Exploring State-Level Change in Health Care Value Over Three Decades in the United States, 1991-2020

To examine trends in state-level health care value over three decades, defined using statewide health care spending and cause-specific mortality, and to explore its associations with potentially modifiable state attributes.

We use stochastic frontier analysis to identify the "inefficiency" of each state's delivery system in converting health care spending into lower mortality-incidence or mortality-prevalence rates, adjusting for underlying population risk (age, smoking, obesity, etc.). We combine these inefficiency scores to score and compare delivery system value for each state and track change over three decades. Then, we use linear regression to look across states and identify state-level attributes significantly associated with greater health care value.

For each US state and year from 1991 to 2020, we extracted mortality-incidence or mortality-prevalence rates for 67 high-mortality health conditions from the Global Burden of Disease 2021 Study and state health care spending from the State Health Expenditure Accounts.

Across US states, value on average increased from 1991 to 2000, remained relatively constant from 2001 to 2010, and then declined from 2011 to 2020 by 16.7% (95% uncertainty interval [UI]: 14.7-20.1) or 13.6 (95% UI: 11.3-15.9) value points. The percentage of state populations with insurance was positively associated with health delivery system value. In contrast, market consolidation among hospitals and among health insurers of small and large groups, and increased for-profit hospital ownership were each associated with a lower health care value. The net effect of these associations was a reduction in the national value score for the decade ending in 2020.

In contrast to the prior two decades, health care delivery system value scores declined over the last decade. This decline was associated with reduced competition among hospitals and health insurers, increased for-profit hospital ownership, and was partly mitigated by wider insurance coverage.