Between 2023 and 2024, national health expenditures (NHE) increased 7.2% to $5.3T, compared with 5.3% growth in gross domestic product (GDP), and NHE accounted for 18.0% of GDP.1 The Centers for Medicare & Medicaid Services (CMS) projects that NHE grew by an additional 7.3% to reach $5.7T in 2025.2 Spending growth reflects changes in the price, volume and intensity of services, and the contribution of utilization to that growth varies across patient populations. Because age, sex and source of coverage shape how much care patients use and where they receive it, differences in utilization across these groups have implications for how providers plan capacity and how policymakers interpret spending growth.
Healthcare utilization and spending differ considerably by payer type, age and sex, which means that as the composition of the U.S. population changes, so will patterns of healthcare demand. In 2025, employer-sponsored insurance covered 53.5% of the population, followed by Medicare at 20.1%, Medicaid at 17.1% and direct-purchase coverage at 10.5%. The share of the U.S. population ages 65 and older increased from 12.4% in 2000 to 18.9% in 2025 and is projected to reach 23.2% by 2050.3 Over the past decade, the share of the population covered by Medicare increased from 16.3% in 2015 to 20.1% in 2025, while the share covered by Medicaid declined from 19.6% to 17.1%.4,5 In 2020, per capita healthcare spending for adults ages 65 and older was $22,356, nearly 2.5x the $9,154 for adults ages 19 to 64 and more than 5x the $4,217 for children.6 Per capita spending for women ages 19 to 64 was 20% higher than for men in the same age group, while spending for men ages 65 and older was 2% higher than for women.
While an aging population will reshape demand, the growth in healthcare spending over the last few decades has been driven less by how much care Americans use than by what care costs. From 1970 to 2024, inpatient admissions per 1,000 population declined by 30.8%, while per capita NHE increased from $2,208 to $15,474 in constant 2024 dollars, a 7x increase.7 Hospital care and physician and clinical services together accounted for more than half of NHE in 2024, and hospital spending alone accounted for 40% of NHE growth from 2022 to 2024, a period in which hospital prices grew at their fastest rate since 2007.8
Developing and implementing policy to “bend the cost curve” in the U.S. healthcare system first requires distinguishing which populations and care settings are the cost drivers. To examine these dynamics, this analysis compares utilization trends across care settings.
The Trilliant Health national all-payer claims database was leveraged to examine visits that occurred across care settings between 2019 and 2025. Healthcare utilization was analyzed both in aggregate and separately for eight care settings, which were inpatient, hospital outpatient, physician office, emergency department (ED), ambulatory surgery center (ASC), urgent care, home health and telehealth. Utilization was calculated as a rate of visits per 1,000 patients, segmented by age, sex and payer type.
The analysis was restricted to continuously enrolled patients. To calculate a true rate, patients who did not consume any care during their enrollment period, despite having a full year of coverage, were included in the denominator.
From 2019 to 2025, visits per 1,000 patients across all care settings increased at a compound annual growth rate (CAGR) of 2.1%, from 11,200 to 12,652 (Figure 1). Physician office visits accounted for the largest volume, at 6,233 per 1,000 patients in 2025, but declined at a -0.1% CAGR over the period. Home health visits per 1,000 patients increased at a 3.2% CAGR, hospital outpatient visits at 2.1%, urgent care visits at 1.7%, ASC visits at 1.6% and inpatient visits at 1.4%. ED visits per 1,000 patients declined at a -1.2% CAGR from 334 to 310 in 2025. Telehealth visits per 1,000 patients increased from 31 in 2019 to 816 in 2025.
Women had higher utilization than men in every year and every care setting (Figure 2). In 2025, women had 15,333 visits per 1,000 patients, 21.7% more than the 12,595 for men, down from a 25.2% gap in 2019. However, the gap narrowed in nearly every care setting between 2019 and 2025 as utilization grew faster among men, most notably for inpatient visits, where the gap fell from 18.3% in 2019 to 9.7% in 2025, and for ASC visits, where it fell from 18.5% to 10.9%. The exceptions were urgent care, where women had about 30% more visits per 1,000 patients than men in both years, and telehealth, where the gap widened from 33.6% to 69.5%. Further illustrating this, from 2019 to 2025, utilization increased at a 3.6% CAGR among men compared with 3.1% among women. The largest differences in growth were for inpatient visits, which increased at a 3.5% CAGR for men compared with 2.2% for women, and ASC visits, which increased at a 4.3% CAGR for men compared with 3.1% for women.
In 2025, patients ages 65 and older had 20,823 visits per 1,000 patients, 2.7x the rate of 7,587 per 1,000 patients under 18 (Figure 3). Patients ages 65 and older had the highest utilization in most care settings, but patients ages 18 to 49 had higher rates of telehealth, urgent care and ED visits, at 1,534, 251 and 341 visits per 1,000 patients, respectively, compared with 541, 188 and 334 for those ages 65 and older. Although utilization increases with age, utilization growth from 2019 to 2025 was generally slower among older age groups. Visits per 1,000 patients increased at a 3.4% CAGR for patients ages 18 to 49, 2.0% for those under 18, 1.4% for those ages 50 to 64 and 1.1% for those ages 65 and older. Inpatient visits among patients ages 65 and older declined at a -0.8% CAGR, compared with growth of 3.5% for those ages 18 to 49 and 2.6% for those ages 50 to 64. Home health followed a similar pattern, declining at a -1.2% CAGR among patients ages 65 and older while increasing at a 5.7% CAGR among those ages 18 to 49. ED visits per 1,000 patients declined in every age group, with the largest decline among patients under 18, at a -2.4% CAGR.
In 2025, patients dually eligible for Medicare and Medicaid had 22,183 visits per 1,000 patients, the highest of any payer type and 2.5x the commercial rate of 9,033 per 1,000 patients (Figure 4). Dual-eligible patients had the highest rates of any payer type for home health, telehealth, inpatient and ED visits, including 7,404 home health visits per 1,000 patients compared with 4,715 for Medicaid patients, the next highest. Traditional Medicare patients had the highest rates of physician office, hospital outpatient and ASC visits. However, dual-eligible patients were also the only payer type with lower utilization in 2025 than in 2019, declining at a -1.3% CAGR. Among Medicare beneficiaries, visits per 1,000 patients increased at a 2.1% CAGR for Medicare Advantage (MA) and a 1.4% CAGR for Traditional Medicare, although Traditional Medicare utilization exceeded MA in every year, reaching 21,478 visits per 1,000 patients in 2025 compared with 19,460 for MA. Medicaid had the highest growth of any payer type at a 5.5% CAGR, driven largely by home health, which increased at an 11.1% CAGR. Among commercial patients, inpatient visits per 1,000 patients increased at a 5.8% CAGR, compared with a 1.9% CAGR for MA and a -2.1% CAGR decline for Traditional Medicare.
However, it is less well known that national health spending has consistently grown at a higher rate than healthcare utilization. From 2019 to 2025, NHE increased at a 6.8% CAGR, compared with a 2.1% CAGR for visits per 1,000 patients across all care settings, with utilization growth varying across age, sex and care setting (Figure 5).
Much of the health economy has been planned around the assumption that an aging and increasingly unhealthy population will generate steadily increasing demand for care. This analysis challenges that longstanding assumption, revealing that spending continues to grow at a higher rate than per-patient utilization and sometimes even in the face of declining per-patient utilization. However, population aging still contributes to increasing overall utilization. Adults ages 65 and older continue to have higher utilization than other age groups in most care settings, and their share of the population is increasing. As noted in our recent study, this shift in population composition can increase overall utilization even when utilization within each age group grows slowly or declines, an example of Simpson’s paradox.9 Spending growth therefore reflects increasing overall utilization in part, but not entirely. Understanding why spending has outpaced per-patient utilization would seem to be a pressing question for policymakers. The concentration of utilization growth among younger, commercially insured and Medicaid patients may reflect both lower point-of-care cost-sharing for Medicaid enrollees and increasing health needs, including worsening health among younger populations. Whether that utilization growth is a concern depends on how much of it consists of high-value versus low-value care.