Each year, 1 in every 20 Americans racks up just as much in medical bills as another 19 combined. This critical five percent of the U.S. population is key to solving the nation's health care spending crisis. Read the rest of our coverage.
If you’re like the average American, you spend around $1,000 per year on health expenses. You likely don’t often have to think about your deductibles and itemized health care costs.
But what if you get an appendicitis and need emergency surgery? Once the pain clears and you return home, the hospital bills begin to arrive—and they’re pricey. At the end of the year, your health care expenses end up totalling $20,000, including the amount your insurance company paid. This puts you far above the national average of $912 per year.
But where do you stack up compared to the rest of the U.S.? Let’s add a dot for every 2 million people in the country. With that hefty bill, you’re near the upper end of the spectrum. Compare that to the big clump on the left: Most Americans pay very little each year.
To get a better sense of the distribution of expenses, let’s sort the dots into 20 equal groups, ordered by total amount spent on health care, to represent every slice of the population. Each of the 20 bars represent about 16 million people.
You are now part of the top five percent of Americans who spent the most on the health care. When we add up the total expenditures for each group, we end up with a very lopsided chart—most of the nation’s medical bills come from your group of people on the right.
What’s most notable about this small slice of people is that they account for over 50 percent of all health care expenditures for all Americans. In other words, if the country’s population were 20 people, it would spend the same amount on its costliest patient as it would for the next 19 combined.
The Five Percent accounts for the same total expenditures as the rest of the population combined. So why not focus on the people who spend the most?
Despite that logic, legislators still prefer broad measures to lower health care spending, favoring higher deductibles and spending caps. That’s partially because it’s so hard to define the factors that push an otherwise healthy person into the costliest five percent of Americans. Besides their unenviable medical bills, they have very little in common with each other.
“When you're working on health care costs, it seems as though the big prize would be to do things to help this largest population,” said Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution. “But the problems they have are very wide-ranging. It’s not like they're all suffering from the same thing.”
Many of them aren’t very old.
Proportion of the Five Percent
1 block
60K people
Proportion of the total population
1 block
1.3M people
Many of the Five Percent are senior citizens — almost half are 65 or older. But while they’re overrepresented among the biggest health care spenders, the elderly are not the majority. Another 20 percent are under 45; 5 percent are under 18.
Very few don’t have health insurance.
Proportion of the Five Percent
1 block
60K people
Proportion of the total population
1 block
1.3M people
Politicians commonly blame “frequent flyers” — uninsured patients who rely on the emergency room for medical care — for rising costs. But the vast majority of the Five Percent have insurance; most report finding it quite useful.
Most have at least one serious illness.
Proportion of the Five Percent
1 block
60K people
Proportion of the total population
1 block
1.3M people
Many of these people do have long-term illnesses. Nearly two-thirds suffer from cancer, heart disease, diabetes, or a stroke (or some combination of the four). But a sizable chunk have no chronic conditions at all.
Many say they’re pretty healthy.
Proportion of the Five Percent
1 block
60K people
Proportion of the total population
1 block
1.3M people
Indeed, more than half say their physical health is good, or even better.
Truth is, there is no single group of sick people to blame for the United State’s high health care bills. Among the Five Percent, there is no “them.” Instead, the sickest five percent of Americans are drawn from all Americans — the young, the old, the chronically ill, and the temporarily injured alike.
There’s a great deal of turnover: On any given year, half of the Five Percenters will get better and drop out of the bracket. Fact is, the chronic conditions plaguing high-cost patients are quite common lower down on the cost scale, too. And no one has figured out how to tell when a stable, low-cost diabetic will jump into needing intense care.
If this spending disparity were a recent phenomenon, researchers might have an easier time picking out a cause. But studies show this distribution has persisted since the 1960s, and possibly even further — before the big entitlement programs of Medicare and Medicaid were founded.
The thing that has changed, of course, is the total amount Americans spend on health care—a figure that has ticked relentlessly upward. In 1960, medical spending accounted for 5 percent of the U.S. gross domestic product. By 2000, it had jumped to 13 percent. As of 2015, it stands at 18 percent.
The reasons behind that sharp rise are still not well understood. But in one light, America’s lopsided medical expenditures are an indication not of inefficiency, but of a willingness to spend. When a person’s health is on the line, the numbers suggest there’s almost nothing they wouldn’t pay.
Whatever the cause, this small percentage of the population holds many of the answers to reducing the enormous amount the U.S. spends on medical care. No solution adds up without addressing them first. In series of articles to be published over the next few weeks, we’ll explore some of the solutions that have been tried in different places—and in different ways—to serve the Platinum Patients.
Andrew McGill is a senior product manager at The Atlantic.
The data presented in this article is sourced from the Medical Expenditure Panel Survey, which is run by the U.S. Department of Health and Human Services. All data is from 2014, the most recent year available.
This article is part of our project The Platinum Patients which is part of a collaboration with the Solutions Journalism Network, supported by a grant from The Commonwealth Fund.