Introduction
Previous research from the Health Care Cost Institute (HCCI) has consistently found that growth in private-sector health care spending is primarily driven by prices. For example, HCCI’s most recent Health Care Cost and Utilization report on employer-sponsored insurance found a 17% increase in per-person spending in California from 2018-2022. In that five-year period, prices increased by nearly 21% while use increased by 14%.[i] High health care prices also translate to higher medical premiums, adding to the affordability challenges facing California’s families and businesses.
HCCI’s previous research has documented wide variation in prices even within states, and this is particularly true in California because of its size and diversity. For example, HCCI’s earlier analysis found that, in 2022, per person spending in the San Francisco metro area was 28% higher than the national average, driven by prices 76% above the national average. In contrast, spending in the Los Angeles metro area was 21% lower than the national average even though prices were 15% higher.[ii]
In this report, we analyze data from the California Health Care Payments Dataset (HPD) for years 2019-2023 to explore private-sector spending and price variation at the county level. This report focuses on people with Employer Sponsored Insurance (ESI) and Individual Marketplace insurance, which together make up 53% of the insured population in California.[iii] The report is divided into three main sections: 1) variation in health care spending and cost burden; 2) service price variation; and 3) the relationship between hospital market concentration and service prices.
Key Findings
- Per-person spending across both the ESI and Individual Marketplace populations is high and rising over time.
- Per-person spending across counties varies 2-fold from the highest spend county to the lowest spend county among ESI enrollees and 3-fold among Individual Marketplace enrollees.
- Among ESI enrollees, per-person health spending made up 7% of per-person income, on average. Among Individual Marketplace enrollees, the ratio of per-person health spending to income was 8%. Both ESI and Individual Marketplace ratios varied widely by county.
- There is wide price variation across different service types, between and within counties.
- Over 40% of counties in California have highly or very highly concentrated hospital markets. Inpatient prices are higher in counties with less competitive hospital markets.
Spending and Cost Burden
We define health care spending as the total amount spent by the health plan and member. This report analyzes total and per-member per-year (PMPY) medical and pharmacy spending captured in the HPD claims data but does not include insurance premiums or services that were privately paid without insurance.
Employer Sponsored Insurance
In California, total spending across ESI enrollees was about $60 billion in 2023, up from $51 billion in 2019. To account for changes in enrollment overtime, we calculated per member per year spending, which divides total spending by all enrollees. In 2023, spending on behalf of people who got insurance through work averaged $5,747 per person. That spending was 20% higher than 2019 when per person spending was $4,772 (Figures 1a-1b).
Per person spending ranged from $4,607 in San Bernardino County to $9,626 in Inyo County (Figure 2). Highest spending counties include Inyo County, Mono County, Amador County, Calaveras County, and Tuolumne County. The lowest spending counties include San Bernardino County, Modoc County, Riverside County, Imperial County, and Kern County.
Among higher spending counties, there were some common characteristics. These counties were more likely to have smaller populations (<15,000 enrollees), were more rural (6 of the top 10 spending counties were rural), and had a higher proportion of medical spending relative to prescription drug spending. For a detailed table of spending at the state and county level by insurance type and year, see Appendix C.
Per-person spending does not fully capture the impact of health care costs on individual households. To better illustrate how health care costs affect people, we measure cost burden by calculating the ratio of per-person health care spending and average per-person income in a geographic area. The cost burden helps to describe the relative affordability of health care. The higher the cost burden ratio, the greater share of income would be allocated to health care. Across the state, cost burden among people enrolled in ESI averaged 7%.[1] This means that per-person health spending was 7% of the average per-person income. From 2019 to 2023, cost burden among this population remained stable.
Across counties, cost burden was highly variable, ranging from 4% in San Francisco County to 18% in Del Norte County among ESI enrollees (Figure 3). The five highest cost burden counties include Del Norte County, Amador County, Tehama County, Lake County, and Siskiyou County. The five lowest cost burden counties include San Francisco County, San Mateo County, Santa Clara County, Marin County, and Alameda County. Most counties (82%) had a higher cost burden than the state average.
Low cost burden counties, such as San Francisco and San Mateo, had higher average incomes ($162,335 and $171,038 respectively), which offset their low or moderate health care spending. High cost burden counties, such as Del Norte and Imperial, had much lower average incomes ($46,919 and $50,637 respectively) and higher than average spending, resulting in a larger proportion of income being consumed by per-person health care spending.
High cost burden counties had similar characteristics to high spending counties, including population size and rurality, as there was substantial overlap between the two groups. The cost burden ratio illustrates that high health care spending in lower income populations creates affordability challenges for many counties, particularly those with smaller and rural populations. A detailed table of cost burden by insurance type at the county and state level is available in Appendix D.
Individual Marketplace
In 2023, total spending across people enrolled through the Individual Marketplace was about $9.5 billion, up from $3.7 billion in 2019. In 2023, PMPY spending was $6,577 for Individual Marketplace enrollees, a 7% increase from $6,144 in 2019 (Figures 1a-1b).
Among Individual Marketplace enrollees there was a wider range in spending than ESI enrollees, from $4,507 in Sierra County to $12,068 in Imperial County (Figure 2). The highest spending counties include Imperial County, Lake County, Inyo County, Del Norte County, and Calaveras County. The lowest spending counties include Sierra County, Tulare County, Los Angeles County, San Bernardino County, and Kern County.
Like ESI enrollees, there were some common characteristics of higher spending counties among Individual Marketplace enrollees. These counties have smaller populations (<3,000 enrollees), and a greater proportion of rural counties had higher spending (4 of the 13 rural counties were among the top 10 spending counties).
Among people with Individual Marketplace coverage, the average cost burden was 8%, meaning per-person health care spending consumed 8% of income, on average. The cost burden ratio decreased slightly from 10% in 2019 to 8% in 2023. Across counties, the cost burden for Individual Marketplace enrollees ranged from 4% in Santa Clara County to 25% in Imperial County (Figure 3). The highest cost burden counties were Imperial County, Lake County, Del Norte County, Trinity County, and Amador County. The lowest cost burden counties were Santa Clara County, San Mateo County, San Francisco County, Marin County, and Alameda County. The same factors drove variation in cost burden among Individual Marketplace enrollees as ESI enrollees. Counties with higher income and low to moderate spending had a lower cost burden, while lower income counties with high spending had the highest cost burden.
Prices
To compare prices across counties in California, we selected five services across the following categories: inpatient, outpatient and professional services. The five selected services were among the most common across each service category, and included childbirth, ER visits and lab tests (the list of codes is available in the methods section). We stratified all service prices by payment arrangement (i.e., fee-for-service or other). Table 1 shows the state ESI and Individual Marketplace benchmark median, 25th and 75th percentile prices for the five selected services, stratified by site of service and payment arrangement.
Employer Sponsored Insurance
C-Section Childbirth Delivery
Inpatient admissions for childbirth had the highest prices of the five services studied, and childbirth prices varied the most. The median price of a c-section delivery was $23,156. We measured the variation in price by looking at the difference between the 75th percentile price and the 25th percentile price. This measure is known as the interquartile range. The larger the range, the more variation there is in service price. The smaller the range, the less variation. In the case of a c-section delivery, the 25th percentile price was $11,152, and the 75th percentile price was nearly 3x higher at $32,945, so the interquartile range was $21,793.
Among people with Employer Sponsored Insurance, fee-for-service c-section delivery prices were higher than those in other payment arrangements. The median fee-for-service price was $25,905 compared to a non-fee-for-service price of $15,709. Approximately 77% of c-section admissions in the data were reimbursed on a fee-for-service basis.
At the county level, there was wide variation in median c-section prices.[2] A c-section delivery ranged from $7,037 in Tulare County to $39,915 in Monterey County, a nearly 6-fold difference. Within counties, there was also wide variation in price for the same service. Inyo County had the highest variation, where c-section interquartile range of prices was $37,427. Kings County had the lowest variation, where the interquartile range was $5,387.
Vaginal Childbirth Delivery
The median price of a vaginal delivery admission was $14,479. The 25th percentile price for vaginal delivery was $9,300, and the 75th percentile price was over twice as high at $20,024, resulting in an interquartile range of $10,724.
Among people with Employer Sponsored Insurance, fee-for-service vaginal delivery prices were higher than those in other payment arrangements. The median fee-for-service price was $14,479 compared to a non-fee-for-service price of $11,464. Approximately 80% of vaginal delivery admissions were reimbursed on a fee-for-service basis.
As with c-section deliveries, there was wide county-level variation in median vaginal delivery prices. A vaginal delivery ranged from $4,888 in Tulare County to $24,399 in Monterey County, a nearly 5-fold difference. Within counties, Santa Barbara County had the highest variation, where vaginal delivery interquartile range of prices was $14,848. Glenn County had the lowest variation, where the interquartile range was $482.
Emergency Room Visit
Emergency Room visits were the most used of the outpatient services studied. The median price of a moderate to high severity Emergency Room visit was $376 but varied widely. The price of an ER visit ranged from $365 (25th percentile) to $2,187 (75th percentile), resulting in an interquartile range of $1,822.
The fee-for-service price of an Emergency Room visit was higher than prices paid with another payment arrangement. For example, the median fee-for-service price was $499, 32% higher than the $376 paid in non-fee-for-service arrangements. Most ER visits were paid with a non-fee-for-service arrangement (58%).
Across counties, an ER visit ranged from $157 in Tulare County to $1,436 in Inyo County, a 9-fold difference. Within counties, Del Norte County had the highest variation, where the ER interquartile range of prices was $2,707. Glenn County had the lowest variation, where the interquartile range was $277.
Comprehensive Metabolic Panel (CMP)
Laboratory tests, including the Comprehensive Metabolic Panel (CMP), can be performed in either an independent office setting or a hospital outpatient setting. The median price of a CMP was much lower when rendered in an office setting ($11) compared to when rendered in an outpatient setting ($148). CMP tests were most frequently rendered in an independent office (70%). The price of an office-based CMP ranged from $9 (25th percentile) to $21 (75th percentile), with an interquartile range of $12, while the price of an outpatient CMP ranged from $49 (25th percentile) to $320 (75th percentile), with an interquartile range of $271.
The fee-for-service prices of a CMP performed in both an office and outpatient setting were similar to prices paid with another payment arrangement. For example, the median fee-for-service price for an office-based CMP was $12, just $1 higher than the non-fee-for-service arrangements ($11). The median fee-for-service price for an outpatient-based CMP was $153, just $6 higher than the non-fee-for-service arrangements ($147). Most CMP tests were paid with a fee-for-service arrangement (69%).
Across counties, office-based CMP prices ranged from $8 in Lassen County to $53 in Yuba County, while outpatient-based CMP prices ranged from $30 in San Luis Obispo County to $583 in Santa Cruz County. Within counties, Stanislaus County had the highest variation for office-based CMP, where interquartile range of prices was $57, and Contra Costa County had the highest variation for outpatient-based CMP, where the interquartile range was $593. Modoc County had the lowest variation for office-based CMP, where the interquartile range was less than $1, and Trinity County had the lowest variation for outpatient-based CMP, where the interquartile range was less than $1.
Complete Blood Count (CBC)
Like CMP tests, Complete Blood Count (CBC) tests can be performed in either an independent office setting or a hospital outpatient setting. The median price of a CBC was the same ($20) when rendered in either an office setting or an outpatient setting. CBC tests were most frequently rendered in an independent office (65%). The price of an office-based CBC ranged from $8 (25th percentile) to $20 (75th percentile), with an interquartile range of $12, while the price of an outpatient CBC ranged from $20 (25th percentile) to $90 (75th percentile), with an interquartile range of $70.
The fee-for-service prices of a CBC performed in an office setting were similar to prices paid with another payment arrangement. For example, the median fee-for-service price for an office-based CBC was $9, and the non-fee-for-service price was $20. Fee-for-service prices of a CBC performed in an outpatient setting were higher than prices paid with another payment arrangement. The median fee-for-service price for an outpatient-based CBC was $82, compared to $20 for non-fee-for-service arrangements. Most CBC tests were paid with a non-fee-for-service arrangement (60%).
Across counties, office-based CBC prices ranged from $5 in Lassen County to $39 in Sutter County, while outpatient-based CBC prices ranged from $20 in Alameda County to $169 in Del Norte County. Within counties, Amador County had the highest variation for office-based CBC, where interquartile range of prices was $31, and Santa Cruz County had the highest variation for outpatient-based CBC, where the interquartile range was $249. Several counties (Alameda, Contra Costa, Napa, Sacramento, San Joaquin, San Mateo, Santa Clara, Solano, Sonoma) had low variation for office-based CBC, where the interquartile range was less than $1, and Trinity County had the lowest variation for outpatient-based CBC, where the interquartile range was less than $1.
Figure 4 shows the county level ESI median price of each service for all payment arrangements. The prices displayed in the maps are limited to office or lab for CMP and CBC tests. A full table with all prices and stratifications is available in Appendix E. Overall, counties with high prices for one service were not necessarily high priced for other services. In other words, there was not one group of counties that had consistently higher or lower prices for every service. Similarly, variation in prices was not consistent among counties. Counties with wide variation for some services had less variation for others.
Individual Marketplace
C-section Childbirth Delivery
Among people with Individual Marketplace insurance, inpatient admissions for childbirth had the highest and widest ranging prices of the five services studied. The median price of a c-section delivery was $17,016. The 25th percentile price was $10,029, and the 75th percentile price was over 3x higher at $30,221, resulting in an interquartile range of $20,192.
Among people with Individual Marketplace insurance, fee-for-service c-section delivery prices were higher than those in other payment arrangements. The median fee-for-service price was $17,897 compared to a non-fee-for-service price of $15,150. Approximately 89% of c-section admissions were reimbursed on a fee-for-service basis.
At the county level, there was wide variation in median c-section prices. A c-section delivery ranged from $7,972 in Tulare County to $47,500 in Sutter County, a nearly 6-fold difference. Within counties, there was also wide variation in price for the same service. San Joaquin County had the highest variation, where c-section interquartile range of prices was $26,864. Kern County had the lowest variation, where the interquartile range was $3,803.
Vaginal Childbirth Delivery
The median price of a vaginal delivery admission was $12,878. The 25th percentile price for vaginal delivery was $9,220, and the 75th percentile price was nearly twice as high at $16,322, resulting in an interquartile range of $7,102.
As with c-section deliveries, fee-for-service vaginal delivery prices were higher than those in other payment arrangements. The median fee-for-service price was $13,184 compared to a non-fee-for-service price of $9,775. Over 90% of vaginal delivery admissions were reimbursed on a fee-for-service basis.
There was wide county-level variation in median vaginal delivery prices. A vaginal delivery ranged from $4,961 in Humboldt County to $27,543 in Sutter County, a greater than 5-fold difference. Within counties, Yuba County had the highest variation, where vaginal delivery interquartile range of prices was $16,196. Imperial County had the lowest variation, where the interquartile range was $484.
Emergency Room Visit
Among people with Individual Marketplace insurance, the median price of a moderate to high severity Emergency Room visit was $408 but varied widely. The price of an ER visit ranged from $365 (25th percentile) to $1,765 (75th percentile), resulting in an interquartile range of $1,400.
The fee-for-service price of an Emergency Room visit was higher than prices paid with another payment arrangement. For example, the median fee-for-service price was $539, 43% higher than the $376 paid in non-fee-for-service arrangements. About 53% of ER visits were paid with a non-fee-for-service arrangement.
Across counties, an ER visit ranged from $152 in Butte County to $1,670 in Imperial County, a nearly 11-fold difference. Within counties, Lake County had the highest variation, where the ER interquartile range of prices was $2,814. Tuolumne County had the lowest variation, where the interquartile range was $113.
Comprehensive Metabolic Panel (CMP)
The Comprehensive Metabolic Panel (CMP) test, which can be performed in either an independent office setting or a hospital outpatient setting, had a lower median price when rendered in an office setting ($11) compared to when rendered in an outpatient setting ($130). CMP tests were most frequently rendered in an independent office (71%). The price of an office-based CMP ranged from $9 (25th percentile) to $12 (75th percentile), with an interquartile range of $2, while the price of an outpatient CMP ranged from $30 (25th percentile) to $231 (75th percentile), with an interquartile range of $201.
The fee-for-service prices of a CMP performed in an office setting were similar to prices paid with another payment arrangement, while the fee-for-service prices of a CMP performed in an outpatient setting were much higher than prices paid with another payment arrangement. For example, the median fee-for-service price for an office-based CMP was $12, just $1 higher than the non-fee-for-service arrangements ($11). The median fee-for-service price for an outpatient-based CMP was $142, which is $126 higher than the non-fee-for-service arrangements ($16). Most CMP tests were paid with a fee-for-service arrangement (78%).
Across counties, office-based CMP prices ranged from $8 in Lassen County to $40 in Yuba County, while outpatient-based CMP prices ranged from $12 in Colusa County to $504 in Santa Cruz County. Within counties, Sutter County had the highest variation for office-based CMP, where interquartile range of prices was $40, and Contra Costa County had the highest variation for outpatient-based CMP, where the interquartile range was $2,239. Several counties (Del Norte, Kings, Lassen, Merced, San Benito, Trinity, and Yolo) had low variation for office-based CMP, where the interquartile range was less than $1, and three counties (Del Norte, Kings, Trinity) had the lowest variation for outpatient-based CMP, where the interquartile range was less than $1.
Complete Blood Count (CBC)
The median price of a CBC was lower when rendered in an office setting ($9) compared to when rendered in an outpatient setting ($23). CBC tests were most frequently rendered in an independent office (66%). The price of an office-based CBC ranged from $8 (25th percentile) to $20 (75th percentile), with an interquartile range of $12, while the price of an outpatient CBC ranged from $20 (25th percentile) to $81 (75th percentile), with an interquartile range of $61.
The fee-for-service prices of a CBC performed in an office setting were similar to prices paid with another payment arrangement. For example, the median fee-for-service price for an office-based CBC was $9, and the median non-fee-for-service price was $20. Fee-for-service prices of a CBC performed in an outpatient setting were higher than prices paid with another payment arrangement. The median fee-for-service price for an outpatient-based CBC was $68, compared to $20 for non-fee-for-service arrangements. More CBC tests were paid with a fee-for-service arrangement (56%).
Across counties, office-based CBC prices ranged from $6 in Del Norte County to $29 in Yuba County, while outpatient-based CBC prices ranged from $12 in San Luis Obispo County to $169 in Del Norte County. Within counties, Sutter County had the highest variation for office-based CBC, where interquartile range of prices was $27, and El Dorado County had the highest variation for outpatient-based CBC, where the interquartile range was $182. Several counties (Alameda, Napa, Placer, Sacramento, San Benito, San Joaquin, San Mateo, Solano, Sonoma, and Stanislaus) had low variation for office-based CBC, where the interquartile range was less than $1, and two counties (Del Norte and Solano) had the lowest variation for outpatient-based CBC, where the interquartile range was less than $1.
Figure 4 shows the county level Individual Marketplace median price of each service for all payment arrangements and limited to outpatient site of service for CMP and CBC tests. [3]
As with the ESI enrollees, county prices and price variation were not consistent across all services for Individual Marketplace enrollees. The county-level price and IQR varied for each service.
Hospital Market Concentration
Hospital market concentration measures the level of competition within a health care market. Higher hospital market concentration means less competition. In highly concentrated markets, patients have few or sometimes only one hospital where they can receive medical care. Previous research has found that low hospital market competition is associated with higher hospital service prices.[i]
To measure county-level hospital market competition, we calculated the Herfindahl-Hirschman Index (HHI), a measure of hospital market concentration commonly used by antitrust regulators and researchers. This measure captures the share of all commercial inpatient admissions (ESI and Individual Marketplace) that occur at each hospital system for enrollees residing in each county. A higher HHI value indicates less competition, and the index ranges from 0 (perfect competition) to 10,000 (perfect monopoly). Figures 5a and 5b show counties by HHI category, along with the distribution of counties by HHI category. In this analysis, 57 total counties that met reporting thresholds for hospital admission counts were included. Of the counties reported, 11 were unconcentrated (19%), 23 were moderately concentrated (40%), 21 were highly concentrated (37%), and 2 were very highly concentrated (4%). Overall, 23 of the 57 counties studied were highly or very highly concentrated.
Note: HHI values less than 1,500 were classified as ‘Unconcentrated’, HHI values between 1,500 and 2,499 were classified as ‘Moderately Concentrated’, values between 2,500 and 4,999 were classified as ‘Highly Concentrated’, and values greater than or equal to 5,000 were classified as ‘Very Highly Concentrated.’
Across both the ESI and Individual Marketplace populations, counties with higher hospital market concentration had higher prices for the inpatient services we analyzed (admissions for vaginal deliveries and c-section deliveries) (Figure 6). The relationship between hospital market concentration and prices was more variable for the outpatient service we examined (ER visits, CMP and CBC laboratory tests). This could be because the hospital market concentration measure was based on inpatient admissions, therefore, a stronger relationship between the concentration measure and inpatient service prices is expected. Services rendered at hospital outpatient departments may not be directly correlated to the HHI measure as those services generally have non-hospital competitors compared to inpatient services. For example, a county may have only one hospital system that provides the majority of inpatient care, but several outpatient departments that provide outpatient services.
Conclusion
Across California, spending is highly variable by county and insurance type. Per-person spending among people enrolled in ESI ranged from $4,607 to $9,626, varying 2-fold from the county with the highest spending to the one with the lowest spending. Among people enrolled in the Individual Marketplace, per-person spending ranged from $4,507 to $12,068, varying by nearly 3-fold across counties. For both the ESI and Individual Marketplace populations, many of the high spending counties had lower income relative to the state average causing their residents to face a greater cost burden. Some counties experienced health care spending that consumed up to 25% of average income. Small, rural counties had a higher cost burden than urban counties.
Prices were highly variable between and within counties across the ESI and Individual Marketplace populations. Prices for the same service varied as much as 42-fold across counties, and 50-fold within a single county. The site of service and payment arrangements used each play a role in service price variation. Services rendered in an outpatient setting generally had higher prices than services rendered in an independent office or lab. The payment arrangement had different effects on price depending on the service; sometimes the fee-for-service payment arrangement had a higher price than other payment arrangements, and other times it had a lower or similar price. Overall, the same counties did not have consistently high or low prices across all services. Many counties in California have uncompetitive hospital markets. Twenty-three counties had high or very high levels of hospital market concentration. Inpatient service prices were higher in counties with higher hospital market concentration.
Methods Note
Study Population
This report compares health care spending and prices across counties, stratified by two commercially insured populations: 1) people enrolled in Employer Sponsored Insurance plans (ESI) and 2) people enrolled in Individual Marketplace plans. The populations were defined as follows:
ESI enrollees met the following enrollment criteria:
- Enrolled in a commercial plan.
- Had a plan offered through an employer.
- Enrolled in either an HMO, PPO, POS, or EPO plan.
- Not enrolled in an individual marketplace plan.
- Under age 65 during study period.
Individual Marketplace enrollees met the following enrollment criteria:
- Enrolled in a commercial plan.
- Enrolled in an individual marketplace plan.
- Had a plan that was purchased through the marketplace exchange.
- Under age 65 during study period.
Service Codes
The following service codes were used for the price comparison section of this report.
| Service Description | Code Type | Service Code |
| Inpatient admission for vaginal delivery | DRG | 807 |
| Inpatient admission for c-section delivery | DRG | 788 |
| Emergency Room visit, moderate complexity | CPT | 99284 |
| Comprehensive Metabolic Panel (CMP) | CPT | 80053 |
| Complete Blood Count (CBC) | CPT | 85025 |
End Notes
[1] The per-capita income data used to calculate the cost burden ratio is from the Bureau of Economic Analysis (BEA) Personal Income by County dataset with years 2019-2023.
[2] Note that data are suppressed for some counties where the volume of services was too low to report.
[3] Note that data is suppressed for some counties where the volume of services was too low to report.
Citations
[i] Health Care Cost Institute. (2024, April). Health Care Cost and Utilization Report. https://healthcostinstitute.org/hccur/
[ii] Health Care Cost Institute. (2026, April). Health Cost Landscape. https://hcl.healthcostinstitute.org
[iii] KFF. (2025, December). Health insurance coverage of the total population. KFF State Facts. https://www.kff.org/state-health-policy-data/state-indicator/total-population/
[iv] Cooper, Z., Craig, S., Gaynor, M., & Van Reene, J. (2018). The price ain’t right? Hospital prices and health spending on the privately insured. The Quarterly Journal of Economics, 134(1), 51-107. https://doi.org/10.1093/qje/qjy020