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This paper exploits the staggered adoption of major concurrent health reforms in countries in Europe and Central Asia after 1990 to estimate their impact on public health expenditure, utilization, and avoidable deaths. While the health systems all derived from the same paradigm under central planning, they have since introduced changes to policies regarding cost-sharing, provider payment, financing, and the rationalization of hospital infrastructure. Social health insurance is predicted to increase this share, although the leads of both social health insurance and primary care fee-for-service suggest endogeneity may be an issue with the outpatient share regressions. Provider payment reforms produce the largest impact on spending, with fee-for-service increasing spending and patient-based payment reducing it. The impact on avoidable deaths is generally negligible, but there is some evidence of improvements due to fee-for-service. Considering the corresponding relative reduction in inpatient admissions and the incentives fee-for-service provides to deliver additional services, perhaps there is an overprovision of services in the primary care setting and an underutilization of more specialized hospital services.

Health care reform --- Health care reorm --- Health planning --- Medical policy --- Comprehensive health planning --- Health care planning --- Health services planning --- Medical care --- Medical care planning --- Public health --- Planning --- Health services administration --- Health reform --- Health system reform --- Healthcare reform --- Medical care reform --- Reform of health care delivery --- Reform of medical care delivery --- Health insurance --- Health care policy --- Health policy --- Medicine and state --- Policy, Medical --- Public health policy --- State and medicine --- Science and state --- Social policy --- Government policy --- Insurance --- Personal Finance -Taxation --- Public Finance --- National Government Expenditures and Health --- National Government Expenditures and Related Policies: General --- Personal Income and Other Nonbusiness Taxes and Subsidies --- Insurance Companies --- Actuarial Studies --- Health: General --- Public finance & taxation --- Insurance & actuarial studies --- Health economics --- Health care spending --- Expenditure --- Tax allowances --- Health --- Expenditures, Public --- Income tax --- Czech Republic

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Government spending on health has grown as a percent of GDP over the last 40 years in industrialized countries. Widespread decentralization of healthcare systems has often accompanied this increase in spending. In this paper, we explore the effect of soft budget constraints on subnational health spending in a sample of OECD countries. We find countries where subnational governments rely primarily on central government financing and enjoy large borrowing autonomy have higher healthcare spending than those with more restrictions on subnational government borrowing.