Century-Long Trends in the Financing and Ownership of American Health Care.

Abstract

Policy Points Over the past century, the tax-financed share of health care spending has risen from 9% in 1923 to 69% in 2020; a large part of this tax financing is now the subsidization of private health insurance. For-profit ownership of health care facilities has also increased in recent decades and now predominates for many health subsectors. A rising share of physicians are now employees. US health care is, increasingly, publicly financed yet investor owned, a trend that has been accompanied by rising medical costs and, in recent years, stagnating or even worsening population health. A reconsideration of US health care financing and ownership appears warranted.

Context: Who pays for health care-and who owns it-determine what care is delivered, who receives it, and who profits from it. We examined trends in health care ownership and financing over a century.

Methods: We used multiple historical and current data sources (including data from the American Medical Association, the American Hospital Association, government publications and surveys, and analyses of Medicare Provider of Services files) to classify health care provider ownership as: public, private (for-profit), and private (not-for-profit). We used US Census data to classify physicians' employers as public, not-for-profit, or for-profit entities or "self-employed." We combined estimates from the official National Health Expenditures Accounts with other data sources to determine the public vs. private share of health care spending since 1923; we calculated a "comprehensive" public share metric that accounted for public subsidization of private health expenditures, mostly via the tax exemption for employer-sponsored insurance plans or government purchase of such plans for public employees.

Findings: For-profit ownership of most health care subsectors has risen in recent decades and now predominates in several (including nursing facilities, ambulatory surgical facilities, dialysis facilities, hospices, and home health agencies). However, most community hospitals remain not-for-profit. Additionally, over the past century, a growing share of physicians identify as employees. Meanwhile, the comprehensive taxpayer-financed share of health care spending has increased dramatically from 9% in 1923 to 69% in 2020, with taxpayer-financed subsidies to private expenditures accounting for much of the recent growth.

Conclusions: American health care is increasingly publicly financed yet investor owned, a trend accompanied by rising costs and, recently, worsening population health. A reassessment of the US mode of health care financing and ownership appears warranted.