Budget Office Research Articles

Why Office of Management and Budget’s (OMB) Social Welfare Function Is Not Society’s Social Welfare Function

Abstract In 2023, the U.S. Office of Management and Budget (OMB) issued guidance documents that specified new procedures for assessing prospective government regulations (Circular A-4) and economic policies more generally (Circular A-94). These revisions to long-standing guidance were not minor updates but shifted policy analyses from an efficiency-oriented perspective to a redistributive approach. OMB broadened the guidelines for reporting distributional consequences of policies and also specified how policy impacts on different income groups should be weighted. The weights assume that the social welfare function is governed by the sum of identical individual utility functions, each of which exhibits a substantial rate of diminishing marginal utility of income. The resulting weights provide a premium for households below the median-income level and a considerable penalty for those at higher-income levels. Application of the weights to property losses creates potentially substantial inefficiencies. If based on current empirical evidence on the income elasticity of the value of a statistical life rather than assuming that there is a complete offset of the weights, application of the weights to mortality risk valuation would generate inequities in protection.

Identifying measures for understanding and addressing county-level disparities in adolescent HPV vaccination coverage in North Carolina.

HPV vaccination coverage is characterized by geographic disparities in the US, with national studies finding lower coverage in rural versus nonrural areas. To direct quality improvement efforts in North Carolina, we sought to understand how different rurality measures characterize these disparities. We used separate negative binomial regression models to test associations between 5 dichotomized county-level rurality measures and HPV vaccination coverage (≥1 dose) among North Carolina adolescents, ages 11-12 (n=326,345). Rurality measures were derived from: Office of Management and Budget's Metropolitan Statistical Areas, Rural-Urban Continuum Codes, Index of Relative Rurality, US Census Bureau classifications, and North Carolina Rural Center classifications. Models controlled for Social Vulnerability Index (SVI) percentile and rate of pediatricians per county. Vaccination data came from the North Carolina Immunization Registry. HPV vaccination coverage was 29% across North Carolina's 100 counties (range: 13%, 46%). Agreement between rurality measures ranged from 54% to 93% of counties. In adjusted analyses, none of the 5 rurality measures correlated with HPV vaccination coverage, but higher SVI and higher rate of pediatricians were positively associated with coverage (p< 0.01). Exploratory moderation analyses suggested regional variation in the relationship between rurality and coverage, with a positive association in one region, a negative association in one region, and no association in four regions. County-level rurality measures did not identify disparities in HPV vaccination coverage in North Carolina. Measures related to social vulnerability and access to pediatricians may be better suited for understanding and addressing the state's substantial county-level vaccination disparities.

Cognitive Difficulty in Middle Eastern and North African Adults Living in the United States Compared With Other Racial and Ethnic Categories, 2017-2021.

Objectives. To estimate the odds of having cognitive difficulties among Middle Eastern and North African (MENA) American adults and compare these odds with those of White, Black, Hispanic/Latino, Asian, American Indian or Alaska Native (AI/AN), and Native Hawaiian/Other Pacific Islander adults nationally and in the 4 states with the largest MENA populations (California, New York, Michigan, and Texas) after adjusting for sociodemographic factors. Methods. We analyzed 2017-2021 American Community Survey data (aged ≥ 45 years; n = 7 284 988), comparing presence of cognitive difficulties by race/ethnicity. Results. MENA adults had greater odds of reporting cognitive difficulties than did White (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.42, 1.56), Black (OR = 1.20; 95% CI = 1.14, 1.26), Hispanic (OR = 1.46; 95% CI = 1.39, 1.53), Asian (OR = 1.31; 95% CI = 1.25, 1.38), and AI/AN (OR = 1.07; 95% CI = 1.01, 1.14) adults. In all 4 states, odds of having cognitive difficulties were higher among MENA than Asian adults. Other racial/ethnic comparisons differed by state. Conclusions. A separate checkbox for MENA Americans approved by the Office of Management and Budget is important so health outcomes can be studied in more detail and funds can be allocated for research and resources at state and national levels. (Am J Public Health. 2024;114(11):1265-1274. https://doi.org/10.2105/AJPH.2024.307803).

Analysis of Historical Federal R&amp;D Priorities: The OMB-OSTP Memorandum and the R&amp;D Section of the Analytical Perspectives in the President's Budget

Each year, the directors of the White House Office of Science and Technology Policy (OSTP) and the Office of Management and Budget (OMB) jointly produce a memorandum of research and development priorities and how those priorities align with the fiscal year budget. This memo guides the actions of executive branch departments and agencies towards the administration’s science and technology priorities. By presenting these priorities yearly, these memoranda serve as a record of the science and technology priorities of respective Presidential administrations and, in turn, can reflect a changing science and technology policy landscape over the duration of several Presidential terms. This paper assesses how science and technology policy priorities, as established in these memoranda, are reflected in the Presidential budget within and across administrations. Additionally, this paper compares and analyzes priority topic areas from the OMB/OSTP memos with another representation of science and technology areas of emphasis: the research and development (R&amp;D) section of the Analytical Perspectives in the President’s budget. The Analytical Perspectives document highlights items from the Presidential budget requests. This paper discerns the extent to which these two sources of priority-setting become aligned in order to identify trends in which science and technology topics are prioritized by the White House across time and administration. This study addresses two core research questions: 1) How do science and technology priorities change over time, both across and/or within Presidential administrations?; and 2) To what extent, if any, are the ideas in the OMB/OSTP science and technology priorities memoranda and the Analytical Perspectives documents aligned?

United States federal indebtedness and fiscal policy trade‐offs

AbstractProjected federal spending and taxes are distributed by birth year, gender, race, and lifetime education, using the Congressional Budget Office's 10‐year budget estimates and the Penn Wharton Budget Models' microsimulation. This enables measurement of conventional federal fiscal imbalance (FI): $162.6 trillion in present value, which is six‐fold larger than current debt held by the public. FI implies a shortfall of 26.1% in federal taxes, alternatively, an excess of 33.4% of federal expenditures. The equi‐proportional shortfall of expenditures plus taxes equals 14.6%. Excluding taxes and transfers of some groups, such as the elderly, increases the measured shortfall.

Taxpayers' Share of US Prescription Drug and Insulin Costs: a Cross-Sectional Study.

Drug prices affect government budgets directly through spending on public programs like Medicare and Medicaid, and indirectly via private coverage for public employees and tax subsidies for private insurance. Yet, the Senate parliamentarian ruled that the Senate could not use streamlined Budget Reconciliation to extend the Inflation Reduction Act's controls on insulin co-payment or drug prices to private insurers on the grounds that their expenditures do not affect the federal budget. To quantify insulin and other drug costs borne by federal, state, and local governments, including direct expenditures and indirect government subsidies that flow through private insurers. Cross-sectional analysis of expenditures for outpatient retail prescription drugs reported by respondents and their pharmacies in the 2019 Medical Expenditure Panel Survey (adjusted downward for drug rebates), supplemented with information on employment-related insurance from the US Office of Management and Budget and other sources. The civilian non-institutionalized US population. Direct (payments by public health insurance programs) and indirect (taxpayer-funded payments via private insurers) government expenditures for outpatient retail drugs. Direct government expenditures for outpatient retail prescription drugs totaled $154.85 billion in 2019, including $15.68 billion for insulin. Indirect government expenditures channeled through private insurers totaled $53.59 billion (including $5.48 billion for insulins). Those indirect expenditures encompassed $32.32 billion in tax subsidies for employer-sponsored private coverage, $25 million for subsidies to private Affordable Care Act marketplace plans, and $21.24 billion for government-paid premiums for public employees and retirees. Overall, government expenditures for outpatient retail prescription drugs totaled $208.44 billion, 58.76% of all-payer spending and 65.96% of spending for insulin. Governments directly or indirectly fund most drug purchases, including substantial expenditures that flow through private insurers. Hence, prices paid by private insurers impact government budgets, supporting the view that government should be allowed to regulate drug prices.

Artificial Intelligence and Machine Learning in Ocular Oncology, Retinoblastoma (ArMOR): Experience with a Multiracial Cohort.

Background: The color variation in fundus images from differences in melanin concentrations across races can affect the accuracy of artificial intelligence and machine learning (AI/ML) models. Hence, we studied the performance of our AI model (with proven efficacy in an Asian-Indian cohort) in a multiracial cohort for detecting and classifying intraocular RB (iRB). Methods: Retrospective observational study. Results: Of 210 eyes, 153 (73%) belonged to White, 37 (18%) to African American, 9 (4%) to Asian, 6 (3%) to Hispanic races, based on the U.S. Office of Management and Budget's Statistical Policy Directive No.15 and 5 (2%) had no reported race. Of the 2473 images in 210 eyes, 427 had no tumor, and 2046 had iRB. After training the AI model based on race, the sensitivity and specificity for detection of RB in 2473 images were 93% and 96%, respectively. The sensitivity and specificity of the AI model were 74% and 100% for group A; 88% and 96% for group B; 88% and 100% for group C; 73% and 98% for group D, and 100% and 92% for group E, respectively. Conclusions: The AI models built on a single race do not work well for other races. When retrained for different races, our model exhibited high sensitivity and specificity in detecting RB and classifying RB.

Cardiovascular Disease Mortality Among Native Hawaiian and Pacific Islander Adults Aged 35 Years or Older, 2018 to 2022.

Native Hawaiian and Pacific Islander (NHPI) adults have historically been grouped with Asian adults in U.S. mortality surveillance. Starting in 2018, the 1997 race and ethnicity standards from the U.S. Office of Management and Budget were adopted by all states on death certificates, enabling national-level estimates of cardiovascular disease (CVD) mortality for NHPI adults independent of Asian adults. To describe CVD mortality among NHPI adults. Race-stratified age-standardized mortality rates (ASMRs) and rate ratios were calculated using final mortality data from the National Vital Statistics System for 2018 to 2022. Fifty states and the District of Columbia. Adults aged 35 years or older at the time of death. CVD deaths were identified from International Classification of Diseases, 10th Revision codes indicating CVD (I00 to I99) as the underlying cause of death. From 2018 to 2022, 10 870 CVD deaths (72.6% from heart disease; 19.0% from cerebrovascular disease) occurred among NHPI adults. The CVD ASMR for NHPI adults (369.6 deaths per 100 000 persons [95% CI, 362.4 to 376.7]) was 1.5 times higher than for Asian adults (243.9 deaths per 100 000 persons [CI, 242.6 to 245.2]). The CVD ASMR for NHPI adults was the third highest in the country, after Black adults (558.8 deaths per 100 000 persons [CI, 557.4 to 560.3]) and White adults (423.6 deaths per 100 000 persons [CI, 423.2 to 424.1]). Potential misclassification of underlying cause of death or race group. NHPI adults have a high rate of CVD mortality, which was previously masked by aggregation of the NHPI population with the Asian population. The results of this study support the need for continued disaggregation of the NHPI population in public health research and surveillance to identify opportunities for intervention. National Institute of General Medical Sciences, National Institutes of Health.

THE INFLUENCE OF COUNTY ASSEMBLIES’ COORDINATING ROLE ON THE IMPLEMENTATION OF STRATEGIC PLANS IN THE NAIROBI CITY COUNTY GOVERNMENT, KENYA

In Nairobi County, just like the rest of Kenya, the county assembly is responsible for legislation, oversight, and representation of the county executive who implements the county strategic plans developed from the devolved functions of the devolution. However, the achievement of strategic plans is still with flaws despite this. The purpose of the study was to assess the influence of the coordinating role on the implementation of strategic plans in the Nairobi City County Government, Kenya. The study was guided by the McKinsey 7s model, the Dynamic Capability Model, and the Resource-Based View Theory. The study was conducted using a quantitative research design. The target population was 123 members of the County Assembly, consisting of 85 elected and 38 nominated members. The population also included 3 officials from the County Assembly's Financial and Budget Office, Procurement Office, and Planning Department. The study involved 85 elected and 38 nominated county assembly members, using simple random sampling. Officials from the Financial and Budget Office, Procurement Office, and Planning Department were selected by census. Primary data was collected with 5-point Likert scales. SPSS regression analysis tested the relationships between dependent and independent variables, with multiple regression used due to activity interconnectedness. Results were presented in descriptive figures and tables, with regression outcomes shown in tables. The study's findings reveal a strong positive correlation (r = 0.847, p &lt; 0.01) between the coordination role of MCAs and the implementation of strategic plans. The standardized coefficient (β =0.847; p =0.000) confirms the strong positive relationship between the coordination role and strategic plan attainment. The differing views among MCAs on coordination roles highlight the need for NCCG to enhance stakeholder engagement by creating clear communication frameworks, organizing regular interaction forums, and involving stakeholders in resource allocation to align their efforts with strategic objectives and improve the execution of strategic plans.

Race and ethnicity representation in phase 2/3 oncology clinical trial publications in the United States: A systematic review.

20 Background: The five 1997 Office of Management and Budget (OMB) races in the US include American Indian or Alaskan Native (AI/AN), Asian, Black or African American, Native Hawaiian or Other Pacific Islander (NHPI), and White, with Hispanic ethnicity. Despite the Affordable Care Act (ACA) mandating OMB-based collecting/reporting standards, race and ethnicity publishing in medical journals is inconsistent, despite being necessary to achieve health equity. We aimed to quantify race and ethnicity reporting rates and calculate representation quotients (RQs) in published oncology clinical trials. Methods: In this systematic review, PubMed/Embase were queried for phase 2/3 clinical trials of the 6 most common noncutaneous solid malignancies, published between 2012-2022, in 4 high-impact journals. Trial characteristics were recorded. The RQs for each race and ethnicity were calculated by dividing the percent of representation in clinical trial publications by the percent of year-matched, site-specific incident cancers in the US, compared with Kruskal-Wallis tests with Bonferroni Correction (BC). Reporting was compared between journal publications and ClinicalTrials.gov. Results: Among 1,202 publications evaluated, 364 met inclusion criteria: 16 JAMA , 241 JCO , 19 Lancet , and 88 NEJM . Publications included 268,209 patients (171,132 women [64%]), with a median of 356 (IQR, 131-800) patients per publication. Reported race and ethnicity included AI/AN in 52 (14%) publications, Asian in 196 (54%), Black or African American in 215 (59%), Hispanic in 67 (18%), NHPI in 28 (8%), and White in 254 (70%). Median RQ varied across race (P &lt; .001 BC) with 1.04 (IQR, 0.09-4.77) for Asian, 0.98 (IQR, 0.86-1.06) for White, 0.42 (IQR, 0.12-0.75) for Black or African American, and 0.00 (IQR, 0.00-0.00) for both AI/AN and NHPI patients. Sensitivity analyses showed similar findings upon subset analysis for US-only clinical trials. There was significantly less race and ethnicity reporting in the clinical trial publications compared with ClinicalTrials.gov documentation for AI/AN (14% vs 45%, P &lt; .001 per McNemar χ 2 with continuity correction [MC]) and NHPI (7.7% vs 43%; P &lt; .001 MC). Conclusions: While most phase 2/3 oncology clinical trials published in high-impact journals report race and ethnicity, most did not report AI/AN and NHPI racial categories. Our findings support a call to action for consistent journal policies and transparent race and ethnicity reporting, in alignment with ACA-concordant race and ethnicity federal reporting requirements.

Effect of Budget Process Reforms on Government Infrastructural Projects Success at the Ministry of Roads and Transport in Kenya

Purpose: The aim of the study was to examine effect of budget process reforms on government infrastructural projects success at the Ministry of Roads and Transport in Kenya Methodology: The descriptive type of survey research design was utilized with the population targeted being 6 staff members at the Ministry of Roads and Transport, 27 budget and appropriation committee members at the parliamentary committee and 8 Parliamentary Budget Office members (PBO) and 3 senior officials from the Kenya National Highway Authority. Census sampling technique was employed to reach the sample size. Hence, all the 44 respondents were involved in the study. A questionnaire was employed to gather information and quantitative techniques adopted for analysis. Validity and reliability of the questionnaire was tested and it had an overall Cronbach Alpha of 0.826. Statistical Package for Social Sciences (SPSS version 21) was integrated to code information gotten from the questionnaires and summarized into percentages and frequencies. The summary was then outlined in pie charts, figures, and tables. Findings: From the analysis, the study found that the major budget reform processes include accountability, enhancing public participation, and strengthening enforcement. The study established that budget reform process had a statistically significant influence on the success of government infrastructural project success. Unique Contribution to Theory, Practice and Policy: System theory can be used to anchor future studies on effect of budget process reforms on government infrastructural projects success at the Ministry of Roads and Transport in Kenya. Accountability measures should be introduced and the relevant bodies held responsible for any mishaps in the project implementation process. It was suggested that there is a need for further studies to be conducted to examine other factors impacting the government infrastructural projects success.

Conceptualising the People's Parliament Approach in the Parliament of Malaysia

This study explores the Parliament of Malaysia’s transition towards a more public-friendly institution, part of a global trend towards transparent and people-centric parliamentary processes. Utilising 16 articles from the Inter-parliamentary Union’s Public Engagement Hub and additional literature, the research compares Malaysia’s initiatives with those of the U.K., Australia, and New Zealand. The analysis focuses on public engagement strategies such as public broadcasting of sessions, committee hearings, public visits, research services, and the potential for a parliamentary budget office and petition systems. Findings indicate Malaysia’s progress in some areas, like public broadcasting and committee hearings, while identifying gaps in others, like interactive visitor experiences and comprehensive digital engagement. The study highlights the challenge of balancing security with accessibility, especially under legal frameworks like the Protected Areas and Protected Places Act 1959 (Act 298). Recommendations include enhancing the Parliament’s virtual tour and establishing a more engaging visitor centre. The study concludes that while Malaysia has made commendable strides in public engagement, there are opportunities for improvement, particularly in areas requiring substantial legal and structural changes. This study contributes to understanding the dynamics of public engagement in parliamentary processes, underscoring the significance of a People’s Parliament spirit in democratic governance.

Reviving the Proposal For a Parliamentary Budget Officer

The 2019 proposal that New Zealand create a parliamentary budget officer should be revived, but with certain changes. First, the parliamentary budget officer should not be asked to estimate the cost of political parties’ electoral platforms, since that is not a proper function of an officer of Parliament, and the political sensitivity and resource intensiveness of such costings could interfere with the officer’s ability to help Parliament hold the executive to account. Second, the parliamentary budget officer should have a broader scope to comment on public finances than was envisaged in 2019. Third, the creation of a parliamentary budget officer should be accompanied by consideration of other ways of strengthening Parliament’s effectiveness in scrutinising public finances, such as having a member of the opposition chair the Finance and Expenditure Committee.

Does innovative behaviour intervene between budgetary participation and performance in the public sector?

Purpose For a public servant (PS) to be innovative, he or she needs to gather and process enough vital information from budget setting processes. However, research addressing how budgetary participation (BP) can trigger innovative behaviour (IB) in PSs and eventually foster task performance (TP) is rare, which is why the authors conduct this research. The purpose of this study is to understand how BP shapes TP through the IB of PSs. Design/methodology/approach The authors develop and test a mediation model with 860 responses from public sector workers across 25 government agencies using the PLS-SEM technique of Smart PLS 4. Possible control factors were addressed for both the mediator and target-independent construct. In particular, the authors use sex, age and tenure as control factors for IB. Also, the authors use job satisfaction, job engagement and perceived fairness in the budgetary system as control factors for TP. Findings The authors find a favourable and significant relationship between BP and TP; BP and IB; and IB and TP. The authors also find that IB partially mediates the relationship between BP and TP, such that BP fosters TP through the innovativeness of PSs. This finding suggests that PSs who participate in budget preparation are able to innovate, which, in turn enable them to perform tasks effectively. Research limitations/implications The authors call on forthcoming researchers to test the mediation model in other public sector settings worldwide. They may also consider other variables that can possibly mediate the positive impacts of BP on TP. Practical implications Lessons are discussed for governments, human resources directors and managers, management accountants, budget officers, procurement officers and other public sector workers and consultants. Originality/value The authors show how BP fosters TP through the innovativeness of PSs, since there is much more to know in this regard. The authors also help to resolve the paradox of inconsistency in the BP–TP literature by using IB as a mediator.

Disparities in access to reproductive genetic services associated with geographic location of residence and maternal race and ethnicity

PurposeTo describe the association between geographic location of residence and use of aneuploidy screening or prenatal genetic counseling and how it is modified by maternal race and ethnicity. MethodsRetrospective cohort of individuals at a tertiary care center between 2017-2019. County of residence was classified as rural or metropolitan based in US Office of Management and Budget 2019 definitions. Maternal race and ethnicity were self-identified. Our composite outcome was defined as use of aneuploidy screening or genetic counseling visit. The composite outcome was compared by geographic location and ethnicity. Logistic regression was used to model the relationship between geographic location and the composite outcome. ResultsA total of 8774 pregnancies were included. Of these, 4770 (54%) had genetic screening, and 3781 (43%) had at least 1 genetic counseling visit. Rural patients were significantly less likely to have the composite outcome compared with metropolitan peers (37.1% vs 47.2%, P < .001). In addition, we identified differences in the composite outcome between White rural patients and LatinX rural patients (37.7% vs 35.6%, P < .001) and between Asian rural patients and LatinX and Black rural patients (41.0% vs 35.6%, P < .001; 41.0% vs 36.8%, P < .001). Logistic regression demonstrated that rural patients were significantly less likely to have the composite outcome compared with metropolitan peers, after adjusting for LatinX ethnicity and gestational age at first prenatal visit (OR 0.72, [0.55, 0.95], P = .002). ConclusionRural, minority patients were significantly less likely to receive reproductive genetic services compared with metropolitan peers extending our knowledge of disparities in maternity care.

An evaluation of Congressional Budget Office's baseline projections of USDA mandatory farm and nutrition programs

AbstractThe Congressional Budget Office (CBO) projections of USDA's mandatory farm and nutrition program outlays are important in shaping US agricultural policy. Using CBO projections and observed outcomes from 1985 through 2020, we examine the degree to which projections of farm, supplemental nutrition assistance program (SNAP), and child nutrition program outlays are unbiased, efficient, and informative. We find that projections for farm and child nutrition program outlays are unbiased, SNAP outlays are unbiased at short‐term but are downward biased beyond a 3‐year horizon. All three series of projections are inefficient. SNAP and child nutrition program outlay projections are informative up to a 5‐year horizon, but the farm program outlay projections are informative for only a 1‐year horizon. Disaggregated farm program data since 2008 suggests that the uninformativeness principally stems from conservation and commodity program projections. The findings may be valuable to CBO, as they continue to improve projections, and to projection users, in adjusting their expectations.

INFLUENCE OF BUDGETING ROLE ON THE IMPLEMENTATION OF STRATEGIC PLANS IN THE NAIROBI CITY COUNTY GOVERNMENT, KENYA

In Nairobi County, just like the rest of Kenya, the county assembly is responsible for legislation, oversight, and representation of the county executive who implements the county strategic plans developed from the devolved functions of the devolution. However, the achievement of strategic plans is still with flaws despite this. The purpose of the study was to evaluate the influence of budgeting roles on the implementation of strategic plans in the Nairobi County Assembly in Kenya. The study was guided by the McKinsey 7s model, the Dynamic Capability Model, and the Resource-Based View Theory. The study was conducted using a quantitative research design. The target population was 123 members of the County Assembly, consisting of 85 elected and 38 nominated members. The population also included 3 officials from the County Assembly's Financial and Budget Office, Procurement Office, and Planning Department. The study involved 85 elected and 38 nominated county assembly members, using simple random sampling. Officials from the Financial and Budget Office, Procurement Office, and Planning Department were selected by census. Primary data was collected with 5-point Likert scales. SPSS regression analysis tested the relationships between dependent and independent variables, with multiple regression used due to activity interconnectedness. Results were presented in descriptive figures and tables, with regression outcomes shown in tables. The study's findings indicate that MCAs perceive their budgeting responsibilities favorably, and a positive correlation, (r = 0.833, p &lt; 0.01) is found between their budgeting roles and strategic plan implementation. Following these findings, the study recommends the need to enhance Nairobi City County Government (NCCG)'s budgeting by training MCAs in advanced techniques and enabling them to oversee budget utilization in line with priorities. MCAs should continuously build capacity to understand compliance, ethics, risks, and plan adherence, promoting collaborative oversight. KEYWORDS: Budgeting Roles, Strategic Plans, Strategic Plan Implementation, County Government

Health Insurance Coverage Projections For The US Population And Sources Of Coverage, By Age, 2024-34.

In the Congressional Budget Office's projections of health insurance coverage, 92.3percent of the US population, or 316million people, have coverage in 2024, and 7.7percent, or 26million, are uninsured. The uninsured share of the population will rise over the course of the next decade, before settling at 8.9percent in 2034, largely as a result of the end of COVID-19 pandemic-related Medicaid policies, the expiration of enhanced subsidies available through the Affordable Care Act health insurance Marketplaces, and a surge in immigration that began in 2022. The largest increase in the uninsured population will be among adults ages 19-44. Employment-based coverage will be the predominant source of health insurance, and as the population ages, Medicare enrollment will grow significantly. After greater-than-expected enrollment in 2023, Marketplace enrollment is projected to reach an all-time high of twenty-three million people in 2025.

The impact of Medicaid expansion on state expenditures through the COVID-19 era.

To investigate the impact of Medicaid expansion on state expenditures through the end of 2022. We used data from the National Association of State Budget Officers (NASBO)'s State Expenditure Report, Kaiser Family Foundation (KFF)'s Medicaid expansion tracker, US Bureau of Labor Statistics data (BLS), US Bureau of Economic Analysis data (BEA), and Pandemic Response Accountability Committee Oversight (PRAC). We investigated spending per capita (by state population) across seven budget categories, including Medicaid spending, and four spending sources. We performed a difference-in-differences (DiD) analysis that compared within-state changes in spending over time in expansion and nonexpansion states to estimate the effect of Medicaid expansion on state budgets. We adjusted for annual state unemployment rate, annual state per capita personal income, and state spending of Coronavirus Relief Funds (CRF) from 2020 to 2022 and included state and year fixed effects. We linked annual state-level data on state-reported fiscal year expenditures from NASBO with state-level characteristics from BLS and BEA data and with CRF state spending from PRAC. Medicaid expansion was associated with an average increase of 21% (95% confidence interval [CI]: 16%-25%) in per capita Medicaid spending after Medicaid expansion among states that expanded prior to 2020. After inclusion of an interaction term to separate between the coronavirus disease (COVID) era (2020-2022) and the prior period following expansion (2015-2019), we found that although Medicaid expansion led to an average increase of 33% (95% CI: 21%-45%) in federal funding of state expenditures in the post-COVID years, it was not significantly associated with increased state spending. There was no evidence of crowding out of other state expenditure categories or a substantial impact on total state spending, even in the COVID-19 era. Increased federal expenditures may have shielded states from substantial budgetary impacts.

An evaluation of the influence of budgeting process on budget performance in Malaysia

PurposeThe purpose of this paper is to evaluate the influence of budgeting process elements (budget participation, preparation, implementation and evaluation) on budget performance of government.Design/methodology/approachA cross-sectional survey was administered among budget officers from government agencies, departments, and units in Malaysia. Descriptive and regression analyses were used to examine the relationship between the budgeting process and budget performance.FindingsThe findings revealed the significant influence of the two predictors: (1) budget participation and (2) budget implementation and evaluation, on budget performance. Both have positive and significant impacts on budget performance. However, budget preparation appeared to have no significant relationship with budget performance, although there is positive effect.Originality/valueThis study provides empirical evidence on the budgeting process factors that influence budget performance. The findings hopefully are of interest to government officials, especially frontline bureaucrats, who seek to ensure that budget performance meets expectations in Malaysia and other countries.