In fiscal year 2021, Medicaid spent 8,651 U.S. dollars per full-year equivalent enrollee. However, spending per enrollee varied by state with North Dakota spending the most per enrollee at 12,434 U.S. dollars, while in South Carolina each Medicaid enrollee cost 5,191 U.S. dollars. This statistic illustrates Medicaid benefit spending per full-year equivalent (FYE) enrollee in the United States in FY 2021, by state.

2022 saw the largest expenditures on Medicaid in U.S. history. At that time about 824 billion U.S. dollars were expended on the Medicaid public health insurance program that aims to provide affordable health care options to low income residents and people with disabilities. Medicaid was signed into law in 1965. By 1975 around 13 billion U.S. dollars were spent on the program.

Groups covered by Medicaid

There are several components of the Medicaid health insurance program. The Children’s Health Insurance Program (CHIP) was started in 1997 to provide health coverage to families and children that could not afford care. As of 2021, children represented the largest distribution of Medicaid enrollees. Despite having the largest proportion of enrollees, those that were enrolled in Medicaid as children had the lowest spending per enrollee. As of 2021, disabled Medicaid enrollees had the highest spending per enrollee.

Medicaid expenditures

Currently, Medicaid accounts for 19 percent of all health care expenditure in the United States. Expenditures on Medicaid programs vary among the U.S. states and depend heavily on whether Medicaid expansion was accepted after the Affordable Care Act was enacted. California and New York are the top states with the highest Medicaid expenditures. It is projected that Medicaid expenditure will continue to increase at both the state and federal levels.

The United States has the highest expenditure on health care per capita globally. However, the U.S. has an unique way of paying for their health care where a majority of the expenditure falls upon private insurances. In FY 2024, around one third of all health expenditure is paid by private insurance. Public insurance programs Medicare and Medicaid accounted for 22 and 17 percent, respectively, of health expenditure during that same year. U.S. health care system Globally health spending has been increasing among most countries. However, the U.S. has the highest public and private per capita health expenditure among all countries globally, followed by Switzerland. As of 2020, annual health care costs per capita in the United States totaled to over 12 thousand U.S. dollars, a significant amount considering the average U.S. personal income is around 54 thousand dollars. Out of pocket costs in the U.S. Aside from overall high health care costs for U.S. residents, the total out-of-pocket costs for health care have been on the rise. In recent years, the average per capita out-of-pocket health care payments have exceeded one thousand dollars. Physician services, dental services and prescription drugs account for the largest proportion of out-of-pocket expenditures for U.S. residents.

More than one in four hospitalizations for those with both Medicare and full Medicaid coverage was potentially avoidable, according to findings reported in Medicare-Medicaid Eligible Beneficiaries and Potentially Avoidable Hospitalizations, published in Volume 4, Issue 1 of the Medicare and Medicaid Research Review. Using data from 2007 to 2009, the study examined potentially avoidable hospitalizations rates by setting, state, and medical condition, and the average cost of these events. Beneficiaries in institutions were much more likely to have these events - 16 percent of beneficiaries in the study population were in an institution, yet comprised 45 percent of all potentially avoidable hospitalizations. The range in rates per 1,000 person years across the states was considerable from a low of 59 (Utah) to a high of 197 (Mississippi), a more than a threefold difference. Five conditions were responsible for nearly 80 percent of potentially avoidable hospitalizations. From 2007 to 2009, the national and state rates were fairly consistent.

In 2021, Medicare spending per beneficiary amounted an average of 15,671 U.S. dollars, a fairly sharp increase from the previous year. Medicare spending per person has being steadily rising over the provided time interval. Growth in health care spending is influenced by increasing volume and use of services, new technologies, and rising prices. This statistic displays the per capita Medicare spending in the U.S. from 2010 to 2021.

The Shared Savings Program County-level Aggregate Expenditure and Risk Score Data on Assignable Beneficiaries Public Use File (PUF) for the Medicare Shared Savings Program (Shared Savings Program) provides aggregate data consisting of per capita Parts A and B FFS expenditures, average CMS-HCC prospective risk scores, average demographic risk scores and total person-years for Shared Savings Program assignable beneficiaries by Medicare enrollment type (End Stage Renal Disease (ESRD), disabled, aged/dual eligible, aged/non-dual eligible).

DISCLAIMER: This information is current as of the last update. Changes to Shared Savings Program Accountable Care Organization (ACO) information occur periodically. Each Shared Savings Program ACO has the most up-to-date information about their organization. Consider contacting the Shared Savings Program ACO for the latest information. Contact information is available in the ACO PUF and the ACO Participants PUF.

In 2021, Medicare spent an average of more than 13,139 U.S. dollars per enrollee in New York, while the average for the United States was 11,080 U.S. dollars per enrollee. This statistic depicts the leading ten U.S. states based on Medicare spending per enrollee in 2021.

The Medicare Part D by Drug dataset presents information on spending for drugs prescribed to Medicare beneficiaries enrolled in Part D by physicians and other healthcare providers. Drugs prescribed in the Medicare Part D program are drugs patients generally administer themselves.

The dataset focuses on average spending per dosage unit and change in average spending per dosage unit over time. It also includes spending information for manufacturer(s) of the drugs as well as consumer-friendly information of drug uses and clinical indications.

Drug spending metrics for Part D drugs are based on the gross drug cost, which represents total spending for the prescription claim, including Medicare, plan, and beneficiary payments. The Part D spending metrics do not reflect any manufacturers’ rebates or other price concessions as CMS is prohibited from publicly disclosing such information.

The Quarterly Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information files contain formulary, pharmacy network, and pricing data for Medicare Prescription Drug Plans and Medicare Advantage (MA) Prescription Drug Plans (with the exception of employer and Program of All-Inclusive Care for the Elderly plans). These non-identifiable files are available on a quarterly basis and are comprised of the following tables:

Plan Information - Information such as plan name, contract ID, plan ID, service area, and plan type. Geographic Locator - MA and Prescription Drug Plans region codes and county codes. Basic Drugs Formulary - Formulary details for each plan including National Drug Codes (NDCs), cost share tier level, and indicators for step therapy, quantity limits, and prior authorization. Excluded Drugs Formulary - Enhanced alternative plans may elect to provide a supplemental benefit and cover excluded drugs. File includes formulary details for excluded drugs that are covered by the plan (for enhanced alternative plans only). Beneficiary Cost - Plan level cost sharing details for preferred, non-preferred, and mail order network pharmacies. Pharmacy Network - National Provider Identifier (NPI) numbers for each network pharmacy including preferred, retail, and mail order indicators. Pricing - Plan level average monthly costs for formulary Part D drugs (note: this table is only available in the quarterly files). Partial Gap Coverage - Plan-RxCUI combinations that are on tiers that offer gap coverage for some drugs on the tier. Indication Based Coverage Formulary File - Includes drugs covered based on FDA-approved indication for each plan. Insulin Beneficiary Cost File - Plan level cost sharing details for insulin at preferred, non-preferred and mail order network pharmacies.

These are large files and can take time to download.

Please read the “Agreement for Use” in the Resources section below. This document contains important information regarding timeframes for obtaining data as well as data accuracy and integrity.

The Monthly Prescription Drug Plan Formulary and Pharmacy Network Information is also available to access for the monthly level information.

Please note: The Part D benefit year information for plans become available in October of the year prior. For example, year 2024 data is available in the fourth quarter file of 2023. Year 2024 data continues to be available in the Q1-Q3 2024 files, then in the fourth quarter of 2024 year 2025 data becomes available.

Estimated release dates for upcoming 2024 quarterly data (files reflect data for the quarter that ended the month before the file was released):

7/18/24 Files older than contract year 2019 can be purchased.

The Centers for Medicare and Medicaid Services estimate that prescription drug expenditure in the United States will reach around 460 billion U.S. dollars in 2024. This amount includes only retail drug spending, excluding nonretail. Estimations of drug spending can vary by investigating organization. For the U.S., among the most relevant drug spending calculations are provided by CMS, ASPE (Assistant Secretary for Planning and Evaluation), and pharmaceutical market researcher IQVIA. High drug prices in the U.S.The United States is the country with the highest total drug spending, and also with the highest per capita pharmaceuticals spending among developed countries. This is mostly connected to higher drug prices in the United States. For example, the price for the blockbuster drug Humira was almost three times higher in the United States than in Germany in 2017. But whereas in other countries, governments more or less directly control drug prices, the U.S. leaves drug pricing to market competition. As a consequence, the U.S. market is the most profitable for pharmaceutical companies. Where the money is spentNearly half of all Americans have taken at least one prescription medicine within the preceding month. The therapeutic areas where spending is the highest are ‘traditionally’ to be found among antidiabetics, oncologics, autoimmune, and respiratory diseases. Based on number of prescriptions filled, antihypertensives, pain reliever, and mental health drugs are the leading classes.

Healthcare premiums under the Affordable Care Act (ACA) have fallen for all consumers nationally in 2023 when compared with the previous two years. This is due to a system of tax credits provided by the American Rescue Plan and the Inflation Reduction Act passed by the United States Congress. After these tax credits, the average person with ACA coverage pays an average monthly premium of 129 U.S. dollars, down from 164 U.S. dollars in 2021. A report from the U.S. Centers for Medicare & Medicaid Services estimates that due to the tax credits, consumers nationally on average save over 800 U.S. dollars per year in premiums. The ACA created a federally run healthcare exchange which is used by 33 states as of 2023. States can also decide to run their own exchange - due to politics or practicality - of which there are 17 plus the District of Columbia.

In 2023, approximately nineteen percent of the Hispanic population in the United States did not have health insurance, a historical low since 2010. In 2023, the national average was 9.1 percent. White Americans had a below-average rate of just 5.8 percent, whereas 8.6 percent of Black Americans had no health insurance.Impact of the Affordable Care ActThe Affordable Care Act (ACA), also known as Obamacare, was enacted in March 2010, which expanded the Medicaid program, made affordable health insurance available to more people and aimed to lower health care costs by supporting innovative medical care delivery methods. Though it was enacted in 2010, the full effects of it weren’t seen until 2013, when government-run insurance marketplaces such as HealthCare.gov were opened. The number of Americans without health insurance fell significantly between 2010 and 2015, but began to rise again after 2016. What caused the change?The Tax Cuts and Jobs Act of 2017 has played a role in decreasing the number of Americans with health insurance, because the individual mandate was repealed. The aim of the individual mandate (part of the ACA) was to ensure that all Americans had health coverage and thus spread the costs over the young, old, sick and healthy by imposing a large tax fine on those without coverage.

In 2021, about 10.43 percent of all Medicare enrolled beneficiaries in the United States were aged 85 years or older. Medicare provides low-cost health coverage to people over the age of 65 and those with disabilities and certain medical conditions. This statistic depicts the distribution of Medicare enrollees in 2021, by age group.

In 2023, 25 million people in the United States had no health insurance. The share of Americans without health insurance saw a steady increase from 2015 to 2019 before starting to decline in 2020 to 2023. Factors like the implementation of Medicaid expansion in additional states and growth in private health insurance coverage led to the decline in uninsured population, despite the economic challenges due to the pandemic in 2020. Positive impact of Affordable Care Act In the U.S. there are public and private forms of health insurance, as well as social welfare programs such as Medicaid and programs just for veterans such as CHAMPVA. The Affordable Care Act (ACA) was enacted in 2010, which dramatically reduced the share of uninsured Americans, though there’s still room for improvement. In spite of its success in providing more Americans with health insurance, ACA has had an almost equal number of proponents and opponents since its introduction, though the share of Americans in favor of it has risen since mid-2017 to the majority. Persistent disparity among ethnic groups The share of uninsured people is higher in certain demographic groups. For instance, Hispanics continue to be the ethnic group with the highest rate of uninsured people, even after ACA. Meanwhile the share of uninsured White and Asian people is lower than the national average.