Selected Publications

The Impact of Government Decentralization on Health Spending for the Uninsured in California

Scheffler, R., and R. Smith. “The Impact of Government Decentralization on Health Spending for the Uninsured in California.” International Journal of Health Care Finance and Economics 6:3 (Sept 2006): 237-258.


We analyze Program Realignment, California’s 1991 policy of decentralizing control of health, mental health, and social services, from the state to the counties. Drawing from the economics literature on intergovernmental transfers and using data constructed for this study, we analyze the impact of Realignment on uninsured health spending. We find a change in the pattern of spending on indigent health services by counties following decentralization. Our results suggest, however, that county-level governments maintain a level of commitment to social-service spending that recent studies indicate may be lacking at the state level.