Mapping Healthcare Financial Burden: County-Level Out-of-Pocket Spending in the U.S.

Area of Science:

• Health Economics
• Geographic Health Disparities
• Public Health Policy

Background:

• Out-of-pocket (OOP) healthcare costs present significant financial challenges, especially relative to local income levels.
• Geographic variations in healthcare spending are known, but the relationship between OOP spending and local economic capacity requires further investigation.

Purpose of the Study:

• To analyze the trend of out-of-pocket healthcare spending relative to per capita income (PCI) across U.S. counties.
• To identify geographic disparities in the population-level healthcare financial burden.

Main Methods:

• Longitudinal ecological county-level analysis (2010-2019) of OOP spending and PCI.
• Calculation of the OOP spending-to-PCI ratio to measure financial burden.
• Use of population-weighted medians, interquartile ranges (IQR), and estimated annual percentage changes (EAPCs) to summarize trends.

Main Results:

• The national median OOP-to-income ratio decreased from 2.09% in 2010 to 1.57% in 2019 (EAPC of -2.61%).
• Most U.S. counties saw a decline in OOP healthcare financial burden.
• Clusters of increasing OOP burden were identified in specific regions, including parts of New York, West Virginia, and the Upper Midwest.

Conclusions:

• National trends show a decline in population-level OOP healthcare financial burden over the past decade.
• Uneven improvements across counties highlight substate "hotspots" of financial burden.
• Integrating OOP spending with local income provides a framework for targeted health system planning and policy evaluation.