Objectives To examine whether out‐of‐pocket expenditures ( OOPE s) exhibit the same geographic variation as Medicare claims, given wide variation in the costs of U.S. health care, but no information on how that translates into OOPE s or financial burden for older Americans. Design Retrospective cohort study. Setting Data from the Health and Retirement Study linked to Medicare claims. Participants A nationally representative cohort of 4,657 noninstitutionalized, community‐dwelling, fee‐for‐service elderly Medicare beneficiaries interviewed in 2006 and 2008. Measurements The primary predictor was per capita Medicare spending quintile according to hospital referral region. The primary outcome was a self‐reported, validated measure of annual OOPE s excluding premiums. Results Mean and median adjusted per capita Medicare payments were $5,916 and $2,635, respectively; mean and median adjusted OOPE s were $1,525 and $779, respectively. Adjusted median Medicare payments were $3,474 in the highest cost quintile and $1,942 in the lowest cost quintile (ratio 1.79, P < .001 for difference). In contrast, adjusted median OOPE s were not higher in the highest than in the lowest Medicare cost quintile ($795 vs $764 for a Q5:Q1 ratio of 1.04, P = .42). The Q5:Q1 ratio was 1.48 for adjusted mean Medicare payments and 1.04 for adjusted mean OOPE s (both P < .001). Conclusion Medicare payments vary widely between high‐ and low‐cost regions, but OOPE s do not.