Where you live determines how much of a cardiac stent procedure lands in your mailbox. In Hawaii, Medicare patients undergoing percutaneous cardiac intervention paid a discharge-weighted average of $9,436 out of pocket in 2023. In South Carolina, the equivalent figure was $4,306. Same federal program, same procedure category, more than twice the cost depending on your zip code.

A $5,000 Gap That Shouldn't Exist Under a Uniform Federal Program

Medicare is structured as a national benefit. Deductibles, coinsurance rates, and coverage rules don't change by state. Yet the gap between what Medicare pays and what beneficiaries owe varies dramatically across state lines, driven by differences in how hospitals set charges, how providers negotiate, and how local market structures translate into patient bills.

Hawaii's $9,436 figure is based on 164 discharges across 4 hospitals, a relatively small sample, but the pattern holds when you look at the broader DRG-level data. For DRG 247 specifically (percutaneous cardiovascular procedure with drug-eluting stent), Alaska had the highest average beneficiary cost-sharing at $6,889, compared to $4,043 in Louisiana, the lowest among ranked states. That's a $2,846 spread on a single, well-defined procedure code. For a Medicare beneficiary on a fixed income, that difference can determine whether a medically necessary procedure is financially survivable.

Connecticut offers a useful mid-tier example: 9 hospitals reported 325 DRG 247 discharges with average beneficiary cost-sharing of $5,501 and an average submitted charge of $82,880. Alaska, by contrast, had an average submitted charge of $176,111 for the same DRG, the highest among ranked states, while Rhode Island's average submitted charge was $61,185 despite ranking third-highest on cost-sharing. The relationship between submitted charges and what patients actually owe is not linear, which complicates any simple explanation of why some states cost so much more.

The Decade-Long Drift Toward Higher Patient Exposure

The state-level variation is striking, but the more durable story is the trend. Across all Medicare inpatient DRGs, the average beneficiary gap grew from $1,884 in 2013 to $3,183 in 2023, a 69% increase over ten years. More telling is what happened to that gap as a share of total payment: it rose from 14.6% to 17.2%.

Medicare's total payment per discharge has grown substantially, from $12,889 to $18,514. But beneficiary exposure has grown faster. In 2023, the average total payment was essentially flat compared to 2022, yet the beneficiary gap still widened and the gap percentage still rose. That means patients absorbed a larger share of a bill that didn't even grow much. For cardiac patients, who tend to be older, sicker, and more likely to have multiple hospitalizations in a year, this trajectory compounds quickly.

High Charges, High Costs, and an Incomplete Explanation

Alaska's DRG 247 numbers raise a question that the data surfaces but doesn't resolve. Its average submitted charge of $176,111 is the highest among ranked states, and its average beneficiary cost-sharing of $6,889 is also the highest. That correlation is intuitive. But Rhode Island's submitted charge of $61,185 is among the lowest, yet its beneficiary cost-sharing of $6,140 ranks third-highest nationally. Connecticut's submitted charge of $82,880 produces cost-sharing of $5,501. The charge-to-cost-sharing relationship clearly breaks down in some markets.

This matters because submitted charges are often treated as a proxy for hospital pricing behavior. If high charges reliably produced high patient costs, the policy lever would be obvious. The Rhode Island case suggests the mechanism is more complicated: lower charges don't guarantee lower patient exposure, and the factors that drive the gap in some states may be entirely different from those driving it in others.

What's consistent across all of this data is the direction. Patient cost exposure is rising, it varies by more than 2x across states for the same procedure, and the gap between what Medicare covers and what lands on the patient's bill has grown every single year for a decade.