County-Level Healthcare and Social Spending and Health Outcomes by Race/Ethnicity and Sex in the U.S.

Abstract

Healthcare and social spending are associated with improved population health, but whether these associations differ by race/ethnicity and sex remains unclear. This study examines heterogeneity in county-level spending-health associations in the United States. A county-level panel study used 2010-2019 data from the Institute for Health Metrics and Evaluation and the Government Finance Database. Outcomes included life expectancy, health-adjusted life expectancy (HALE), age-standardized mortality (ASMR), and infant mortality, stratified by race/ethnicity and sex. Primary exposures were per capita healthcare and social spending. Fixed-effects models adjusted for time-varying covariates. Data analysis was conducted in 2026. Each additional $1,000 in healthcare spending was associated with higher life expectancy (0.073 years), higher HALE (0.057 years), and lower ASMR (-7.299 per 100,000). Associations were strongest among White populations (life expectancy: 0.092; HALE: 0.070; ASMR: -8.776) and consistent across sex. However, healthcare spending was not significantly associated with life expectancy, HALE, or ASMR among Black or Hispanic populations. In contrast, social spending was consistently associated with higher life expectancy (0.148), higher HALE (0.116), and lower ASMR (-5.837) among Hispanic populations. Social spending was most consistently associated with lower infant mortality among Black and Hispanic populations. Healthcare and social spending were associated with improved population health, but associations varied by spending type, outcome, and racial/ethnic group. Public spending alone may be insufficient to reduce health inequities without addressing structural barriers to access and utilization. Equity-focused policies are needed to ensure public investments reach populations with the greatest unmet needs.