Earmarks and the public health system

The Health Resources and Services Administration is a critical funder of health care and public health activity. Between fiscal years 1999 and 2012, HRSA awarded over 85,000 grants and $95 billion (constant 2012 dollars). Historically, these grants have both been competitively awarded and non-competitively awarded, e.g., through earmarks. The question of political influence in federal grant-making has been of interest to scholars and policymakers for decades, but rarely has this interest been examined systematically, or quantitatively, in public health. To better characterize political influence, we constructed a county-based dataset over; we geocoded HRSA grantee data and constructed measures of policymaker influence and seniority, by county, for each of those years. For FYs 2005 and 2008-2010 (where earmark data were tracked uniformly by the Office of Management and Budget), political influence yielded sizable earmarks: $633 million among 483 counties in FY05, $406 million among 492 counties in FY08, $378 million among 493 counties in FY09, and $407 million among 438 counties in FY10 (all in constant 2012 dollars). This represents 5% of total HRSA grants during that time period. An analysis of 3,143 counties in FY05 & FY08-10 indicated counties received an average of $1.72 per capita in FY05, $1.47 in FY08, $1.37 in FY09, and $1.60 in FY10. Each committee chairship by a representative increased a county's earmark total by $1.60 per capita earmark (p=.004), and being on the appropriations committee increased earmarks 80 cents per capita. This project is among the first to characterize political influence on public health expenditures.