 20.1 57.7 30.2 3.2 1.7 13.5
5-17.................................. 51.1 64.5 20.8 5.0 2.0 13.9
18-24................................. 24.8 51.2 12.3 9.9 2.8 28.2
25-34................................. 40.9 64.7 8.9 4.7 1.2 22.9
35-54................................. 74.7 72.7 7.5 5.6 2.6 15.2
55-59................................. 11.3 70.3 10.5 7.7 4.7 13.2
60-64................................. 9.8 62.9 15.2 11.8 7.1 13.6
65+................................... 31.7 35.2 96.4 33.5 3.6 1.0
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Total........................... 264.3 61.8 23.5 9.2 2.6 15.4
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\1\ People may have more than one source of health insurance; percentages may total to more than 100.
\2\ Group health insurance through employer or union.
\3\ Military health care or veterans coverage.
Source: Congressional Research Service analysis of data from the March 1996 Current Population Survey.
Other demographic characteristics
Table C-26 shows the rate of health insurance coverage by
type of insurance and selected demographic characteristics--
race, family type, region, and poverty level--for people under
age 65. In 1995 whites were most likely to have health
insurance (87 percent) while Hispanics were least likely (65
percent). Hispanics comprised 12 percent of the under 65
population, but were 23 percent of the uninsured population;
comparable numbers for blacks were 13 percent and 17 percent,
respectively. The rate of employment-based health coverage was
highest among whites (73 percent) and the rate of Medicaid/
Medicare coverage was highest for blacks (29 percent). \2\
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\2\ Medicaid covered 12 percent of the nonelderly population and
Medicare covered less than 2 percent. About 27 percent of blacks had
Medicaid coverage.
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People in male-headed or two-parent families with children
were most likely to be insured (86 percent), followed by those
in female-headed families with children (81 percent) and in
families with no children (80 percent). While the rates of
coverage were similar for male-present (one- or two-parent) and
female-headed (single-parent) families with children, the
sources of coverage were quite different: coverage was
employment based for 73 percent of male-present families
compared to 37 percent of female-headed families, while
coverage came from Medicaid/Medicare for 10 percent of male-
present families compared to 43 percent of female-headed
families.
People living in the Midwest were more likely to have
insurance (88 percent) than people in the Northeast (86
percent), West (80 percent), and South (80 percent). About 70
percent of those living in the Northeast and Midwest had
employment-based health insurance compared to about 60 percent
in the South and West.
TABLE C-26.--HEALTH INSURANCE COVERAGE BY TYPE OF INSURANCE AND DEMOGRAPHIC CHARACTERISTICS FOR PEOPLE UNDER AGE
65, 1995
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Type of insurance (percent) \1\
Population ---------------------------------------------
(in Medicaid
millions) Employment or Other \3\ Uninsured
based \2\ Medicare
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Race/ethnicity:
White............................................. 164.2 72.9 8.8 9.4 13.3
Black............................................. 30.6 48.8 29.2 5.6 22.3
Hispanic.......................................... 27.0 41.3 23.1 3.6 34.9
Other............................................. 10.8 58.5 17.9 9.0 20.3
Family type:
Female-headed with children....................... 30.0 36.8 43.0 6.6 19.3
Male- or two-parent-headed with children.......... 114.6 73.4 10.3 6.5 14.4
No children....................................... 88.0 64.7 7.9 10.9 20.4
Region:
Northeast......................................... 44.7 69.2 13.1 6.4 14.5
Midwest........................................... 54.4 72.1 12.1 8.0 12.3
South............................................. 81.0 61.7 13.8 9.0 20.5
West.............................................. 52.6 60.8 15.3 8.7 20.1
Poverty level:
<1.0 of poverty................................... 33.7 15.3 49.1 7.4 32.9
1.0-1.49 of poverty............................... 20.9 37.2 26.3 10.5 32.4
1.5-1.99 of poverty............................... 22.1 56.0 14.3 9.1 27.2
2.0+ of poverty...................................