Summarize below attached article pictures

COSTS & SPENDING by 2028 the insured share of the population is expected to fall to 89.4 percent (from 90.6 per cent in 2018) (exhibit 2). The share of health care spending financed by federal, state, and local governments is expected to increase by 2 percentage points during 2019 28, reaching 47 percent in 2028 (exhibit 3). The increase is primarily due to the federal govern- ment's share, which is projected to grow from 28 percent in 2018 to 31 percent by 2028, driven by faster growth in Medicare spending related to increasingly higher enrollment. The projected business and household share is expected to fall from 55 percent in 2018 to 53 percent in 2028. Chronological Overview Of Key National Health Expenditure Trends 2015 For 2019, national health spending is pro- jected to have increased at a rate similar to that for 2018 (4.5 percent versus 4.6 percent) (exhib it 1).1 Contributing to this trend is decelerating growth in private health insurance spending. That growth is projected to have slowed from 5.8 percent in 2018 to 3.8 percent in 2019 be cause of slower per enrollee growth, which was mostly driven by a significant slowdown in growth in the net cost of private health insurance as a result of the health insurance tax moratori- um.\" The number of enrollees in private health insurance is projected to have fallen 0.3 percent in 2019, inuenced by the repeal of the individ- ual mandatef' and this decrease contributes to a slight decline in the insured share of the EXHIBIT 2 National health expenditure: (NHE) and health insurance enrollment. aggregate and per enrollee amounts. and average annual growth, by source of funds, selected calendar years 2016-20 Source of funds 2016 2017 2018 2019' 2020' 2023' 2028' EXPENDITURE, BILLIONS Private health insurance 51,1199 51,1750 51,2430 51,2900 51,3569 51554.7 $1,9818 Medicare 676.8 705.1 750.2 800.7 858.5 1,075.6 1,559.4 Medicaid 565.4 580.1 597.4 621.0 649.0 765.5 1,017.1 PEI! ENI'IOLLEE SPENDING Private health insurance 5 5550 5 5,813 5 6,199 5 6,455 3 6,772 3 7,682 3 9,597 Medicare 12,137 12,334 12,784 13,328 13,909 16,065 20,751 Medicaid 7,948 8,041 8,201 8,382 8,608 9,808 12,486 ENROLLMENT, MILLIDNS Private health insurance 201.8 202.1 200.5 199.8 200.4 202.4 206.5 Medicare 55.8 57.2 58.7 60.1 61.7 67.0 75.1 Medicaid 71.1 72.1 72.8 74.1 75.4 78.1 81.5 Uninsured 28.7 29.7 30.7 31.5 31.4 33.0 37.2 Population 3225 324.6 326.6 328.9 331.3 338.5 351.6 Insured share of total population 91.1% 90.8% 90.6% 90.4% 90.5% 90.3% 89.4% Average annual growth 2016|I 2017 2018 2019' 2020' 2021-23' 2024-28' EXPENDITURE, BILLIONS Private health insurance 5.6% 4.9% 5.8% 38% 5.2% 4.6% 5.0% Medicare 4.3 4.2 6.4 6.7 7.2 7.8 7.7 Medicaid 4.2 2.6 3.0 3.9 4.5 5.7 5.8 PEI ENIOLLEE SPENDING Private health insurance 4.8% 4.7% 6.7% 4.1% 4.9% 4.3% 4.6% Medicare 1.6 1.6 3.7 4.3 4.4 4.9 5.3 Medicaid 1.4 1.2 2.0 2.2 2.7 4.4 4.9 ENROLLMENT, MILLIONS Private health insurance 07% 0.2% 0.8% 0.3% 0.3% 0.3% 0.4% Medicare 2.7 2.5 2.6 2.4 2.7 2.7 2.3 Medicaid 2.7 1.4 1.0 1.7 1.8 1.2 0.9 Uninsured 28 3.7 3.1 2.8 0.4 1.6 2.4 Population 0.8 0.7 0.6 0.7 0.7 0.7 0.8 sounce Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group. unres For definitions, sources, and methods for NHE categories. see CM5.gov. National Health Expenditure Accounts: methodology paper. 2018 (see exhibit I notes). Numbers might not add to totals because of rounding. Percent changes are calculated from unrounded data. Tables with data for all years of the projection period can be found at [Migrant NHE projections ZUleZBitables [see note 13 in text). \"Projected. hAnnual growth, 2015716. 706 HEALTH AFFAlRS APRlL 2020 3924 Downloaded from Hmlllmilirs org on March 3|, 2020 Copyright 11mm HOPE The People-ioJ'wplc Health Foundation. Inc. Furpcrwnalusc only Allrighlsrescncd Reusepcrmissinnsnil-Icalilmffairsmrg. EXHIBIT 3 National health expenditures (NHE) amounts, average annual growth, and percent distribution, by type of sponsor, selected calendar years 2016-28 Type of sponsor 2016 Expenditure, billions NHE 33,3474 Businesses, household, and other private revenues 1,828.0 Private businesses 652.8 Household 950.5 Other private revenues 224.7 Governments 1,519.4 Federal government 951.9 State and local governments 567.5 Average annual growth 2016' NHE 4.6% Businesses, household, and other private revenues 4.9 Private businesses 4.8 Household 4.7 Other private revenues 6.1 Governments 4.3 Federal government 4.8 State and local governments 3.4 Distribution 2016 NHE 100% Businesses, household, and other private revenues 55 Private businesses 20 Household 28 Other private revenues 7 Governments 45 Federal government 28 State and local governments 17 2017 2010 2019' 2020- 33,4873 33,6494 33,8146 54014.2 1,921.0 2,013.1 2,092.1 2,200.5 684.2 726.0 760.3 801 .6 992.5 1,035.7 1,073.3 1,130.1 244.3 250.7 258.6 266.9 1,566.3 1,636.3 1,722.4 1,813.7 978.5 1,033.9 1,093.2 1,154.5 587.8 602.5 629.2 659.2 2017 2010 2019- 2020- 4.2% 4.6% 4.5% 5.2% 5.1 4.5 3.9 5.2 4.3 6.2 4.6 5.4 4.4 4.4 3.6 53 8.7 2.6 3.2 4.0 3.1 4.5 5.3 53 2.3 5.6 5.8 5.6 3.6 2.5 4.4 4.9 2017 2010 2019- 2020- 100% 100% 100% 100% 55 55 55 55 20 20 20 20 20 28 28 28 7 7 7 7 45 45 45 45 2a 29 29 29 17 1 7 16 1 6 2023' 2028' 54706.3 36,1 92.5 2,537.6 3,255.5 91 9.5 1 ,1 58.1 1,311.5 1,714.4 306.5 383.0 2,168.7 2,937.0 1,405.6 1,941.6 763.1 995.3 2021-23' 2024-28' 5.4% 5.6% 4.9 5.1 4.7 4.7 5.1 5.5 4.5 4.6 6.1 6.3 6.8 6.7 5.0 5.5 2023' 2028' 1 00% 1 00% 54 53 20 1 9 28 28 7 6 46 47 30 31 1 6 1 6 sounc: Centers for Medicare and Medicaid Servtces, Office of the Actuary, National Health Statistics Group. "01:: For definitions, sources, and methods for NHE categories, see CMSgov. National Health Expenditure Accounts' methodology paper, 2018 [see exhibit 1 notes). Numbers might not add to totals because of rounding. Percent changes are calculated from unrounded data. Tables with data for all years of the projection period can be found at CMS.gov. NHE projections 20197287tables [see note 13 in text). aProjected hAnnual growth, 201516. populationto 90.4 percent in 2019 from 90.6 percent in 2018 (exhibit 2). Spending growth in Medicaid is expected to have acceler- ated to 3.9 percent from 3.0 percent in 2018, partially offsetting the slower growth in private health insurance spending. Part of this accelera- tion is due to somewhat faster Medicaid enroll- ment growth, which is primarily attributable to expansions in Virginia and Maine. 2020 In 2020, growth in national health spending is expected to accelerate to 5.2 percent (exhibit 1). The majority of this acceleration is driven by faster expected growth in personal health care prices as measured by the Personal Health Care Price Index (from 1.5 percent in 2019 to 1.9 percent in 2020). The projected price trend reects anticipated increases in economy- wide ination, as well as a return to the some- what higher historical average growth rates for the prices of medical goods and serviceswhich averaged just 1.3 percent for 201618. Another factor contributing to faster growth is the tem- porary reinstatement of the health insurance tax in 2020, after a moratorium in 2019 and before the permanent repeal that takes effect in 2021.3 As a result of this tax, the net cost of health insurance is projected to grow more rapidly, in- creasing at a rate of 10.3 percent in 2020 com pared to 3.6 percent in 2019 (exhibit 4). The faster growth in the net cost of health insurance is a primary reason for the accelerations in spending growth for private health insurance, Medicaid, and Medicare6 202123 During 202123, growth in national health spending is expected to average 5.4 per cent, which is a slightly faster rate than that of 5.2 percent anticipated for 2020 (exhibit 1). The acceleration is more than accounted for by faster average annual growth in personal health care prices of 2.4 percenta rate closer to their long term average historical growth rate of 2 .8 percent over the past three decades. This faster price APRIL 2020 Downloaded from HcaIIhAnirs org ml March 3 I, 2020. Copyright ijccl Hope The People-lo-l'mplo Health Foundation, Inc. 39:4 For puma use only .111 right; reserved Rouse pcrmlsslolls m Harmon\"; org HEALTH AFFAlRS 707 EXHIBIT 4 National health expenditures (NHE) amounts and average annual growth, by spending category, selected calendar years 2016-28 Spending category 2016 2017 2018 2019' 2020' 2023' 2028' Expenditure, billions NHE 53,347.4 53,487.3 53,649.4 53,8i 4.6 54,0142 54,7063 56,1925 Health consumption expenditures 3,190.7 3,319.0 3,475.0 3,633.2 3,823.6 4,482.5 5,903.3 Personal health care 2,838.3 2,954.5 3,075.5 3,2i 9.3 3,377.5 3,979.6 5,255.5 Hospital care 1,089.5 1,140.6 1,191.8 1,253.0 1,316.4 1,563.0 2,088.0 Professional services 883.2 924.0 965.1 1,008.6 1,057.6 1,235.9 1,608.6 Physician and clinical services 665.6 696.9 725.6 757.4 794.4 932.4 1,224.4 Other professional services 92.7 97.5 103.9 109.3 114.8 134.8 175.5 Dental services i249 129.6 135.6 141.9 148.3 168.7 208.7 Other health, residential, and personal care 173.6 183.2 191.6 200.0 210.3 248.9 327.1 Home health care 93.0 97.1 102.2 108.9 1 16.2 143.0 201.3 Nursing care facilities and continuing care retirement communities 163.0 166.2 168.5 175.1 183.2 210.7 266.2 Retail outlet sales of medical products 436.0 443.2 456.3 473.6 493.9 578.2 764.4 Prescription drugs 322.3 326.8 335.0 345.7 358.7 420.3 560.3 Durable medical equipment 51.0 52.4 54.9 58,3 62.0 74,0 98.4 Other nondurable medical products 62.7 64.1 66.4 69.5 73.2 83.8 105.7 Government administration 44.9 44.8 47.5 49,8 52.0 62.1 84.2 Net cost of health insurance 218.8 228.3 258.5 267.8 295.2 331.7 432.9 Government public health activities 88.7 91.4 93.5 96.4 98.9 109.1 130.6 Investment 156.7 168.3 174.4 181.4 190.7 223.7 289.2 Noncommercial research 47.4 50.1 52.6 55.5 58.6 69.7 89.0 Structures and equipment 109.3 118.2 121.8 125.8 132.0 154.0 200.2 Average annual growth 2016II 2017 2018 2019' 2020' 2021-23' 2024-28' NHE 4.6% 4.2% 4.6% 4.5% 5.2% 5.4% 5.6% Health consumption expenditures 4.8 4.0 4.7 4.6 5.2 5.4 5.7 Personal health care 4.7 4.1 4.1 4,7 4.9 5,6 5.7 Hospital care 5.3 4.7 4.5 5,1 5.1 5,9 6.0 Professional services 5.4 4.6 4.4 4.5 4.9 5.3 5.4 Physician and clinical services 5.4 4.7 4.1 4,4 4.9 5,5 5.6 Other professional services 5.5 5.2 6.5 5.2 5.1 5.5 5.4 Dental services 5.1 3.8 4.6 4,6 4.5 4,4 4.4 Other health, residential, and personal care 5.5 5.5 4.6 4.4 5.1 5.8 5.6 Home health care 4.2 4.5 5.2 6,6 6.7 7,2 7.1 Nursing care facilities and continuing care retirement communities 3.1 2.0 1.4 3.9 4.6 4.8 4.8 Retail outlet sales of medical products 2.4 1.7 2.9 3,8 4.3 5,4 5.7 Prescription drugs 1.7 1.4 2.5 3.2 3.7 5.4 5.9 Durable medical equipment 4.9 2.9 4.7 6,3 6.3 6.1 5.9 Other nondurable medical products 4.1 2.2 3.6 4.8 5.2 4.6 4.7 Government administration 5.0 0.2 6.0 4,7 4.4 6.1 6.3 Net cost of health insurance 5.9 4.3 13.2 3.6 10.3 4.0 5.5 Government public health activities 3.4 3.0 2.4 3.1 2.5 3.3 3.7 Investment 1.7 7.4 3.6 4,0 5.1 5,5 5.3 Noncommercial research 2.1 5.7 5.0 5.7 5.6 5.9 5.0 Structures and equipment 1.5 8.1 3.0 3,3 4.9 5,3 5.4 souncl Centers for Medicare and Medicaid Services. Office of the Actuary, National Health Statistics Group. Mons For definitions, sources, and methods for NHE categories, see CMSgov. National Health Expenditure Accounts: methodology paper, 2018 (see exhibit 1 notes). Numbers might not add to totals because of rounding. Percent changes are calculated from unrounded dataTables with data for all years of the projection period can be found at CMS.gov. NHE projections 20l 97287tables (see note 13 in text). \"Projected. hAnnual growth, 201516. 708 HEALTH AFFAIRS growth is driven in part by expected increases in wage growth for health care workers (especially for some occupations where shortages are likely to occur) ,7 after a recent period during which wages for healthsector workers have grown more slowly than overall wages have.8 Medicaid spending growth is projected to av APRIL 2020 39:4 erage 5.7 percent in 202123, up from 4.5 per- cent in 2020, mostly because ofhigher spending for hospital services. Partially offsetting this in crease is a lower projected spending growth rate for private health insurance (4.6 percent per year for 202123), related in part to the permanent repeal of the health insurance tax starting in Downloaded [mm HmllhAairs org on March 3 l, 2020. Copyright ijecl HOPE The Peuple-IePwple Health Foundation. Ine. For personal use only. All rights reserved Reuse permissions m Healllvt'airsmg 2021.3 Finally, spending growth for prescription drugs is expected to average 5.4 percent per year during 202123 because of faster expected growth in drug prices, slowing growth of re bates, and anticipated increases in spending as- sociated with new prescription drugs (exhibit 4) .9 202425 During 202428, growth in nation- al health spending is expected to average 5.6 per- cent, slightly faster than the rate projected for 202123 (exhibit 1). Among the payers, spend- ing growth is mostly anticipated to be compara- ble to the increase in 202123. Average rates of growth for private health insurance and Med- icaid spending are projected to increase modest- ly (to 5.0 and 5.8 percent, respectively) from the previous period, whe Medicare spending growth is projected to be relatively faster than that for the other major payers but remain below 8 percent. Notably, by 2028as the babyboom generation continues to transition from private health insurance to Medicareseventy-five mil- lion people (or more than 20 percent of the pop- ulation) are projected to be enrolled in Medicare and account for $1 out of every $4 spent on health care. This contributes substantially to growth in the share of health expenditures sponsored by the government (to 47 percent) (exhibit 3). Model And Assumptions The national health expenditure projections are based on current law and are developed using actuarial and econometric modeling methods in addition to judgments about future trends that affect the health care sector."J This analysis in- corporates Medicare projections and economic and demographic assumptions from the 2019 Medicare Trustees Report,\" with updates to ac- count for more recently available macroeconom- ic data. The Further Consolidated Appropriations Act of 2020 repealed three taxes previously mandat- ed under the ACA: the medical device tax, the annual tax on health insurance providers, and the excise tax on highcost employer-sponsored health insurance. These changes are reected in the projections. Furthermore, a new rule that allows employers to subsidize employee premi- ums in the health insurance Marketplaces is scheduled to take effect in 2020 and is antici- pated to result in modest shifts in enrollment from traditional employersponsored insurance to individually purchased plans.12 It is important to note that there is inherent uncertainty associated with these projections. Specifically, to project future trends in medical spending, this analysis relies on assumptions about future macroeconomic conditions, such as growth in disposable personal income, econ- omywide ination, and historical relationships between these variables, and these assumptions do not account for potential future legislative changes that could affect national health spend ing or insurance coverage. To the extent that the assumptions used in this analysis differ from ultimate outcomes, they may result in deviations between health spending projections and actual experience. Factors Accounting For Growth In exhibit 5, average annual personal health care spending growth is decomposed to illustrate the relative contributions of such underlying factors as growth in the use and intensity of services, growth in personal health care prices, popula tion growth, and the changing age-sex mix. Pric es and quantities associated with nonpersonal health care spendingsuch as those applicable to the net cost of private health insurance, research, and other nonpersonal health care sectorsarc not reected. Over the coming de- cade, in comparison with the previous five years, the pattern of growth in personal health care spending is expected to be driven less by rising use and intensity of services and more by rising personal health care price ination. During 201928, personal health care spend ing growth is expected to average 5.5 percent, with growth in personal health care prices ex pected to account for 2.4 percentage points (or 43 percent) of that increase. This is a faster rate than the unusually low growth that occurred over 201418, which was inuenced by both low economywide ination and even slower growth in personal health care ination.While economy wide prices are projected to grow faster than personal health care ination through 2021, per sonal health care prices are expected to rise more rapidly than economywide prices over the rest of the projection periodin large part because of faster expected growth in input prices facing medical providers. Accordingly, when coupled with the slightly faster economywide ination that is anticipated, personal health care price growth is projected to rise from 1.5 percent in 2018 to 2.8 percent by 2028 (data not shown). Growth in the use and intensity of services is expected to account for about one-third of the total projected growth over 201928 (exhibit 5). Lower expected rates of growth in incomes (which generally causes people to consume less health care), combined with the absence of in creases in the use and intensity of services that were observed over 201416 under the ACA based insurance coverage expansion, are the crit ical factors that explain slower expected growth in use and intensity in 201928 compared to APRIL 2020 39:4 HEALTH AFFAIRS Downloaded [mm HeallhAffmrs mg m. Vlarch 3 I. 2020, Copyright r-mjccn HOPE The Pmplc-mrmplc Health Fun mum. Inc, For personal use only All nghls reserved Reuse permlsslmls a1 Healllmffmrs mg 709 EXHIBIT 5 Faclors accounting for growth in personal health care (PHC) expenditures, calendar years 1990-2023 8% 19902007 Average annual change N W b 53 cs 0\\ l l Residual use and intensity PHC Pricelndex Population growth Age-sex mix 200813 201418 2019283 souncll Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Sta? tistits Group; and Department of Commerce, Bureau of Economic Analysis and Bureau of the Census. Nnrll Growth in the total PHC Price lndex is equal to the sum of economywide and relative F'HC inflation and is a chaineweighted index of the price for all personal health care deflators. "Use and intensity" includes the quantity and mix of services. As a residual, this factor also includes any errors in measuring prices or total spending. "Ageesex mix" refers to that mix in the population. aProjected. 710 201418 (1.8 percent versus 2.3 percent). The contribution to personal health care spending growth from the changing composi- tion of the population by age and sex is projected to grow at a relatively stable pace0.5 percent for 201928, compared to 0.6 percent for 2014 18. However, as a share of personal health care spending growth, the contribution made by changing demographics is projected to decline from 14 percent in 2018 to 9 percent by 2028 (data not shown). Outlook For Spending And Enrollment By Payer MEDICARE Medicare expenditures are projected to have grown 6.7 percent in 2019, slightly faster than the rate of 6.4 percent in 2018, and to have reached $800.7 billion (exhibit 1). This trend primarily reects faster growth in Medicare spending on personal health care, which accel- erated from 5.7 percent in 2018 to 6.6 percent in 2019. In particular, the rate of Medicare spend- ing growth is projected to have increased rapidly for hospitals (from 4.6 percent in2018 to 6.3 per- cent in 2019) and for prescription drugs (from HEALTH AFFAIRS APRIL 2020 39:4 5.9 percent to 6.9 percent).13 In 2020, Medicare spending growth is pro- jected to accelerate to 7.2 percent (exhibit 2). This faster rate is largely due to more rapid growth in enrollment, from 2.4 percent in 2019 to 2.7 percent in 2020. Also contributing are the concurrent expirations of the moratorium on the health insurance tax and the ACA- mandated 0.75 percent payment update reduc- tion that was applicable to Medicare's fee-for- service hospital payments in 2019. As a result, per enrollee Medicare expenditures are expected to grow slightly more rapidly in 2020 than they did in 2019 (4.4 percent versus 4.3 percent). During 202123, Medicare spending is pro- jected to increase at an average rate of 7.8 percent per year. Faster expected growth for this period is principally driven by expected accelerations in growth in Medicare spending for hospital ser- vices (from 7.1 percent in 2020 to an average of 8.1 percent for 202123) and for physician and clinical services (from 6.1 percent in 2020 to an average of7.4 percent for 202123) . Both sectors are expected to experience more rapid increases in the use and intensity of services that more closely resemble their long-term average.11 For the 202428 period, Medicare spending growth is expected to average 7.7 percent, as a slightly slower average Medicare enrollment growth rate of 2.3 percent (compared to an av- erage of 2.7 percent over 202123) offsets a somewhat faster per enrollee expenditure growth rate of5.3 percent (compared to 4.9 per- cent over 202123). MEDICAID Following growth of 3.0 percent in 2018, Medicaid expenditures are projected to have increased 3.9 percent in 2019 and to have reached $621.0 billion (exhibit 1). Most of the increase is attributable to enrollment growth, which is projected to have accelerated from 1.0 percent to 1.7 percent as Virginia and Maine broadly implemented Medicaid expansions. Per enrollee, growth is expected to have been slightly faster in 2019 as the program's price factors (the payment rates made to medical providers per Service or per good) increased from 2.4 percent in 2018 to 3.1 percent in 2019.\" However, the use and intensity of services is expected to grow more slowly in 2019 because of the inux of younger and healthier enrollees related to Med- icaid expansion. In 2020, Medicaid spending growth is pro- jected to accelerate to 4.5 percent (exhibit 2). This rate is the net result of several factors that mainly affect per enrollee trends: an increase in the growth of the net cost of insurance related to the reinstatement of the health insurance tax for that year; fewer payments recovered by the gov- ernment from Medicaid managed care organiza- Downloaded rmm HulthAau: mg m Much 3 I, 1020. Copyright ijecl HDPE The People-m-Foople Health Foundalion, In: For Personal use only All alghlsrmrved. Reuse permissions a Health/mm mg tions;15 and faster expected growth in Medicaid payment rates per service and per good (to 3.5 percent). Somewhat offsetting these factors are the mandated reductions to disproportionate share hospital payments,16 which account for slowing growth in that sector to 1.2 percent (from 4.4 percent in 2019), and the impacts on use and intensity associated with Medicaid expansions in Idaho, Nebraska, and Utah. During 202123, average Medicaid spending growth is projected to climb to 5.7 percent. This accelerating projected growth rate reects an expected resumption of faster growth in the use and intensity of medical goods and services following the expansion-related slower growth in that metric in 2019 and 2020. Particularly notable is Medicaid spending for hospital ser- vices, a sector in which this increasingly higher growth in use is expected to more than offset further reductions to disproportionate share hospital payments. During 202428, the average growth rate for Medicaid spending is projected to be 5.8 percent, slightly faster than during 202123. Two drivers primarily explain this projected rate: the expira tion of reductions to disproportionate share ho S pital payments on September 30, 2025, and a progressively higher share of enrollment attrib utable to aged and disabled beneficiaries, who tend to use a greater number of, and more costly, services. PRIVATE HEALTH msunnuc: AND our-or- pocur SPENDING For private health insurance spending, growth is expected to have decreased from 5.8 percent in 2018 to 3.8 percent in 2019, with total expenditures of $1.3 trillion (exhibit 1). The primary factor inuencing this deceleration is a signicant slowdown in growth in the net cost of private health insurance (from 15.3 per cent in 2018 to 2.0 percent in 2019),\" which resulted for two reasons: The health insurance tax, which was in place during 2018, was not imposed in 2019 and thus contributed to a smaller difference between premiums and bene fits; and insurers in the individual market expe- rienced lower claims costs in 2018 than were expected when premiums were setSa trend that resulted in lowerthanantieipated loss ratios and that led, in turn, to rebates that were de ducted from 2019 premiums. Finally, private health insurance enrollment is projected to have declined 0.3 percent in 2019 (exhibit 2). This decrease is assumed to be mostly attributable to the repeal of the individual mandate.5 For out-of-pocket spending, growth is ex- pected to have increased from 2.8 percent in 2018 to 3.7 percent in 2019, with total expendi- tures of $389.6 billion (exhibit 1). This accelera tion is associated with an increase in the average deductible for people enrolled in private health insurance plans,17 as well as a projected increase in the number of uninsured peoplefrom 30.7 million in 2018 to 31.5 million in 2019 (exhibit 2) prineipally as a result of the repeal of the individual mandate.5 In 2020, private health insurance spending growth is expected to accelerate to 5.2 percent from the rate of 3.8 percent projected for 2019. This acceleration is primarily due to the imposi- tion of the health insurance tax, which leads to a projected sharp rebound in growth (to 8.4 per- cent) in the net cost of private health insurance in 2020. Also contributing is a return to positive enrollment growth (0.3 percent) after declines in 2018 and 2019. For 202123, despite faster growth in prices for medical goods and services, private health insurance spending growth is expected to slow to 4.6 percent per year, on average (exhibit 1). This projected slower growth is mostly a result of the repeal of the health insurance tax after 2020, which is expected to lead to significantly slower growth in the net cost of private health insurance in 2021. Average out-ofpocket spending is pro- jected to increase by 0.1 percentage point relative to 2020 and to grow 4.1 percent over 202123. The price increases projected over this period are anticipated to result in only modestly accelerat- ing growth in outof-pocket spending, in part because of the expectation that employers will not increase deductibles and copayments as much as they have in the recent past but instead will look for other ways to achieve savings.\" For 202428, minor growth accelerations are expected in both average private health in surance spending and average out-of-pocket spendingto 5.0 percent and 4.3 percent, re spectively (exhibit 1). Underlying these gradual accelerations is faster projected price growth. For private health insurance, growth in per en rollee spending is projected to average 4.6 per- cent over 202428, less than the average annual per enrollee growth rate for Medicare (5.3 per- cent) and Medicaid (4.9 percent) over the same period (exhibit 2). Outlook For Major Medical Services And Goods HOSPITALS In 2019, total spending for hospital care is expected to have increased by 5.1 percent, an acceleration from growth of 4.5 percent in 2018, and to have totaled $1.3 trillion (exhibit 4). The overall increase was driven by an accelera- tion in projected Medicaid hospital spending growthto 4.4 percent from 2.0 percent in 20181which resulted in part from program ex- pansion by additional states and rising payment APRIL 2020 Downloaded from Hahn/mm org on Marclill,2(l'10 Cap, \"gm r-mjm HOPE The l'cuplc-tn-I'mplc Health Foundahnn. Inc. 3924 Far pcrmnnl use only All righl: reserved Reuse permissions m Hcammrrmrsmg HEALTH AFFAIRS 711 COSTS 81 SPENDING rates to hospitals. Medicare hospital spending growth is also expected to have accelerated (from 4.6 percent in 2018 to 6.3 percent in 2019), be- cause of an anticipated increase in per enrollee spending growth.\" In 2020, hospital spending growth is expected to remain at 5.1 percent, the same rate as in 2019. This stability is a net result of differing projected spending growth patterns for the major under lying payers. For Medicare, hospital spending growth is expected to accelerate again by nearly a percentage point (to 7.1 percent) attributable in part to a higher price update for fee-forservice payments, including the expiration of a payment reduction under current law.\"3 For Medicaid, however, hospital spending growth is expected to decelerate strongly (to 1.2 percent) because of the implementation of $6 billion in federal dis- proportionate share hospital payment cap reduc tions in 2020.20 During 202123, total hospital spending growth is expected to rise to 5.9 percent peryear. Reecting both continued strong projected en rollment growth by the baby-boom generation and per enrollee spending increases that would be more consistent with the longerterm history, growth in Medicare hospital spending is ex pected to increase at an average rate of 8.1 per- cent during this period.13 Despite further annual federal disproportionate share hospital payment cap reductions scheduled under current law ($8 billion per year ,20 the Medicaid spending growth rate is also expected to increase (to 5.0 percent per year, on average), as a result of ex pected faster growth in per enrollee spending associated with the increasing proportion of aged and disabled beneficiaries.13 Over the remainder of the projection period (202428), hospital spending is expected to in crease at 6.0 percent per year, on average.While Medicare hospital spending growth during these years is expected to be slightly lower (at under 8 percent per year) than it was during 202123, the average annual growth rate for Medicaid hospital spending is expected to increase to 6.1 percent.13 In addition to changes in the ben- eficiary mix, this acceleration reects a onetime expected increase in spending growth in 2026, following the expiration of the disproportionate share hospital payment cap reductions in 2025. PHYSICIAN AND CLINICAL SERVICES Spending for physician and clinical services is projected to have grown 4.4 percent in 2019 (totaling $757.4 billion), compared to 4.1 percent in 2018 (exhibit 4). Underlying this trend is an expected acceleration in the Medicaid spending growth rate to 4.3 percent in 2019 from 2.9 per cent in 2018, which is partly attributable to in- creased spending from states that elected to ex pand Medicaid and to anticipated increases in Medicaid payment rates. On the other hand, spending growth for physician and clinical ser- vices paid for through private health insurance is expected to have slowed to 3.3 percent from 3.9 percent in 2018, a result that is consistent with a modest 201819 u season and is also associated with the repeal of the individual mandate.\"22 Growth in spending for all physician and clin- ical services is projected to accelerate to 4.9 per- cent in 2020 and then to an average rate of 5.5 percent over 202123. In 2020, the trend is primarily inuenced by a projected 4.4 percent increase in private health insurance spendinga result of faster growth in the use and intensity of servicesand to a 0.3 percent increase in private health insurance enrollment. Slightly offsetting these factors is Medicare spending growth for physician and clinical services, which is pro- jected to decelerate to 6.1 percent in 2020 be cause of slower projected growth in spending per enrollee.\" For the 202123 period, faster spending growth for overall physician and clinical services is largely driven by a projected increase in the average price growth rate (to 1.6 percent from 1.0 percent in 2020). Despite recent low price growth, it is expected that the costs of providing careparticularly the costs associated with the wages of physician and clinical services providerswill increase more rapidly, ultimate- ly leading to higher price growth. During 202428, growth in physician and clinical services is projected to be similar to that in 202123, averaging 5.6 percent per year. The continued shift of aging baby boomers out of private health insurance and into Medicare sig nificantly contributes to a higher average annual growth rate of 7.6 percent for Medicare spend- ing on physician and clinical services, compared to a more modest annual growth rate of 4.8 per- cent for private health insurance spending on these services.13 PRESCRIPTION DRUGS Prescription drug spending growth is expected to have remained slow but to have accelerated from 2.5 percent in 2018 to 3.2 percent in 2019 (exhibit 4), with expenditures totaling $345.7 billion. This trend is largely driven by faster growth in Medicaid drug spendingwhich, at 4.7 percent, followed a low growth rate in 2018 of 1.4 percent that is partially attributable to lower spending on hep- atitis C drugs in that year. In addition, Medicare prescription drug spending growth is expected to have increased from 5.9 percent in 2018 to 6.9 percent in 2019, in part because of faster growth in the use and intensity of prescription drugs.\"'13