As shown in Fig the proportion of the

As shown in Fig. 1, the proportion of the state budget spent on health care increased by 50% from 14.1% to 21.3% over the study period. The largest part of this spending was for Medicaid and other medical benefit payments, 77% of the total in FY2014. Other significant components were for prison healthcare (9.7%), state hospitals (6.6%) and retiree dental benefits (6.4%). Some potentially important components of healthcare spending, such as retiree health benefits, could not be separately identified in the budget. Per capita healthcare spending rapidly increased from $330 in FY1990 to about equal other social spending at $613 in FY2014.
Discussion Given the shifting emphasis away from social spending and public health, one might expect that health outcomes have worsened, at least relative to what they might have otherwise have been. And indeed, evidence suggests that, not only does the US lag other countries in life expectancy despite greater national wealth (National Research Council & Institute of Medicine, 2013), but that increases in life expectancy in the US have been both slow and uneven in recent decades (Chetty et al., 2016). From 1985 to 2010, life expectancy increased by only 3.9 years in the United States, substantially less than the average increase in other developed countries, which was 6.2 years during this time (Organisation for Economic Co-operation & Development, 2016). California beat the US national average, achieving a 5.3 year increase (Institute for Health Metrics and Evaluation, 1985–2010), but this was still nearly a full year less than the average of peer countries. (Only one state--New York--achieved an average increase in life expectancy on par with peer countries). All in all, the evidence suggests that both in California and in the US as a whole, health outcomes have deteriorated relative to what they could have been during this period. Some have argued that resources for healthcare and other social spending originate from distinct sources, and that it FMK makes no sense to compare spending across categories. Yet, as Emanuel and Fuchs (2008) have argued, such claims are misperceptions that distort important policy discussions (Emanuel & Fuchs, 2008). Governments pay for increases in healthcare costs by taxing, borrowing, or, most commonly, reducing services from other sectors (Emanuel & Fuchs, 2008; Fossett & Burke, 2004). This analysis shows that in California, public health and other non-medical social spending declined as healthcare spending increased, and no surprise: a persistent reluctance to raise taxes, even in a state government controlled entirely by Democrats, imposes a firm cap on total expenditures. Increasing medical spending also creates challenging political constraints. In 2009 Republicans complained that there had been a 40% increase in state funding in the previous 6 years, and rhetorically asked voters what they had to show for it (Devore, 2009). The number itself was wildly off, but their sophistry contained a kernel of truth: voters were being asked to pay more for medical care for poor people, current and retired state employees, and those in long-term care facilities. Given that Medi-Cal enrollment was flat over this period, the cost increases were almost entirely attributable to increasing cost of service, not greater coverage: most voters could not see the benefits (Tatum, 2014). Yet while economists debate how much, if any, medical benefit is purchased with each annual increase in expenditures, this much is clear: population health is not improving as fast as it could. During the period analyzed here, 1990–2014, US performance in life expectancy worsened relative to other OECD countries. In 1990, US life expectancy at birth (75.3) was in the broad middle of the pack (Organisation for Economic Co-operation and Development, 2016). US life expectancy (76.7) had fallen to the bottom quartile by 2000, continued to fall in ranking through 2014 (78.9), and fell by 0.1 years the following year (Organisation for Economic Co-operation and Development, 2016; Xu, Murphy, Kochanek, & Arias, 2016).