Colorado spends the most on out-of-pocket health care costs, according to a JPMorgan Chase Institute healthcare spending study. But that’s not necessarily a bad sign.

The study, examining anonymous data from 2.3 million Chase customers across 23 states from 2013-16, found that families increased their health care spending when they came into more income or assets.

That means Colorado’s average $916 spent on out-of-pocket health care in 2016 could be a sign of a state of people with high income, especially considering that health care spending was only 1.6 percent of people’s gross income, Diana Farrell, president and CEO of JPMorgan Chase Institute, said.

“Some of it may not be good in sense of higher prices or need,” she said. “Some of it is a more positive story of people seeking health care when they need it and being wealthy enough to afford it.”

But there’s also a flip side to this. If people spend more on health care when their financial fortunes improve, there are people who aren’t spending money on potentially critical health care because they can’t afford to, she said.

“We can connect the health care spending to other financial attributes of those same families,” Farrell said about the study, which was released Tuesday. ”We can see very clearly that often people are in effect not paying for health care unless they have an income spike or other assets they need.”

Most Americans don’t have the cash on hand to buffer an unexpected health care cost, she said. Nationally, there’s a spike in health care payments from March to April when about 80 percent of tax refunds are distributed.

In the meantime, bills may pile up or people may not be able to access medications or services that require immediate payment, Farrell said. There’s a disturbing trend of people not seeking care only when they can afford it, not when they need it, she said.

Out-of-pocket health care spending grew at an average annual rate of 4.3 percent from 2013 to 2016, according to the study. Although doctor’s fees were the most frequent cost, dental and hospital payments were the heftier expenses.

The study showed a diversity of health care pricing and access across states and within a state, she said.

“We knew there would be significant differences across states and within states,” she said. “The extent of the difference was really surprising for us.”

In Colorado, consumers in Douglas, Boulder and Broomfield counties spent the most on out-of-pocket costs at $1,224, $1,200 and $952, respectively. People spending the largest percentage of their gross income on health care were in Weld (1.9 percent), Larimer and Adams (both 1.7 percent) counties.

Denver County folks spent $851 on average, which was 1.4 percent of gross income. But the metro Denver area logged an average of $904 out-of-pocket expenses in 2016, or about 1.5 percent burden, making it the third most expensive metro behind Austin and Houston, Texas.

The study accounted for demographic differences and acknowledged that it only tracked card-based and electronic payments, which tend to be more common among people who are more educated, white and married.

Farrell said the health care conversation needs to pay greater attention to consumers seeking care instead of focusing on insurers and health care providers.

Reform efforts should look into whether employers can take a more active role in helping manage costs and into creating greater transparency with insurance costs, she said.