At the Intersection of Health, Health Care and Policy Cite this article as: C. Eugene Steuerle and Julia B. Isaacs The Scheduled Squeeze On Children's Programs: Tracking The Implications Of Projected Federal Spending Patterns Health Affairs, 33, no.12 (2014):2214-2221 doi: 10.1377/hlthaff.2014.0777

The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/12/2214.full.html

For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml

Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.

Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on December 22, 2014 at UNIV OF MASSACHUSETTS

Resource Allocation By C. Eugene Steuerle and Julia B. Isaacs 10.1377/hlthaff.2014.0777 HEALTH AFFAIRS 33, NO. 12 (2014): 2214–2221 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.

doi:

C. Eugene Steuerle ([email protected]) is an institute fellow and the Richard B. Fisher Chair at the Urban Institute, in Washington, D.C. Julia B. Isaacs is a senior fellow at the Urban Institute.

The Scheduled Squeeze On Children’s Programs: Tracking The Implications Of Projected Federal Spending Patterns ABSTRACT 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.

H

ow do children fare in the US budget? And what role does the budget for health care play with regard to children? According to many researchers, investing early in a person’s life produces some of the highest returns, both for the person and for society in general.1 From a health perspective, adult health outcomes are linked to childhood health, and evidence also points to the linkage between poor childhood health and lower earnings in adulthood.2,3 Since personalities form early,4,5 later gains can extend well beyond earnings and health to social and emotional well-being throughout life. Of course, earlier investment, whether in children or almost anything else, can compound returns over more years. And society gains when investments in children result in more educated and reliable adult workers and parents. Economists sometimes allude to “revealed 2214

H e a lt h A f fai r s

D e c em b e r 2 0 1 4

33:12

preference”: watching what people do in deed rather than word, to assess their real preferences. The government budget provides a type of societal revealed preference on choices made about using public resources. And it does so both at the margin and on average. It’s one thing to note that a dollar was spent on children. It’s another if a lot more was spent on other priorities, and still another if the additional revenues from economic growth were not shared with children. When it comes to the federal budget as a whole, children have never been a priority. However, they have had some share in the broad expansion in domestic spending in recent decades. About 10 percent of the federal budget is currently spent on children, compared to 43 percent spent on Social Security, Medicare, and Medicaid (with the children’s portion of these programs counted only as children’s spending, to avoid double counting). At the same time, children

Downloaded from content.healthaffairs.org by Health Affairs on December 22, 2014 at UNIV OF MASSACHUSETTS

in the United States have had worse health and other outcomes such as educational attainment than children in other rich nations.6 And in the United States children had higher poverty rates than other age groups.7 In this article we first discuss the history of federal spending on children and other major priorities over the past five decades. Then we move to the more telling and ominous consequences for children’s programs of continuing on the budgetary path now largely laid out. An examination of the direction set out in current law for the budget as a whole, or of what that law would provide after being adjusted according to any budgetary proposal made by the president or congressional leaders, shows that children would share essentially none of the additional spending that accompanied economic growth. The Congressional Budget Office (CBO) states that it develops its projections using “current law”—that is, the assumption that the law will not change in the future, after expected changes in demographics, the economy, and related factors are adjusted for.8 Excluding health care, children’s programs would lose money in absolute terms, as their share of total government spending would decline quite significantly by 2024. Essentially, nonchild health and retirement spending— which grows automatically unless Congress and the president agree to legislate otherwise—and interest on the debt absorb all of the additional revenues made available by economic growth, and then some. To be clear, this squeeze comes from both the spending and the tax sides of the budget. Our data on spending for children, defined for these purposes as those ages eighteen and younger, come from an elaborate budget exercise that we and other researchers have conducted annually at the Urban Institute since 2007 and a related exercise in 2000.9 For many purposes we add to spending the value of tax subsidies, such as the nonrefundable portion of the earned income tax credit (EITC) and the child tax credit. We estimate the share of a program’s spending on children mainly according to the following rule: When the presence of a child adds to the resources provided to the household by the government, we treat the additional spending as part of the children’s budget. To give two examples, 100 percent of the supports for children’s education are counted. With health care spending, we estimate the additional insurance value provided by coverage for the child.While all budgetary classification is arbitrary at some level, the conclusions reached here would hold under almost any classification scheme. At the same time, we do not examine the effi-

cacy or adequacy of the various programs, other than to note that some programs such as education are more “investment” oriented than others.

Historical Trends In Federal Spending On Defense, Children, Health, And Retirement Trends Certain large trends dominate the history of domestic spending and tax subsidies and explain much of what has happened to children in the federal budget. Since the end of World War II, the federal government extensively expanded its domestic policy, fueled largely by the conversion of the defense budget to domestic spending. Along the way, children have benefited from both expansions of some programs and the enactment of new programs, with growth in either case mainly in means-tested programs that limit eligibility for participation on certain income thresholds. Benefits from these programs—such as Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps), and the EITC—go mainly to lowerincome families with children. Meanwhile, relative to the economy as a whole, the more universally based support programs for families with children that do not depend on income thresholds for eligibility, such as the income tax exemption for dependents, have waned. The more means-tested welfare approach to the expansion of most children’s programs (such as Medicaid and Head Start), as opposed to the more universal approach of programs such as Social Security and Medicare, saves money and may target resources to the children who need them most. However, the means-tested welfare approach has other consequences, such as segregation of children by income class in terms of the doctors they can see or the early childhood education programs they can attend. Average tax rates have remained relatively constant since the end of World War II, averaging about 18.5 percent of gross domestic product (GDP) during that period.Yet domestic spending absorbed much of the funds made available by the drop in defense spending, which fell from about 14 percent of GDP at the end of the Korean War to around 4 percent of GDP in 2013. This freed up about 10 percent of GDP, or $1.7 trillion annually, by 2014.10 Huge portions of that domestic spending expansion went for retirement and health programs. In the 1960s new legislation established or expanded programs such as Medicare, Social Security, and Medicaid. The first two of these programs are fairly universal, and, indeed, people with above-average incomes generally get more lifetime benefits than those with belowDece mber 2014

33:12

Downloaded from content.healthaffairs.org by Health Affairs on December 22, 2014 at UNIV OF MASSACHUSETTS

Health A ffairs

2215

Resource Allocation average incomes (although not necessarily more relative to their contributions). This is in part because the positive correlation between income and life span leads people who are better off on average to receive more years of benefits. In recent decades some growth in retirement and health spending came through new legislation (laws for the Medicare Part D drug program and Medicaid expansions; and the Affordable Care Act, with its net new expenditures). But much growth in those retirement and health programs—as well as many tax subsidies for health, housing, and other purposes—comes about automatically without any vote by Congress. Demographic change fuels some of the growth. Recently the oldest baby boomers started to retire, placing upward pressure on Social Security and Medicare. In addition, costs grow because legislation in the 1970s indexed each cohort’s benefits to rising wages;11,12 lifetime benefits grow as life expectancies expand; and, when birth rates fall, larger shares of the population move to end-of-life stages, when they become eligible for benefits. The combination of indexing benefits to wages and additional years of support causes Social Security to grow faster than the economy. To that growth must be added the increased proportion of beneficiaries relative to workers, which will play its way out as the mid1960s’ drop in the birth rate starts winding its way into the higher costs and lower GDP growth associated with retirement of the baby boomers. Health care faces many of the same demographic issues: People receive federal benefits for larger shares of their lives, while the decline in birth rates means that a smaller share of the population is working and paying taxes to provide the promised benefits. The fee-for-service health care payment structure has also effectively “indexed” health spending to grow rapidly, as patients demand more of what providers can increasingly supply. Cost constraints are limited as long as most of the cost of each additional service is shifted to other people. Meanwhile the health care industry has been quite adept at providing new and better goods and services without the level of competition that tends to reduce relative prices more in other fast-growing industries. Children How about children? During the postwar period they have benefited from a large number of new programs and expansions of old ones. Traditional welfare—known as Aid to Families with Dependent Children, the dominant federal social welfare program for children in 196013—was supplemented over time by EITCs, SNAP, educational spending for the disadvantaged (Title I, Part A, of the Elementary and Secondary Education Act of 1965), school lunches, 2216

Health Affairs

D e c e m b e r 20 1 4

3 3: 1 2

The lack of real automatic growth per person in most children’s programs forced most growth to come from new legislation.

child credits, and a host of other programs. Indeed, in 1960 very few federal programs were targeted to children, and only 3 percent of outlays were spent on children. By 1980 children’s share of federal budget spending had grown to nearly 7 percent. It dropped back to 5 percent in 1985 and has ranged from 9.0 percent to 10.7 percent for the past decade.13 Looking at the outlays tells only part of the story. Three tax programs—the EITC, the child credit, and the dependent exemption—each provide more support for children than any program but Medicaid. The extra value of the employee exclusion from income tax for employer-provided health insurance ranks just behind these tax programs, SNAP, and dependent benefits in Social Security. When these tax programs are counted with federal spending programs, spending on children has dropped from about 20 percent of the domestic budget in 1960 (defined to include direct spending and tax subsidies for children but to exclude defense and international affairs) to about 15 percent today.13 Of course, while domestic spending was rising broadly, children’s spending still rose modestly as a percentage of GDP (from its small base). Going back at least as far as the 1960s, the dependent exemption was the largest federal program for children. It was indexed for inflation only for years after 1984. Legislation in 1986 almost doubled its value, but its decline relative to real growth in the economy has been substantial over time: It has fallen from 1.3 percent of GDP in 1960 to 0.2 percent in 2013.13 With the main exceptions of Medicaid and Social Security dependent benefits, most government spending on children does not grow automatically. Many programs in areas such as education, child care, and housing require annual appropriations. That is, they lack the permanence of spending entitlements (by definition,

Downloaded from content.healthaffairs.org by Health Affairs on December 22, 2014 at UNIV OF MASSACHUSETTS

In contrast to federal spending, state and local spending has traditionally been tilted toward children.

1960 and 2011, real per capita annual federal spending and tax subsidies on children grew by $5,400 (from $873 to $6,273), while real per capita annual spending (excluding tax subsidies) on the elderly grew by about $23,900 (from $4,066 to $27,975).13 With increased longevity, the elderly also received a substantial increase in the number of years of annual support.

Scheduled Declines In Budgets For Children programs that do not require new appropriations) and most tax subsidies. Programs such as child nutrition, SNAP, and child-related tax credits keep pace with inflation and population growth. However, they do not keep pace with growth in the economy, wage growth, or advances in health care technology in the way that Social Security, Medicare, and Medicaid do. Most legislated spending increases for children have been for means-tested programs that determine eligibility in a manner similar to welfare. That tended to limit costs. The lack of real automatic growth per person in most children’s programs (with the major exception of Medicaid, enacted in the Social Security Amendments of 1965) forced most growth to come from new legislation. Discretionary spending, by definition, requires new appropriations, but even direct spending entitlements and permanent tax subsidies for children generally lacked provisions that would make them grow automatically, even if the economy itself grew. The EITC benefited from several legislative expansions. However, it was not indexed for inflation until after 1986, and it has never been indexed for real wage growth. SNAP might grow through new legislation or when unemployment increases the number of eligible beneficiaries. Nonetheless, levels of support did not rise with real wages as the economy expanded. And the child tax credit is not even indexed for inflation. As a response to the Great Recession, the American Recovery and Reinvestment Act of 2009 temporarily increased spending on children (over and above what other laws provided) by an estimated $26 billion in 2009 and $63 billion in 2010, but only $7 billion in 2013.12 Much of that money went to support educational and Medicaid spending by states and, in the former case, to offset some of the teacher layoffs at the state level. In summary, the broadly based domestic spending expansion meant that on net, between

Federal programs that grow automatically absorb ever larger portions of the revenues provided by economic growth and of the economy itself. At the same time, Congress often cuts taxes over time and fails to increase them in line with the rising costs of spending programs. The resulting deficits and increase in debt-to-GDP ratios add to projections of rising interest payments, particularly when the Federal Reserve ends its attempts to deal with recession by keeping interest rates low. Think of spending as being in three piles: discretionary spending, spending on mandatory or permanent programs with built-in growth, and spending on mandatory programs without builtin growth. In budgetary agreements between President Barack Obama and Congress from 2011 to 2014 that will be implemented in future years, discretionary spending was frozen and then reduced further through sequestration that began in 2013. In effect, Congress decided to squeeze discretionary spending between the high spending growth in permanently growing programs and low taxes, at least as measured relative to the nation’s bills. The squeeze is not quite as intense for those permanent entitlements and tax subsidies with little or no built-in growth—for example, EITC and SNAP. While these nondiscretionary programs have not been cut legislatively, they still need new legislation to avoid declining in value relative to the economy. As a result, children’s programs, whether discretionary or permanent, generally either do not increase automatically as the economy grows or suffer from real declines in absolute spending. Meanwhile, the automatically growing permanent programs from which children largely do not benefit (mostly health and retirement programs and interest on the debt) absorb more money than all of the revenues that increase with economic growth, leaving children’s programs potentially under further pressure from future deficit reduction. Demographic trends add to the constraints on children’s programs. The baby-boom retirement wave leads not only to growing shares of the December 2014

33 : 1 2

Downloaded from content.healthaffairs.org by Health Affairs on December 22, 2014 at UNIV OF MASSACHUSETTS

Health Affairs

2217

Resource Allocation budget spent on health and retirement programs but also—a fact that is usually less recognized— to lower growth rates for GDP, personal income, adult employment, and income tax collections. This trend is partially mitigated by the growing employment rates for people older than age sixty-five.14 Congress and the president have been unable to come to any real agreement on the spending and tax subsidies that still grow automatically. Their decision to pare the discretionary spending budget, the lack of any tax agreement (other than to remove the 2001 and 2003 tax cuts for very high-income taxpayers starting in 2013), and continued predictions of large remaining deficits and rising interest costs mean that without a significant course correction, children’s spending will decline. To be clear: This is not a prediction but simply a projection based upon what the Congressional Budget Office calls “current law.”8 Under that set of assumptions, outlays on children as a share of the federal budget would decline from 10.2 percent of total outlays in 2013 to 7.8 percent in 2024.13 Adding in tax programs, spending on children would decline from 2.8 percent of GDP to 2.3 percent over the same period. Only children’s health spending would increase, rising from about 0.5 percent of GDP to 0.6 percent (Exhibit 1). Tax and nonhealth spending programs would each fall from about 1.1 percent of GDP to 0.9 percent and 0.8 percent, respectively. On a per capita basis, federal spending on chil-

dren would increase for health (from $1,100 in 2013 to $1,600 in 2024), remain flat for tax provisions (at $2,400), and fall for all other spending (from $2,400 to $2,200). Research on the importance of social determinants of health, such as education and housing, has shown that decreased spending in areas other than health can affect children’s health outcomes and child development.15 According to CBO projections, annual total federal spending would rise by close to $1.4 trillion by 2024, relative to 2013.13 Yet 58 percent of that additional spending would go for increases in payments for Social Security, Medicare, and Medicaid, excluding children (Exhibit 2). Interest on the debt would absorb another 36 percent: The interest costs would rise because of both the increased debt that arises from an unwillingness to pay the nation’s bills and projected higher future interest rates. Basically, everything else in aggregate would get close to nothing. Children would get just two cents on the dollar—or a reduction if health care were excluded. These relative changes are not simply a result of the relative growth in the numbers of elderly people. The CBO does not provide ten-year estimates on annual spending on the elderly. However, separate research shows lifetime benefits in Social Security and Medicare growing continually (for reasons stated above), so that a twoearner, average-wage couple who retire in 2030 will get about $1.3 million in benefits. In contrast, a similar couple retiring in 2010 would receive about $1 million.16

Exhibit 1 US Spending On Children As A Percentage Of Gross Domestic Product (GDP): Health And Nonhealth Programs And Tax Provisions, 2007–24

SOURCE Authors’ analysis of data from the US budget for fiscal year 2015 and previous years, and from the following: (1) Hahn H, et al. Kids’ share 2014 (see Note 13 in text) (2) Congressional Budget Office. Updated budget projections: 2014 to 2024 [Internet]. Washington (DC): CBO; 2014 Apr [cited 2014 Oct 24]. Available from: http://www.cbo.gov/sites/default/files/45229-UpdatedBudget Projections_2.pdf. (3) Rohaly J, Carasso A, Saleem MA. The Urban-Brookings Tax Policy Center microsimulation model: documentation and methodology for version 0304 [Internet]. Washington (DC): Tax Policy Center; 2005 Jan 10 [cited 2014 Oct 24]. Available from: http://www.taxpolicycenter.org/publications/url.cfm?ID=411136.

2218

H e a lt h A f fai r s

D e c em b e r 2 0 1 4

33:12

Downloaded from content.healthaffairs.org by Health Affairs on December 22, 2014 at UNIV OF MASSACHUSETTS

Exhibit 2 Shares Of Projected Growth In Federal Outlays From 2013 To 2024 Going To Children And Other Major Budget Items Billions of dollars Major budget item Nonchild Social Security, Medicare, Medicaid

2013 1,472

2024 2,259

Growth (2013–24) 787

Percent of growth 58

Interest on the debt

221

714

493

36

Children Defense

351 633

377 590

26 −43

2 −3

All other outlays Total outlays

777

881

104

8

3,455

4,821

1,366

100

SOURCE Authors’ analysis of data from the US budget for fiscal year 2015 and previous years, and from the following: (1) Hahn H, et al. Kids’ share 2014 (see Note 13 in text). (2) Congressional Budget Office. Updated budget projections: 2014 to 2024 [Internet]. Washington (DC): CBO; 2014 Apr [cited 2014 Oct 24]. Available from: http://www.cbo.gov/sites/default/files/45229-Updated BudgetProjections_2.pdf.

State And Local Policy Our work on the budget for children has concentrated on the federal government, chiefly because data at the subnational level are sparser, with delayed availability. We have only recently extended our analysis of spending on children to the state and local level for 1998–2011. In contrast to federal spending, state and local spending has traditionally been tilted toward children, largely through spending on public schools. Combined federal, state, and local public spending shows less of a bias against children: At the federal level, approximately $6 is spent per elderly person for every $1 spent per child, but the ratio falls to a bit more than $2 to $1 when state and local spending are included. During the recession, state budgets were cut. However, federal spending on children, boosted temporarily by the American Recovery and Reinvestment Act, provided additional support for state spending on education, Medicaid, and other areas. Even so, local public schools laid off teachers. The number of people employed in local public schools (that is, teachers, principals, and support staff) fell 3 percent between 2010 and 2012, despite rising student enrollment.13 State and local budgets are subject to some of the same pressures as the federal budget. Total state spending on Medicaid (including federally funded spending but excluding local spending) has recently begun to exceed state spending on K–12 education; state pension plans demand increased funding as a share of total spending; and research shows that spending on children declines in communities as the proportion of elderly in their populations increases.17–19 We are unable to project future state and local spending on children. However, we doubt that it will be robust enough to offset the projected declines in federal spending relative to incomes.

Federal Spending On Health: Implications For Children Spending on children comes in all shapes and sizes. However, Medicaid provides more dollars of support for children than any other federal program. And when federal, state, and local programs are considered, Medicaid is second only to public schooling. Medicaid spending on children is projected to continue to grow, as a result of rising health care costs and expansions under the Affordable Care Act. Our estimates show that the Medicaid expansion in that legislation plays a far more important role in expanding the health budget for children than do the new subsidies it provided through health exchange subsidies, which are largely for middle-class households. As the share of total government spending on health care increases, other shares necessarily fall—regardless of whether total government spending becomes larger or smaller relative to the economy. In the economy as a whole, health care growth per capita has absorbed about onethird of average per capita income growth from 1990 to 2010.20 Complicating the budgetary picture is a debate normally defined as a health policy issue: preventive versus acute care. Clearly, preventive care and acute care can both enhance productivity and economic growth. Preventive care is often cheaper than acute care and, when provided to the young, is more likely to lead to additional ability to work, higher future incomes, and subsequent government revenues. At the same time, growth in chronic illness and rates of autism in children could affect health, education, and other budgets. In 2013 overall federal spending on health care for children reached $87 billion. As a share of total federal spending on children, federal health December 2 014

3 3: 12

Downloaded from content.healthaffairs.org by Health Affairs on December 22, 2014 at UNIV OF MASSACHUSETTS

H ea lt h A f fai r s

2 219

Resource Allocation Conclusion

Exhibit 3 Health Spending On Children As A Percentage Of Total Federal Spending On Children, 1960–2013

SOURCE Authors’ analysis of data from the US budget for fiscal year 2015 and previous years; and from Hahn H, et al. Kids’ share 2014 (see Note 13 in text). NOTES Actual data for 1960 and 1995 are shown in five-year increments; linear interpolation was used between those data points to produce the trend line. The data series from 1995 on is complete with annual observations.

spending on them went from less than 5 percent in 1980 to almost 20 percent in 2013 (Exhibit 3). Spending on health care has both a positive and a negative impact on the budget for children. Health spending has grown so fast relative to other spending that children have shared in that growth in terms of dollars. However, only a modest share of spending on health care is for children: Just 10 percent of federal health spending went to children in 2010.21 Thus, despite the modest growth in the percentage of total government spending appropriated to children’s health, the inexorable growth in the share of total government spending for overall health care forced most children’s programs to compete for an ever-shrinking share of the remaining pie. Of course, shares are not the only issue: The size of the pie itself is also affected by economic growth and by what revenues the government is willing to collect. Economic growth, in turn, is affected by how well the nation invests in children. The topics of health care, fiscal policy, and spending on children remain inexorably linked.

This article relies in part upon research for various Kids’ Share reports funded by the Annie E. Casey Foundation and First Focus, as well as some related research funded by the Foundation for Child Development for spending by age

2220

H e a lt h A f fai r s

D e c em b e r 2 0 1 4

33:12

Our purpose in this article has been to lay out the nature, source, and consequences of the pressures on the budget for spending on children, with emphasis on the inconsistent role played by health care policy. Any budget exercise pushes to the fore inevitable issues of balance. Here they include the allocation of future revenue growth to children versus higher health, retirement, and tax subsidies for other people; whether increasing weight should be given to spending oriented toward investment, such as education and preventive health care, or to spending oriented toward consumption, such as higher retirement support; whether the nation should use more or less means testing, especially when it segregates the young by income class when they receive services such as health care and education; the balance in future budget deals between possible legislative increases in taxes and slowing down of automatic spending growth; and whether better health care over time requires that beneficiaries work longer as they live longer or continue to shift the costs of more years of support to younger generations. There is no guarantee that addressing these issues will reverse the scheduled relative decline in government spending for children. But at least doing so would force the nation to decide whether taking this path is intentional or accidental. On the optimistic side, economic growth makes it possible to do for children in this century what was done for the elderly in the past century, without abandoning those previous gains. If per capita GDP grows in another halfcentury by even a fraction of its approximately 170 percent growth since 1961,22 there will be a number of extraordinary opportunities for investing in children. This is important not simply because children today have a poverty rate above that of the population as a whole, but because what the government provides to tomorrow’s public will come largely from what today’s children—tomorrow’s workers and taxpayers—can support. ▪

group. The authors acknowledge the related work of other researchers who worked with them on various Kids’ Share reports, including, most recently, Sara Edelstein, Heather Hahn, Ellen Steele, and Katherine Toran. The conclusions

expressed are those of the authors and do not necessarily reflect those of officers or trustees of the Urban Institute or any organizations that provide financial support to the Institute.

Downloaded from content.healthaffairs.org by Health Affairs on December 22, 2014 at UNIV OF MASSACHUSETTS

NOTES 1 Currie J, Almond D. Human capital development before age five. In: Ashenfelter O, Card D, editors. Handbook of labor economics. Vol. 4B. Philadelphia (PA): Elsevier; 2010. p. 1315–486. 2 Currie J, Stabile M, Manivong P, Roos LL. Child health and young adult outcomes. J Hum Resour. 2010;45(3):517–48. 3 Currie J. Healthy, wealthy, and wise: socioeconomic status, poor health in childhood, and human capital development. J Econ Lit. 2009;47(1): 87–122. 4 Center on the Developing Child. Science of adversity and resilience [Internet]. Cambridge (MA): Harvard University; [cited 2014 Oct 24]. Available from: http://developing child.harvard.edu/activities/sar/ 5 Halfon N. Life course health development: a new approach for addressing upstream determinants of health and spending. Expert Voices [serial on the Internet]. 2009 Feb [2014 Oct 24]. Available from: http://www.nihcm.org/pdf/Expert Voices_Halfon_FINAL.pdf 6 Adamson P. Child well-being in rich countries: a comparative overview [Internet]. Florence: UNICEF Office of Research—Innocenti; 2013 [cited 2014 Oct 24]. (Innocenti Report Card 11). Available from: http:// www.unicef-irc.org/publications/ pdf/rc11_eng.pdf 7 DeNavas-Walt C, Proctor BD, Smith JC. Income, poverty, and health insurance coverage in the United States: 2012. Current Population Reports [serial on the Internet]. 2013 Sep [cited 2014 Oct 24]. Available from: http://www.census .gov/prod/2013pubs/p60-245.pdf 8 Williams C. What is a current-law economic baseline? [Internet]. Washington (DC): Congressional Budget Office; 2005 Jun 2 [cited 2014 Oct 24]. (Economic and Budget Issue Brief). Available from: http:// www.cbo.gov/sites/default/files/ economicbaseline.pdf 9 Toran K, Isaacs J, Hahn H, Fortuny K, Steuerle CE. Data appendix to

10

11

12

13

14

15

16

Kids’ Share 2012: report on federal expenditures on children through 2011 [Internet]. Washington (DC): Urban Institute; [cited 2014 Oct 24]. Available from: http://www.urban .org/UploadedPDF/412599-DataAppendix-to-Kids-Share-2012.pdf Office of Management and Budget. Historical tables [Internet]. Washington (DC): White House; [cited 2014 Oct 24]. Tables 2.1 and 3.1. Available from: http://www.white house.gov/omb/budget/historicals Ball RM. Social Security amendments of 1972: summary and legislative history [Internet]. Washington (DC): Social Security Administration; 1973 Mar [cited 2014 Oct 24]. Available from: http://www.ssa.gov/ history/1972amend.html Social Security Administration. Social Security amendments of 1977 [Internet]. Washington (DC): Social Security Administration [cited 2014 Oct 24]. Available from: http:// www.socialsecurity.gov/history/ pdf/Downey%20PDFs/Social %20Security%20Amendments %20of%201977%20Vol%202.pdf Hahn H, Isaacs J, Edelstein S, Steele E, Steuerle CE. Kids’ share 2014: federal expenditures on children in 2013 and future projections [Internet]. Washington (DC): Urban Institute; 2014. Available from: http:// www.urban.org/UploadedPDF/ 413215-Kids-Share-2014.pdf Steuerle CE, Quakenbush C. Correcting labor supply projections for older workers could help social security and economic reform [Internet]. Washington (DC): Urban Institute; 2012 Jul [cited 2014 Oct 24]. (Brief No. 35). Available from: http://www.urban.org/uploaded pdf/412631-correcting-labor-supplyprojections.pdf National Research Council. U.S. health in international perspective: shorter lives, poorer health. Washington (DC): National Academies Press; 2013. Steuerle CE, Quakenbush C. Social security and Medicare taxes and benefits over a lifetime: 2013 update

17

18

19

20

21

22

[Internet]. Washington (DC): Urban Institute; 2013 Nov [cited 2014 Oct 24]. Available from: http://www .urban.org/UploadedPDF/412945Social-Security-and-Medicare-Taxesand-Benefits-over-a-Lifetime.pdf National Association of State Budget Officers. 2010 state expenditure report: examining fiscal 2009–2011 state spending [Internet]. Washington (DC): NASBO; 2011 [cited 2014 Oct 24]. Available from: http:// www.nasbo.org/sites/default/files/ 2010%20State%20Expenditure %20Report.pdf Poterba JM. Demographic structure and the political economy of public education. J Policy Anal Manage. 1997;16(1):48–66. Tax Policy Center. State and local government finance data query system (SLF-DQS) [Internet]. Washington (DC): The Center; [cited 2014 Nov 3]. Available from: http:// slfdqs.taxpolicycenter.org/pages .cfm Steuerle G. A slower rate of health cost growth? What happens when an irresistible force meets an increasingly immovable object? [Internet]. Ann Arbor (MI): Altarum Institute; 2013 May 10 [cited 2014 Oct 24]. Available from: http://altarum.org/ health-policy-blog/a-slower-rate-ofhealth-cost-growth-what-happenswhen-an-irresistible-force-meets-anincreasingly Hahn H, Kenney GM, Coyer C, Toran K. Federal health expenditures on children on the eve of health reform: a benchmark for the future [Internet]. Washington (DC): Urban Institute; 2012 [cited 2014 Oct 24]. Available from: http://www.urban .org/UploadedPDF/412557-federalhealth-expenditures.pdf Bureau of Economic Analysis. National economic accounts [Internet]. Washington (DC): Department of Commerce; [last modified 2014 Sep 29; cited 2014 Oct 24]. Available from: http://www.bea.gov/national/ Index.htm

Dece mber 2014

33:12

Downloaded from content.healthaffairs.org by Health Affairs on December 22, 2014 at UNIV OF MASSACHUSETTS

Health A ffairs

2221

The scheduled squeeze on children's programs: tracking the implications of projected federal spending patterns.

Federal programs for children are under increasing budgetary pressure. According to current federal law or any budget alternative being offered by the...
287KB Sizes 2 Downloads 3 Views