Local Government Expenditure Centralization And Spatial Variation In Working-Age Mortality
OFH Contributors
Key Takeaways
Counties with more centralized local government spending—where county governments perform a larger share of total expenditures—show less spatial variation in working-age mortality across census tracts compared with counties with decentralized spending.
The reduction in place-based inequalities in mortality is most pronounced for midlife age groups (35–44 and 45–54), suggesting that fiscal structure, not just spending amounts, shapes health disparities within counties.
These findings support the idea that how public funds are organized and deployed locally, beyond how much is spent, may influence “place-based” health disparities in the U.S. context.
Executive Summary
Introduction
Population health varies sharply across small geographic areas in the United States, with working-age mortality rates differing markedly between neighboring neighborhoods. Prior research has linked differences in subnational spending to variations in average health outcomes across jurisdictions. However, much of the variation in health occurs within counties, raising the question of whether the structure of local government finance—and not just spending levels—shapes spatial inequality in mortality. This study examines whether the centralization of local government expenditures—that is, the extent to which county governments rather than myriad cities, towns, and districts perform local spending—is associated with within-county variation in working-age mortality between census tracts.
Main Findings
- Counties where a higher proportion of total local government spending is handled by the county government exhibit less spatial variation in mortality rates across census tracts than less centralized counties.
- After adjusting for overall spending amounts and demographic controls, this negative association remains strongest among those aged 35–44 and 45–54—indicating that centralized fiscal structures may yield more uniform health outcomes within counties for these age groups.
- The reduction in spatial variation appears tied to structural characteristics of fiscal governance rather than the total level of expenditures, suggesting that where and how spending authority is vested locally matters for geographic health disparities
Conclusion
This study highlights that the organization of local public finance—specifically, the concentration of spending authority at the county level—is associated with narrower mortality disparities across neighborhoods. These results underscore that local government structure, in addition to the amount spent on services, can influence place-based health inequalities. Policies aimed at reducing spatial health disparities may therefore benefit from considering the fiscal architecture of local governments, not simply aggregate funding levels.