1. www.bea.gov 1 U.S. Health Care Expenditures in the NHEA and in GDP Robert Kornfeld U.S. Bureau of Economic Analysis Pan American Health Organization Washington, DC October 7, 2011

2. www.bea.gov 2 Joint BEA-CMS Project to Reconcile Two Measures of Health Care Spending ▪ The National Health Expenditure Accounts (NHEA), from the Centers for Medicare and Medicaid Services (CMS) ▪ Health-related expenditures included in GDP (expenditures approach), part of the National Income and Product Accounts (NIPAs) from BEA References: ▪ Hartman, Micah B., Robert J. Kornfeld, and Aaron C. Catlin. 2010. “A Reconciliation of Health Care Expenditures in the National Health Expenditures Accounts and in Gross Domestic Product.” Survey of Current Business 90 (September): 42-52. ▪ Hartman, Micah B., Robert J. Kornfeld, and Aaron C. Catlin. 2010. “Health Care Expenditures in the National Health Expenditures Accounts and in Gross Domestic Product: A Reconciliation.” BEA working paper.

3. www.bea.gov 3 Why a Reconciliation? ▪ Dramatic increase in the share of the economy devoted to health care ▪ Size and scope of the Patient Protection and Affordable Care Act ▪ Understanding and accounting for health care spending in a comprehensive and consistent way is essential for  assessing the role of health care spending in the US Economy  making long-term projections of health care expenditures and the financial requirements for Medicaid and Medicare  identifying sources of growth in health care spending  helping users decide which definitions and measures are most useful

4. www.bea.gov 4 Health Expenditures: Services ▪ Hospital care ▪ Physician and clinical services ▪ Dental services ▪ Home health care ▪ Nursing care facilities, continuing care retirement communities ▪ Other professional services ▪ Net cost of health insurance ▪ Other health, residential, and personal care ▪ Hospitals ▪ Physician services and labs ▪ Dental services ▪ Home health care ▪ Nursing homes ▪ Other professional medical services ▪ Net health insurance ▪ Final consumption expenditures of nonprofits serving households CMS: National Health Expenditures BEA: Personal Consumption Expenditures (PCE) for Services in GDP

5. www.bea.gov 5 Health Expenditures: Goods ▪ Prescription drugs ▪ Other non-durable medical products ▪ Durable medical equipment ▪ Prescription drugs ▪ Nonprescription drugs and other medical products ▪ Therapeutic medical equipment, corrective eyeglasses and contact lenses CMS: National Health Expenditures, Retail Outlet Sales of Medical Products BEA: Personal Consumption Expenditures (PCE) for Goods in GDP

6. www.bea.gov 6 Health Expenditures: Private Investment ▪ Structures ▪ Equipment ▪ Private Research ▪ Health care structures ▪ Electro-medical equipment and medical instruments CMS: National Health ExpendituresBEA: Expenditures in GDP

7. www.bea.gov 7 Health Expenditures: Government Activities ▪ Government administration ▪ Government public health activities ▪ Government-sponsored research ▪ Government Investment in Equipment and Structures ▪ Medicaid and Medicare are “sources of funds” ▪ Federal and state and local government consumption expenditures for health ▪ Government Investment in Equipment and Structures ▪ Medicaid and Medicare are “government social benefits” CMS: National Health ExpendituresBEA: Expenditures in GDP

8. www.bea.gov 8 Health Expenditures Financed by Government Health Insurance: SNA vs NIPA SNA: Government health insurance programs are “social transfers in kind” ▪ “Household final consumption expenditures” include spending financed by cash, private insurance, but not social transfers in kind ▪ “Actual household final consumption expenditures” include spending financed by cash, private insurance, social transfers in kind ▪ “General government final consumption expenditures” include social transfers in kind and collective consumption NIPA: Government health insurance programs (Medicare, Medicaid) are “government social benefits” ▪ PCE for health include spending financed by cash, private insurance, and government social benefits ▪ PCE are similar to “actual household final consumption expenditures” in the SNA ▪ Government consumption expenditures do not include social transfers in kind

9. www.bea.gov 9 Similar estimates of total health spending…

10. www.bea.gov 10 …but large discrepancies in estimates of spending for specific categories NHEA estimate less GDP estimate, 2009 Physicians/Labs

11. www.bea.gov 11 Key Differences: Services and Goods ▪ NHEA and GDP accounts place some types of health spending in “different sounding” categories ▪ Some expenditures counted as “health-related” only in GDP or only in the NHEA ▪ Some different data sources  Hospitals: GDP relies on the Service Annual Survey (SAS); NHEA relies on the American Hospital Association (AHA) ▪ Timing of revisions differs  CMS releases estimates in January  BEA releases annual revision of GDP in July ▪ NHEA tend to measure revenues of health-care industries; GDP measures spending for commodities

12. www.bea.gov 12 Key Differences: Services and Goods ▪ Different treatment of patient care directly purchased by government, with general revenue (such as a VA hospital)  NHEA: part of spending for hospital care  GDP: part of government consumption expenditures ▪ Different treatment of nonprofit services (NPISHs)  NHEA: total revenues of nonprofits from all sources  GDP: spending for nonprofit services reported in two parts  Commodity sales to households (in PCE household consumption expenditures) plus  Final consumption expenditures of NPISHs (gross output net of sales and own account investment)

13. www.bea.gov 13 Physician and Clinical Services (NHEA), Physician Services and Labs (GDP), 2009 Key differences  NHEA estimate includes additional outpatient care centers  NHEA estimate includes services directly purchased by government  Commodity sales (GDP) vs. industry sales (NHEA)

14. www.bea.gov 14 Hospitals: NHEA vs Household Consumption Expenditures in GDP, 2009 Key differences  NHEA estimate includes services directly purchased by government (mainly VA hospitals)  Commodity sales (GDP) vs. industry sales (NHEA)  Nonfederal hospital revenues: SAS estimate (GDP) exceeds AHA estimate (NHEA)  GDP also includes final consumption expenditures of NPISHs

15. www.bea.gov 15 NHE for Other Health, Residential, and Personal Care ▪ $123 billion in 2009 ▪ Includes some categories of spending not counted as health- related expenditures in GDP  Residential substance abuse and mental health facilities (social assistance expenditures in GDP)  Home and community waivers programs under Medicaid (partly social assistance expenditures in GDP)  Health spending in schools (education expenditures in GDP)

16. www.bea.gov 16 Net Cost of Health Insurance (NHEA), PCE for Net Health Insurance (GDP), 2009 Key similarities  Both estimated as premiums less benefits  Both include administrative cost of privately managed Medicare and Medicaid Key differences  Slightly different data sources and methodologies  PCE for net health insurance also includes income loss insurance

17. www.bea.gov 17 Government Administration, Public Health, Research (NHEA), Government Consumption Expenditures for Health (GDP), 2009

18. www.bea.gov 18 Key Differences: Government Activities ▪ NHEA include some additional spending as health- related  DOD health spending: defense-related in GDP  Research grants: Government or NPISH education services ▪ Patient care directly purchased by government, with general revenue (VA hospitals)  NHEA: spending for hospital care  GDP: government consumption expenditures

19. www.bea.gov 19 Key Differences: Government Activities ▪ Patient care provided by government facilities and purchased by households and insurers (state and local government hospitals)  NHEA: all revenues part of spending for hospital care, not government activities  GDP: government consumption expenditures measured as  Gross output (costs of production) less  Sales to other sectors (mostly PCE) and own-account investment