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Concept: Budget


Background Spending and quality under global budgets remain unknown beyond 2 years. We evaluated spending and quality measures during the first 4 years of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC). Methods We compared spending and quality among enrollees whose physician organizations entered the AQC from 2009 through 2012 with those among persons in control states. We studied spending changes according to year, category of service, site of care, experience managing risk contracts, and price versus utilization. We evaluated process and outcome quality. Results In the 2009 AQC cohort, medical spending on claims grew an average of $62.21 per enrollee per quarter less than it did in the control cohort over the 4-year period (P<0.001). This amount is equivalent to a 6.8% savings when calculated as a proportion of the average post-AQC spending level in the 2009 AQC cohort. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (P<0.001), 9.1% (P<0.001), and 5.8% (P=0.04), respectively, by the end of 2012. Claims savings were concentrated in the outpatient-facility setting and in procedures, imaging, and tests, explained by both reduced prices and reduced utilization. Claims savings were exceeded by incentive payments to providers during the period from 2009 through 2011 but exceeded incentive payments in 2012, generating net savings. Improvements in quality among AQC cohorts generally exceeded those seen elsewhere in New England and nationally. Conclusions As compared with similar populations in other states, Massachusetts AQC enrollees had lower spending growth and generally greater quality improvements after 4 years. Although other factors in Massachusetts may have contributed, particularly in the later part of the study period, global budget contracts with quality incentives may encourage changes in practice patterns that help reduce spending and improve quality. (Funded by the Commonwealth Fund and others.).

Concepts: Health care, Massachusetts, Health care in the United States, Incentive, Budget, Blue Cross and Blue Shield Association, Edward Harkness, Commonwealth Fund


Amid local government budget cuts, there is concern that the ring-fenced public health grant is being appropriated, and Directors of Public Health (DsPH) find it difficult to make the case for investment in public health activity. This paper describes what DsPH are making the case for, the components of their case and how they present the case for public health.

Concepts: Local government, Budget


Launched in 2003, the US President’s Emergency Plan for AIDS Relief (PEPFAR) is the largest disease-focused assistance program in the world. We analyzed PEPFAR budgets for governance and systems for the period 2004-14 to ascertain whether PEPFAR’s stated emphasis on strengthening health systems has been manifested financially. The main outcome variable in our analysis, the first of its kind using these data, was the share of PEPFAR’s total annual budget for a country that was designated for governance and systems. The share of planned PEPFAR funding for governance and systems increased from 14.9 percent, on average, in 2004 to 27.5 percent in 2013, but it declined in 2014 to 20.8 percent. This study shows that the size of a country’s PEPFAR budget was negatively associated with the share allocated for governance and systems (compared with other budget program areas); it also shows that there was no significant relationship between budgets for governance and systems and HIV prevalence. It is crucial for the global health policy community to better understand how such investments are allocated and used for health systems strengthening.

Concepts: President of the United States, Finance, Budget, Budgets


Despite the success of recent efforts to increase access to improved water, sanitation, and hygiene (WASH) globally, approximately one-third of schools around the world still lack adequate WASH services. A lack of WASH in schools can lead to the spread of preventable disease and increase school absences, especially among women. Inadequate financing and budgeting has been named as a key barrier for integrating successful and sustainable WASH programs into school settings. For this reason, the purpose of this review is to describe the current knowledge around the costs of WASH components as well as financing models that could be applied to WASH in schools. Results show a lack of information around WASH costing, particularly around software elements as well as a lack of data overall for WASH in school settings as compared to community WASH. This review also identifies several key considerations when designing WASH budgets or selecting financing mechanisms. Findings may be used to advise future WASH in school programs.

Concepts: Costs, Cost, School, Hygiene, Success, Sanitation, Water supply, Budget


OBJECTIVES:: State health departments across the country are responsible for assuring and improving the health of the public, and yet financial constraints grow only more acute, and resource allocation decisions become even more challenging. Little empirical evidence exists regarding how officials working in state health departments make these tough allocation decisions. DESIGN:: Through a mixed-methods process, we attempt to address this gap in knowledge and characterize issues of resource allocation at state health agencies (SHAs). First, we conducted 45 semistructured interviews across 6 states. Next, a Web-based survey was sent to 355 public health leaders within all states and District of Columbia. In total, 207 leaders responded to the survey (66% response rate). PARTICIPANTS:: Leaders of SHAs. RESULTS:: The data suggest that state public health leaders are highly consultative internally while making resource allocation decisions, but they also frequently engage with the governor’s office and the legislator-much more so at the executive level than at the division head level. Respondents reported that increasing and decreasing funding for certain activities occur frequently and have a moderate impact on the agency or division budget. Agencies continue to “thin the soup,” or prefer cutting broadly to cutting deeply. CONCLUSIONS:: Public health leaders report facing significant tradeoffs in the course of priority-setting. The authorizing environment continues to force public health leaders to make challenging tradeoffs between unmet need and political considerations, and among vulnerable groups.

Concepts: Monotonic function, Economics, Empirical, State, Order theory, Resource allocation, Budget


To address how natural disturbance, forest harvest, and deforestation from reservoir creation affect landscape-level carbon © budgets, a retrospective C budget for the 8500 ha Sooke Lake Watershed (SLW) from 1911 to 2012 was developed using historical spatial inventory and disturbance data. To simulate forest C dynamics, data was input into a spatially-explicit version of the Carbon Budget Model-Canadian Forest Sector (CBM-CFS3). Transfers of terrestrial C to inland aquatic environments need to be considered to better capture the watershed scale C balance. Using dissolved organic C (DOC) and stream flow measurements from three SLW catchments, DOC load into the reservoir was derived for a 17-year period. C stocks and stock changes between a baseline and two alternative management scenarios were compared to understand the relative impact of successive reservoir expansions and sustained harvest activity over the 100-year period.

Concepts: Agriculture, Germany, Water quality indicators, British Columbia, Budget, Colored dissolved organic matter, Logging, Dissolved organic carbon


Federal programs for children are under increasing budgetary pressure. According to current federal law or any budget alternative being offered by the president or congressional leaders, spending on children would decline as a share of the budget and of the national economy. This article summarizes past, current, and projected budgets for children’s programs. It traces significant historical expansions of means-tested programs, such as the Supplemental Nutrition Assistance Program; depicts fairly significant declines in more universal supports, such as the income tax exemption for dependents; and shows the future squeeze on children’s programs brought about by automatic growth in health, retirement, and tax subsidy programs, along with the failure of revenues to keep pace with the overall growth in spending. Federal programs for health care have been a mixed blessing for children: Medicaid has grown to be the largest federal support for children, but overall federal health care costs eat away at the share of the budgetary pie left for anything else.

Concepts: Health care, President of the United States, United States Congress, Income, Tax, Budget, Taxation in the United States, Tax exemption


Planning and self-control were examined in relation to preschoolers' (41- to 74-months) saving behavior. Employing a marble run paradigm, 54 children participated in two trials in which they could use their marbles immediately on a less desirable run, or save for a more desirable run. Twenty-nine children received the opportunity to create a budget. On Trial 1, children in the budgeting condition saved significantly more than did children in the control condition, and their planning ability related to saving (after controlling for age and language). Those who consistently budgeted at least one marble for the more desirable run were more likely to save. Control children’s performance improved across trials, with no between-condition differences on Trial 2. Self-control was not related to saving.

Concepts: The Trial, Control, The Opportunity, Budget, SAVE, Marble


The Affordable Care Act (ACA) of 2010 placed a substantial emphasis on public health and prevention. Subsequent research on its effects reveals some notable successes and some missteps and offers important lessons for future legislators. The ACA’s Prevention and Public Health Fund, intended to give public health budgetary flexibility, provided crucial funding for public health services during the Great Recession but proved highly vulnerable to subsequent budget cuts. Several programs that aimed to increase strategic thinking and planning around public health at the state level have proven to be more enduring, suggesting that the convening authority of the federal government can be a powerful tool for progress, especially when buttressed by some funding. Most important, by expanding insurance and mandating a minimum level of coverage, the ACA both increased access to clinical preventive services and freed up local public health budgets to engage in population health activities. Expected final online publication date for the Annual Review of Public Health Volume 39 is April 1, 2018. Please see for revised estimates.

Concepts: Health care, Health economics, Medicine, Public health, Health, Population health, Late-2000s recession, Budget


The purpose of this article was to describe methods that sexually transmitted disease (STD) programs can use to estimate the potential effects of changes in their budgets in terms of disease burden and direct medical costs.

Concepts: Medicine, Public health, Epidemiology, Sexually transmitted disease, Human sexual behavior, United Nations Population Fund, Budget