Has the Shift to Managed Care Reduced Medicaid Expenditures? Evidence from State and Local‐Level Mandates

From 1991 to 2009, the fraction of Medicaid recipients enrolled in HMOs and other forms of Medicaid managed care (MMC) increased from 11 percent to 71 percent. This increase was largely driven by state and local mandates that required most Medicaid recipients to enroll in an MMC plan. Theoretically, it is ambiguous whether the shift from fee‐for‐service into managed care would lead to an increase or a reduction in Medicaid spending. This paper investigates this effect using a data set on state‐ and local‐level MMC mandates and detailed data from the Centers for Medicare and Medicaid Services (CMS) on state Medicaid expenditures. The findings suggest that shifting Medicaid recipients from fee‐for‐service into MMC did not on average reduce Medicaid spending. If anything, our results suggest that the shift to MMC increased Medicaid spending and that this effect was especially present for risk‐based HMOs. However, the effects of the shift to MMC on Medicaid spending varied significantly across states as a function of the generosity of the state's baseline Medicaid provider reimbursement rates.     

Demographic,Employment, Expenditure,and Income‐Related Dependency Ratios: Population Aging in the Fifty States

Old‐age dependency ratios (OADR) are frequently used to measure the economic impact of U.S. population aging. However, at the state level youth‐dependence, and the “birth dearth,” are important. While federal expenditures on elder Social Security, Medicare, and Medicaid are large, state expenditures on dependent youth are much higher than on elders. The states are ranked by the OADR and three other dependency ratios that consider youth and a state's employment, fiscal outlay, and per‐capita income. Very different rankings are found. States with higher OADR ratios had lower total dependency expenditures. Projections for 2030 are compared with 2000 results.     

Presidential campaign expenditures: Evidence on allocations and effects

This paper analyzes the impact of presidential campaign spending on election results. Analyses of expenditures and voting are often plagued by simultaneity between campaign spending and expected vote share. However, game-theoretic models of resource-allocation decisions made by a central actor (i.e., a presidential campaign) suggest that candidates will spend more in close races and in races likely to be pivotal. We provide empirical support for this theory; using Federal Communications Commission data from the 1972 presidential election, we find that expenditures were higher in states where the election was expected to be closer and in states likely to be pivotal. We use these two factors as instruments in a two-stage least squares model to estimate the effect of spending on votes. We find that, contrary to previous theory and research, presidential campaign spending significantly increases a candidate's vote share.     

Structure of State‐Level Tax and Expenditure Limits

While much consideration has been given to the approval process, base classification, and codification of tax and expenditure limits (or TELs), these factors tell us nothing about how they actually work. This study focuses exclusively on the technical elements of these limits and finds how states estimate their limits have over time eroded their potency. More specifically, if a state resets or rebases its limit annually by using actual revenues or expenditures for the preceding year, the limit will trend closely with actual revenues or expenditures, effectively restricting growth in spending as prescribed by law. However, if the law requires a state to estimate its limit using the appropriation limit for the preceding year instead of actual revenues or expenditures, that is, without rebasing, the limit will reflect cumulative changes to the base when it was first approved. Over time, the TEL cap is significantly above the states revenues or expenditures as it remains unaffected by the state's underlying fiscal and economic environment.     

When is Growth Not Growth? The Curious Case of Mental Health Budgeting in New York

This article argues that the adverse impact of Medicaid on state budgets alleged in various public debates has been overstated, in some measure because of the inaccurate and misleading manner in which Medicaid expenditures are appropriated in state budgeting systems. Data on Medicaid and mental health spending in the state of New York is used for analysis. The first section provides a Medicaid spending and budgeting background. The second section discusses Medicaid and mental health in New York. The third section describes actual budgeted spending for mental health in New York, and the final section provides a discussion and concluding comments.     

Road to Ruin? A Spatial Analysis of State Highway Spending

Do states engage in infrastructure expenditure competition to attract new economic activity? Economic theory is inconclusive on the matter. States might respond to increased infrastructure spending in competitor states by increasing their own infrastructure spending. Conversely, states may decrease spending in the presence of positive spillovers from competitor states' infrastructure investment. Using spatial econometric techniques and focusing specifically on highway spending, we demonstrate that states expend less on highways when spending in neighboring states increases. We explore this possibility further by modeling state personal income growth as a function of own‐state and neighbor‐state highway spending. Our findings suggest positive spillovers influence interstate relationships for highway spending rather than race‐to‐the‐top competition for economic activity.     

Providing Adequate Educational Funding: A State–by–State Analysis of Expenditure Needs

While school finance research and litigation has traditionally focused on the equity of funding across school districts, courts and policy makers are increasingly addressing the adequacy of educational resources. This article reviews recent developments in adequacy research and estimates the additional expenditures required to achieve adequacy across states. Using the cost–adjusted national median of current per–pupil expenditures as a benchmark for adequacy, the results suggest that additional spending of $15.6–18.5 billion is needed nationally to reach the benchmark in all districts. The additional spending would be concentrated in a small number of states, particularly in urban and urban fringe districts.     

Contribution limits and the effectiveness of campaign spending

Much work on the apparent ineffectiveness on incumbent spending in congressional elections has hypothesized that the productivity of incumbent spending is low because incumbents operate on the “flat part” of their election returns function. Differences in campaign spending associated with state campaign finance laws allows for a test of this hypothesis because restrictions on campaign contributions tend to reduce campaign spending. Exploiting cross-state variation in campaign finance laws, this study tests whether campaign expenditures by state House candidates are more productive when candidates are subject to contribution limits. The results show that campaign expenditures by incumbents and challengers are more productive when candidates run in states with campaign contribution limits, as opposed to in states without limits. In states with contribution limits, incumbent spending and challenger spending are equally productive, and spending by both candidates is quantitatively important in increasing their vote shares.     

Tax decentralization and local government size

This paper investigates the relationship between fiscal federalism and the sizes of local governments. While many empirical studies emphasized that grants encourage the growth of local public spending and local taxes constrain it, they are more silent regarding the effects of different types of tax autonomy. The paper addresses this issue by arguing that tax decentralization as organized on tax bases used only by local governments (tax-separation), rather than on tax-base sharing, would restrain local public expenditures. Using an unbalanced panel of OECD countries, the key finding is that only property taxes—mostly based on a “tax-separation” scheme—seem to favor smaller local governments. Thus, while tax decentralization is a necessary condition for limiting the growth of local governments, it does not appear sufficient, as tax-separation schemes among government levels would in fact be required.     

Public Health Insurance and Medical Spending: The Incidence of the ACA Medicaid Expansion

This paper examines the incidence of the cost burden associated with expanding public health insurance to low-income adults in the context of the Affordable Care Act. Using data from the Medical Expenditures Panel Survey (MEPS), I exploit exogenous variation in Medicaid eligibility rules across states, income groups and time. I find that public insurance eligibility reduced mean out-of-pocket spending by 19.6 percent among targeted households, but it did not causally increase total expenditures among beneficiaries. Rather, Medicaid expansion shifted the burden of payment from eligible households and private insurance (21.5 percent reduction) to taxpayers in the form of public insurance (46.6 percent increase). The efficiency of these public funds can be summarized by a mean Marginal Value of Public Funds of 0.70 in the full sample, 0.99 among households with at least one pre-existing condition, and 1.26 in states with an above-median number of public hospitals.     

Party system nationalization,presidential coalitions,and government spending

This paper argues that there is a strong relationship between geographical patterns of political parties' electoral performance and the composition of central government expenditures. When party system nationalization is high, the composition of spending will focus more on non-targetable expenditures, while targetable expenditures increase as the party system distribution of votes across different districts becomes less homogenous. However, the effect of party nationalization on spending type is conditioned by the size of the presidential coalition; targeted transfers will increase if the coalition size decreases, even if party nationalization is high. I find support for these hypotheses with an empirical analysis of district-level electoral and government expenditure data for several countries in Latin America between 1990 and 2006.     

Fiscal Decentralization and Natural Disaster Mitigation: Evidence from the United States

How decentralized government structure influences public service delivery has been a major focus of debate in the public finance literature. In this paper, we empirically examine the effect of fiscal decentralization on natural disaster damages across the U.S. states. We construct a unique measure of decentralization using state and local government expenditures on natural resources, which include investment in flood control and mitigation measures, among others. Using state‐level panel data from 1982 to 2011, we find that states that are more decentralized in natural resource expenditures have experienced more economic losses from floods and storms. This effect is only pronounced in states that are at higher risks of flooding. Our findings suggest that fiscal decentralization may lead to inefficient protection against natural disasters and provide implications for the assignment of disaster management responsibilities across different levels of government in the U.S. federal system.     

Decentralization and access to social services in Colombia

Decentralization is meant to improve access to public services, but relatively few studies examine this question empirically. We explore the effects of decentralization on access to health and education in Colombia using an original database covering over 95 % of Colombian municipalities. We show that decentralization improved enrollment rates in public schools and access of the poor to public health services. In both sectors, improving access was driven by the financial contributions of local governments. Small increases in own-shares of spending led to surprisingly large increases in the access of the poor in both sectors. Our theoretical model implies that where local information dominates productive efficiency, elected local governments will provide services better tailored to local needs. Decentralizing such services should increase their use by the public. Together, theory and empirics imply that decentralization made the Colombian state more accountable. It provided local officials with the information and incentives they need to allocate resources in a manner responsive to voters’ needs and improve the impact of public expenditures.     

China's Local Political Budget Cycles

This article examines the political budget cycles in Chinese counties. The shift to a more performance-based cadre evaluation and mobility system during the reform era has created an incentive structure for local leaders to increase government spending at strategically important time points during their tenure to enhance the prospect of official promotion. Such expenditures help local leaders to impress their superiors with economic and political achievements, especially those visible and quantifiable large-scale development projects. At the same time, economic and fiscal decentralization increased the capacity of local leaders to influence government budget expenditures as the need rises. The hypothesized curvilinear relationship between a leader's time in office and increased spending was tested using a comprehensive data set of all Chinese counties from 1997 through 2002. The panel data analysis shows that growth in local government spending per capita is the fastest during a leader's third and fourth years in office.     

Public‐Sector Unions and the Size of Government

Public‐sector unions are generally thought to increase the size of government through collective bargaining. This article challenges this idea for the case of teacher unions in the United States and argues that while collective bargaining institutions sometimes lead to increased education spending, this is not the norm. Using a new longitudinal data set spanning all states before and after they granted collective bargaining rights to teachers, the article shows that although states that mandate districts to bargain with teachers have higher education expenditures than states that do not, the differences precede collective bargaining. Difference‐in‐differences analyses find no evidence that introducing collective bargaining rights led to average increases in the level of resources devoted to education. Although existing theories cannot explain these null findings, the article shows one reason behind them is that most laws granting collective bargaining rights to teachers were not unambiguously prolabor, but included both pro‐ and anti‐union provisions.     

Budgeting Rules and Program Outcomes

It is not efficient for a budget system either to enable excessively frequent changes in programs and tax policies or to be rigid and unresponsive. Program durability is one measure of how a budget system weighs the competing goals of resoluteness and responsiveness. The federal budget has different processes—mandatory and discretionary spending and tax expenditures—each based in separate congressional committees and relying on separate procedures. This article examines the budget systems' durability. One finding is that mandatory spending programs and tax expenditures are more durable than programs backed by discretionary spending. However, while programs targeted to vulnerable populations and supporting long‐term planning, such as in income support and health, might benefit from durability, these programs display shorter durability, not longer. While displaying greater durability, tax expenditures do respond to changes in different economic sectors, based on the changes in spending of other budget systems.     

“The Big Society,” Public Expenditure,and Volunteering

The debate on volunteering has paid insufficient attention to the relationship between public spending and volunteering. The importance of this relationship is highlighted by the British government's “Big Society” plan, which asserts that an increase in volunteering will compensate for the withdrawal of public agencies and spending. This idea is based on the widely held belief that a high degree of government intervention decreases voluntary activities. This article uses a multidisciplinary approach to improve understanding of how public spending affects the decision to volunteer. A theoretical model conceptualizes this relationship in terms of time donation by employed individuals. The model is tested empirically through an econometric analysis of two survey data sets and interpretative analysis of narratives of local volunteers and public professionals. The results suggest that volunteering is likely to decline when government intervention decreases and that a collaborative approach to sustaining volunteering is needed.     

Decentralization as a constraint to Leviathan: a panel cointegration analysis

This paper extends the empirical literature about the effects of fiscal decentralization on the growth of government along three dimensions. It distinguishes between the effects of the level of decentralization from the way local governments finance their expenditures (common pool versus own resources); it uses a panel cointegration approach to separate the long run effects of decentralization from the short run dynamics; and it extends and revises the datasets generally used in these empirical analyses. The results show that the amount of revenue raised by sub-national governments leads to a long-term fall in the size of government but grants have the opposite effect. In addition, a greater decentralization of expenditure leads to greater overall spending. When the short-term is considered these influences work slowly, as the speed of adjustment towards the desired government size is relatively sluggish. In addition, in the short run, there is also a clear effect from the role of local revenue raising powers that stimulates the growth of government. These results appear robust to changes in the composition of the variables, countries and periods included the sample.     

On the distribution of federal taxes and expenditures,and the new war between the states

As federal government expenditures have grown, there has been an increasing awareness of the distribution of taxes and expenditures across states. States in the Northeast have claimed that sunbelt states have been getting more than their fair share of federal spending, with the sunbelt states denying the charge. A theory of political coalitions is developed to explain why the sunbelt should be unable to receive differentially high expenditures, although the sunbelt may pay less than a proportional amount in taxes because of its relatively low income. An empirical test shows that the data are in agreement with this theory.     

The Medicaid Mandates of the 1980s: An Intergovernmental Perspective

Medicaid, the health care program for the poor, has undergone significant changes in the last fifteen years. Many of those changes relate to the intergovernmental nature of the program. Medicaid is jointly operated, with the federal and state governments sharing program costs. Despite a set of program guidelines dictated by the federal government, states have traditionally had substantial latitude in Medicaid decisions. However, a series of developments in the 1980s led to increasing constraints on state Medicaid discretion, including federal mandates to expand Medicaid coverage. This article examines the inception and effectiveness of the Medicaid mandates from the perspective of interstate equity of health care services for poor families.