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The Medicaid expansions made addiction treatment more accessible but they also made it less costly to obtain the prescription opioids that can trigger an addiction. We investigated the association between the Medicaid expansions and drug-related deaths. We add to the literature by explicitly accounting for the properties of illicit drug markets and by conducting a simulation-based power analysis to assess whether a plausible change in drug-related mortality could be detected with our data. We identify three main challenges in isolating the effect of the Medicaid expansions on drug-related mortality that cannot be sufficiently addressed with current data: (a) nonparallel preexpansion trends in drug-related mortality, (b) the contemporaneous surge in the supply of illicitly manufactured fentanyl, and (c) lack of statistical power. We argue that more comprehensive data are needed to answer this question.

Birth defects are a leading cause of infant mortality in the United States, accounting for 20.6% of infant deaths in 2017 (1). Rates of infant mortality attributable to birth defects (IMBD) have generally declined since the 1970s (1-3). U.S. linked birth/infant death data from 2003-2017 were used to assess trends in IMBD. Overall, rates declined 10% during 2003-2017, but decreases varied by maternal and infant characteristics. During 2003-2017, IMBD rates decreased 4% for infants of Hispanic mothers, 11% for infants of non-Hispanic black (black) mothers, and 12% for infants of non-Hispanic white (white) mothers. In 2017, these rates were highest among infants of black mothers (13.3 per 10,000 live births) and were lowest among infants of white mothers (9.9). During 2003-2017, IMBD rates for infants who were born extremely preterm (20-27 completed gestational weeks), full term (39-40 weeks), and late term/postterm (41-44 weeks) declined 20%-29%; rates for moderate (32-33 weeks) and late preterm (34-36 weeks) infants increased 17%. Continued tracking of IMBD rates can help identify areas where efforts to reduce IMBD are needed, such as among infants born to black and Hispanic mothers and those born moderate and late preterm (32-36 weeks).

Over the past decade, rising youth use of e-cigarettes and other electronic nicotine delivery systems (ENDS) has prompted aggressive regulation by state and local governments. Between 2010 and 2019, ten states and two large counties adopted ENDS taxes. Applying a continuous treatment difference-in-differences approach to data from two large national datasets (Monitoring the Future and the Youth Risk Behavior Surveillance System), this study explores the impact of ENDS taxes on youth tobacco use. We find that ENDS taxes reduce youth e-cigarette consumption, with estimated e-cigarette tax elasticities of -0.06 to -0.21. However, we estimate sizable positive cigarette cross-tax elasticities, suggesting economic substitution between cigarettes and e-cigarettes for youth. These substitution effects are particularly large for frequent cigarette smoking. We conclude that the unintended effects of ENDS taxation may more than fully offset any public health gains.

We study the effect of state recreational marijuana laws (RMLs) on workers’ compensation (WC) benefit receipt among adults 40-62 years. We find that WC receipt declines in response to RML adoption both in terms of the propensity to receive benefits and benefit amount. We estimate complementary declines in non-traumatic workplace injury rates and the incidence of work-limiting disabilities. We offer evidence that the primary driver of these reductions is an improvement in work capacity, likely due to access to an additional form of pain management therapy.

As the opioid crisis has escalated, states have enacted numerous policies targeting opioid access and monitoring possible misuse. Recently, the majority of states have passed electronic prescribing mandates for controlled substances. These mandates require that controlled substances be prescribed electronically directly to the pharmacy. The electronic system maintains a rich patient history that prescribers will observe when issuing a prescription while also reducing opportunities for fraud. The first enforced mandate was implemented in New York in March 2016; thus empirical evidence about the effects of such mandates is limited. We study how adoption of the New York e-prescribing mandate affected opioid supply and opioid-related overdoses. We estimate that the mandate reduced the rate of overdoses involving natural and semi-synthetic opioids by 22 %. We find little evidence of any corresponding changes in overdose rates involving illicit opioids.

Since 2010, the Food and Drug Administration has contracted with states to perform random checks of tobacco retailers to identify illegal sales to youths. We test whether the inspections affect youth access and smoking for boys and girls. Using the 2010–13 Monitoring the Future survey and data on the number and location of inspections in the first several years of the program, we find the checks have been successful at limiting access to cigarettes in small retail establishments. As for reducing smoking, we observe reductions only among girls. Boys continue to smoke with about the same incidence and intensity as before the inspections. The likely reason for this is that girls are generally more successful at purchasing illicit products at retail establishments while underage. Therefore, enforcing the minimum legal age laws for purchasing tobacco products likely curtails the access of girls to the illegal product.

Importance In 2011, critical congenital heart disease was added to the US Recommended Uniform Screening Panel for newborns, but whether state implementation of screening policies has been associated with infant death rates is unknown. Objective To assess whether there was an association between implementation of state newborn screening policies for critical congenital heart disease and infant death rates. Design, Setting, and Participants Observational study with group-level analyses. A difference-in-differences analysis was conducted using the National Center for Health Statistics’ period linked birth/infant death data set files for 2007-2013 for 26 546 503 US births through June 30, 2013, aggregated by month and state of birth. Exposures State policies were classified as mandatory or nonmandatory (including voluntary policies and mandates that were not yet implemented). As of June 1, 2013, 8 states had implemented mandatory screening policies, 5 states had voluntary screening policies, and 9 states had adopted but not yet implemented mandates. Main Outcomes and Measures Numbers of early infant deaths (between 24 hours and 6 months of age) coded for critical congenital heart disease or other/unspecified congenital cardiac causes for each state-month birth cohort. Results Between 2007 and 2013, there were 2734 deaths due to critical congenital heart disease and 3967 deaths due to other/unspecified causes. Critical congenital heart disease death rates in states with mandatory screening policies were 8.0 (95% CI, 5.4-10.6) per 100 000 births (n = 37) in 2007 and 6.4 (95% CI, 2.9-9.9) per 100 000 births (n = 13) in 2013 (for births by the end of June); for other/unspecified cardiac causes, death rates were 11.7 (95% CI, 8.6-14.8) per 100 000 births in 2007 (n = 54) and 10.3 (95% CI, 5.9-14.8) per 100 000 births (n = 21) in 2013. Early infant deaths from critical congenital heart disease through December 31, 2013, decreased by 33.4% (95% CI, 10.6%-50.3%), with an absolute decline of 3.9 (95% CI, 3.6-4.1) deaths per 100 000 births after states implemented mandatory screening compared with prior periods and states without screening policies. Early infant deaths from other/unspecified cardiac causes declined by 21.4% (95% CI, 6.9%-33.7%), with an absolute decline of 3.5 (95% CI, 3.2-3.8) deaths per 100 000 births. No significant decrease was associated with nonmandatory screening policies. Conclusions and Relevance Statewide implementation of mandatory policies for newborn screening for critical congenital heart disease was associated with a significant decrease in infant cardiac deaths between 2007 and 2013 compared with states without these policies.

We use the universe of birth records in the United States from 2013 to 2018 to examine the effect of e-cigarette tax rates on pre-pregnancy smoking and prenatal smoking. We study these questions using two-way fixed effects models and pregnancy fixed effects models. We show that e-cigarette taxes increase pre-pregnancy smoking, increase prenatal smoking, and lower smoking cessation during pregnancy. These findings imply that e-cigarettes and traditional cigarettes are substitutes among pregnant women. We also find evidence that e-cigarette taxes reduce pre-pregnancy and third trimester e-cigarette use.

Importance Given high rates of opioid-related fatal overdoses, improving naloxone access has become a priority. States have implemented different types of naloxone access laws (NALs) and there is controversy over which of these policies, if any, can curb overdose deaths. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses. Objectives To identify which types of NALs, if any, are associated with reductions in fatal overdoses involving opioids and examine possible implications for nonfatal overdoses. Design, Setting, and Participants State-level changes in both fatal and nonfatal overdoses from 2005 to 2016 were examined across the 50 states and the District of Columbia after adoption of NALs using a difference-in-differences approach while estimating the magnitude of the association for each year relative to time of adoption. Policy environments across full state populations were represented in the primary data set. The association for 3 types of NALs was associated: NALs providing direct authority to pharmacists to prescribe, NALs providing indirect authority to prescribe, and other NALs. The study was conducted from January 2017 to January 2019. Exposures Fatal and nonfatal overdoses in states that adopted NAL laws were compared with those in states that did not adopt NAL laws. Further consideration was given to the type of NAL passed in terms of its association with these outcomes. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses. Main Outcomes and Measures Fatal overdoses involving opioids were the primary outcome. Secondary outcomes were nonfatal overdoses resulting in emergency department visits and Medicaid naloxone prescriptions. Results In this evaluation of the dispensing of naloxone across the United States, NALs granting direct authority to pharmacists were associated with significant reductions in fatal overdoses, but they may also increase nonfatal overdoses seen in emergency department visits. The effect sizes for fatal overdoses grew over time relative to adoption of the NALs. These policies were estimated to reduce opioid-rated fatal overdoses by 0.387 (95% CI, 0.119-0.656;P = .007) per 100 000 people in 3 or more years after adoption. There was little evidence of an association for indirect authority to dispense (increase by 0.121; 95% CI, −0.014 to 0.257;P = .09) and other NALs (increase by 0.094; 95% CI, −0.040 to 0.227;P = .17). Conclusions and Relevance Although many states have passed some type of law affecting naloxone availability, only laws allowing direct dispensing by pharmacists appear to be useful. Communities in which access to naloxone is improved should prepare for increases in nonfatal overdoses and link these individuals to effective treatment.

Objectives We assessed the impact of varying levels of smokefree regulations on birth outcomes and prenatal smoking. Methods We exploited variations in timing and regulation restrictiveness of West Virginia's county smokefree regulations to assess their impact on birthweight, gestational age, low birthweight, very low birthweight, preterm birth, and prenatal smoking. We conducted regression analysis using state Vital Statistics individual-level data for singletons born to West Virginia residents between 1995-2010 (N = 293,715). Results Only more comprehensive smokefree regulations were associated with statistically significant favorable effects on birth outcomes in the full sample: Comprehensive (workplace/restaurant/bar ban) demonstrated increased birthweight (29 grams, p

Research summary: Shareholder activism has become more widespread, yet the role of corporate governance as antecedent to shareholder activism remains equivocal. We propose a new conceptual model that characterizes the stochastic of observable shareholder activism as a compound product of two latent components representing (1) shareholder activists' propensity to target a company and (2) executives' propensity to settle activists' demands privately. Our model explicitly decouples corporate governance expectations for the two latent components embedded in activism process, and thus allows us to relax assumptions of homogenous shareholder interests and constrained managerial discretion where corporate managers are expected to negotiate privately and settle only value-creating activist demands. Bayesian analysis of zero-inflated Poisson regression reveals that corporate governance relationships with activism vary across shareholder demands and private settlements. Managerial summary: Increasing shareholder activism has generated debates as to whether activism promotes managerial accountability and responsibility or instead encourages managerial short-termism. Our research model allows for heterogeneous interests among a company's shareholders. We theorize and empirically investigate a broader role of corporate governance: governance mechanisms need to ensure that executives are not (1) ignoring activists' value-increasing demands or (2) accommodating activists' value-decreasing demands in a private, opaque manner that disenfranchises other shareholders. Our results indicate that corporate governance implications differ for visible shareholder demands in contrast with private activism. A plausible application of our model is that it provides estimates of the probability of the numbers of shareholder demands to be received by a firm and the probability of privately settling a demand. Copyright © 2015 John Wiley & Sons, Ltd.

Screening newborns for critical congenital heart disease (CCHD) using pulse oximetry is recommended to allow for the prompt diagnosis and prevention of life-threatening crises. The present review summarizes and critiques six previously published estimates of the costs or cost-effectiveness of CCHD screening from the United Kingdom, United States, and China. Several elements that affect CCHD screening costs were assessed in varying numbers of studies, including screening staff time, instrumentation, and consumables, as well as costs of diagnosis and treatment. A previous US study that used conservative assumptions suggested that CCHD screening is likely to be considered cost-effective from the healthcare sector perspective. Newly available estimates of avoided infant CCHD deaths in several US states that implemented mandatory CCHD screening policies during 2011-2013 suggest a substantially larger reduction in deaths than was projected in the previous US cost-effectiveness analysis. Taking into account these new estimates, we estimate that cost per life-year gained could be as low as USD 12,000. However, that estimate does not take into account future costs of health care and education for surviving children with CCHD nor the costs incurred by health departments to support and monitor CCHD screening policies and programs.

Following Flint’s switching from the Detroit Water Authority to the Flint River as the source of its tap water, we show, using birth records, that there were lower average birthweights and higher incidence of low birthweight (

Background Several countries and many U.S. states have allowed, for cannabis to be used as therapy to treat chronic conditions or pain., This has increased the use of cannabis, particularly among older people.Because cannabis has been linked to adverse cardiac events in the medical literature, there may be unintended consequences on increased use among older people. Methods We analyze cardiac-related mortality data from the U.S. National Vital Statistics System for 1990–2014. We use difference-in-difference fixed-effects models to assess whether there are increased rates of cardiac-related mortality following passage of medical cannabis programs. We also analyze whether states with more liberal rules on dispensing cannabis show higher mortality rates. Results For men, there is a statistically significant 2.3% increase in the rate of cardiac death following passage. For women, there is a 1.3% increase that is also statistically significant. he effects increase or both men and women with age. The effects are also stronger in states with more a lax approach to cannabis dispensing. Conclusion Policymakers should be aware of a potential unintended consequence of allowing broader use of cannabis, specifically for those more at risk of cardiovascular events.

Since 2007, many states passed laws prohibiting text messaging while driving. Using vehicular fatality data from across the United States and standard difference-in-differences techniques, bans appear moderately successful at reducing single-vehicle, single-occupant accidents if bans are universally applied and enforced as a primary offense. Bans enforced as secondary offenses, however, have at best no effect on accidents. Any reduction in accidents following texting bans is short-lived, however, with accidents returning to near former levels within a few months. This is suggestive of drivers reacting to the announcement of the legislation only to return to old habits shortly afterward. (JEL D12, K42, R41)

Many states have banned electronic cigarette sales to minors under the rationale that using e-cigarettes leads to smoking traditional combustion cigarettes. Such sales bans would be counterproductive, however, if e-cigarettes and traditional cigarettes are substitutes, as bans might push teenagers back to smoking the more dangerous combustion cigarettes. We provide evidence that these sales bans reduce the incidence of smoking conventional cigarettes among high school seniors. Moreover, we provide evidence suggesting that sales bans reduced e-cigarette usage as well. This evidence suggests that not only are e-cigarettes and smoking regular cigarettes positively related and not substitutes for young people, banning retail sales to minors is an effective policy tool in reducing tobacco use.

Importance In 2011, critical congenital heart disease was added to the US Recommended Uniform Screening Panel for newborns, but whether state implementation of screening policies has been associated with infant death rates is unknown. Objective To assess whether there was an association between implementation of state newborn screening policies for critical congenital heart disease and infant death rates. Design, Setting, and Participants Observational study with group-level analyses. A difference-in-differences analysis was conducted using the National Center for Health Statistics’ period linked birth/infant death data set files for 2007-2013 for 26 546 503 US births through June 30, 2013, aggregated by month and state of birth. Exposures State policies were classified as mandatory or nonmandatory (including voluntary policies and mandates that were not yet implemented). As of June 1, 2013, 8 states had implemented mandatory screening policies, 5 states had voluntary screening policies, and 9 states had adopted but not yet implemented mandates. Main Outcomes and Measures Numbers of early infant deaths (between 24 hours and 6 months of age) coded for critical congenital heart disease or other/unspecified congenital cardiac causes for each state-month birth cohort. Results Between 2007 and 2013, there were 2734 deaths due to critical congenital heart disease and 3967 deaths due to other/unspecified causes. Critical congenital heart disease death rates in states with mandatory screening policies were 8.0 (95% CI, 5.4-10.6) per 100 000 births (n = 37) in 2007 and 6.4 (95% CI, 2.9-9.9) per 100 000 births (n = 13) in 2013 (for births by the end of June); for other/unspecified cardiac causes, death rates were 11.7 (95% CI, 8.6-14.8) per 100 000 births in 2007 (n = 54) and 10.3 (95% CI, 5.9-14.8) per 100 000 births (n = 21) in 2013. Early infant deaths from critical congenital heart disease through December 31, 2013, decreased by 33.4% (95% CI, 10.6%-50.3%), with an absolute decline of 3.9 (95% CI, 3.6-4.1) deaths per 100 000 births after states implemented mandatory screening compared with prior periods and states without screening policies. Early infant deaths from other/unspecified cardiac causes declined by 21.4% (95% CI, 6.9%-33.7%), with an absolute decline of 3.5 (95% CI, 3.2-3.8) deaths per 100 000 births. No significant decrease was associated with nonmandatory screening policies. Conclusions and Relevance Statewide implementation of mandatory policies for newborn screening for critical congenital heart disease was associated with a significant decrease in infant cardiac deaths between 2007 and 2013 compared with states without these policies.

This paper examines the antecedents of shareholder activism using a novel methodological approach that enables researchers to relax conventional, limiting assumptions about shareholder activism. We...