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This study explores the effect of in-person schooling on youth suicide in the United States. We show that youth suicide rates historically declined during summers and rose again earlier in counties with an August school starting date. We document a departure from this pattern at the onset of the COVID-19 pandemic: youth suicides fell 25 percent in March 2020, when schools closed, and remained low throughout summer. Leveraging county variation in the timing of reopening, we find that returning to in-person instruction increased youth suicides by 12–18 percent. Analysis of Google search data suggests that bullying is a likely mechanism. [ABSTRACT FROM AUTHOR]

We evaluate the impact of paid sick leave (PSL) mandates on PSL coverage, work absences, and presenteeism (that is, attending work while sick) for private-sector workers in the United States. Our identification strategy relies on geographic and temporal variation in mandate enactment, as well as within-county variation in the propensity to gain PSL following a mandate. We find that PSL mandates increase coverage rates and work absences for those most likely to gain coverage, and these effects are larger for women and households with children. We also provide evidence that PSL mandates reduce the rate of presenteeism. [ABSTRACT FROM AUTHOR]

Vaccination represents a canonical example of externalities in economics, yet there are few estimates of their magnitudes. I estimate social and externality benefits of influenza vaccination in two settings. First, using a natural experiment, I estimate the impacts of aggregate vaccination rates on mortality and work absences in the United States. Second, I examine a setting with large potential externality benefits: vaccination mandates for healthcare workers. I find that the social benefits of vaccination are substantial, most of benefits operate through an externality, and the benefits of healthcare worker vaccination are particularly large. [ABSTRACT FROM AUTHOR]

In this article, we present data from the monthly Pandemic Food and Stigma Survey (PFSS), a nationwide representative sample of adults in the United States designed to identify how the pandemic is affecting concerns about food and the environment. Two surveys were conducted in May and June 2020. Our analysis suggests that the public's concern about contracting COVID-19 has been high; however, infection with COVID-19 was not the only concern. A majority of respondents remained strongly concerned about environmental issues, such as climate change, while responses to sudden relaxations of environmental and food safety policies varied. We analyze the PFSS data to identify factors associated with concerns about pandemic and environmental regulatory changes. In general, we find that people whose food security has been threatened by COVID-19 remain concerned about relaxation of environmental regulations, and those most inclined to take steps to reduce spread of the virus, such as wearing masks and social distancing, are more concerned about relaxed regulations than those less willing to take mitigating actions. [ABSTRACT FROM AUTHOR]

The priority aim of this study is to investigate the effect of carbon footprint, which is an indicator of environmental degradation, on health expenditures for the USA. In the study, cointegration analysis was performed for the period 1970–2016 by using health expenditures, carbon footprint, gross domestic product per capita and life expectancy at birth variables. According to the results of standard cointegration analysis, only cointegration relationship between health expenditures and income was found. In the models with carbon footprint, no cointegration relationship was discovered between the original values of the variables. This result was approached with suspicion, and it was thought that there might be a hidden cointegration between healthcare expenditures and carbon footprint. For this purpose, the hidden cointegration analysis and crouching error correction model proposed by Granger and Yoon [18] were employed among the positive and negative components of the variables of healthcare expenditures and carbon footprint. The results of the hidden cointegration analysis revealed that there was a hidden cointegration relationship between the positive components of healthcare expenditures and the positive components of carbon footprint. Analysis results show that a 1% increase in carbon footprint will cause a 2.04% increase in healthcare expenditures in the long term in the USA. When the positive components of the variables were considered, it was concluded that there was a one-way long-term asymmetric causality relationship between carbon footprint and healthcare expenditures. As a result of the study, it was proposed that the carbon footprint should be diminished to prevent the increasing burden of the healthcare expenditures on the budget. [ABSTRACT FROM AUTHOR]

Household-level food insecurity is one of the largest public health concerns facing millions of people in the United States today. Although recent work has highlighted gaps in food security rates between minority and non-Hispanic white households, little is known about how these households evolve through the overall distribution of food security over time. As such, we employ nonparametric estimators of distributional mobility to household-level data on food security from the Early Childhood Longitudinal Survey, Kindergarten Class of 1998–1999 study. Results suggest that Hispanic and non-Hispanic white households with children are equally mobile in the long run whereas non-Hispanic black households with children tend to be less upwardly mobile and more downwardly mobile in food security status over time. [ABSTRACT FROM AUTHOR]

The recession that started in the United States in December 2007 has had a significant impact on the Spanish economy through a large increase in the unemployment rate and a long recession which led to tough austerity measures imposed on public finances. Taking advantage of this quasi-natural experiment, we use data from the Spanish Ministry of Health from 1996 to 2015 to provide novel causal evidence on the short-term impact of changes in healthcare provision and regulations on health outcomes. The fact that regional governments have discretionary powers in deciding healthcare budgets and that austerity measures have not been implemented uniformly across Spain helps isolate the impact of these policy changes on health indicators of the Spanish population. Using Ruhm's (Q J Econ 115(2):617-650, 2000) fixed effects model, we find that medical staff and hospital bed reductions account for a significant increase in mortality rates from circulatory diseases and external causes, but not from other causes of death. Similarly, mortality rates do not seem to be robustly affected by the 2012 changes in retirees' pharmaceutical co-payments and access restrictions for illegal immigrants. Our results are robust to changes in model specification and sample selection and are primarily driven by accidental and emergency deaths rather than in-hospital mortality, which suggests a larger role for decreases in accessibility rather than decreases in healthcare quality as impact channels. [ABSTRACT FROM AUTHOR]

We develop a method for comparing levels and trends in inequality in mortality in the United States and France between 1990 and 2010 in a similar framework. The comparison shows that while income inequality has increased in both the United States and France, inequality in mortality in France remained remarkably low and stable. In the United States, inequality in mortality increased for older groups (especially women) while it decreased for children and young adults. These patterns highlight the fact that despite the strong cross-sectional relationship between income and health, there is no necessary connection between changes in income inequality and changes in health inequality. [ABSTRACT FROM AUTHOR]

Aim: To investigate hepatitis A-related healthcare resource use and costs in the US., Methods: The Merative Marketscan Commercial Claims and Encounters database was retrospectively analyzed for hepatitis A-related inpatient, outpatient, and emergency department (ED) claims from January 1, 2012 to December 31, 2018. We calculated the hepatitis A incidence proportion per 100,000 enrollees, healthcare resource utilization, and costs (in 2020 USD). Results were stratified by age, gender, and select comorbidities., Results: The overall hepatitis A incidence proportion was 6.1 per 100,000 enrollees. Among individuals with ≥1 hepatitis A-related claim, the majority (92.6%) had ≥1 outpatient visit related to hepatitis A; 9.1% were hospitalized and 4.2% had ≥1 ED visit. The mean (standard deviation [SD]) length of hospital stay was 5.2 (8.1) days; the mean (SD) number of outpatient and ED visits were 1.3 (1.3) and 1.1 (0.6), respectively. The incidence proportion per 100,000 was higher among adults than children (7.5 vs. 1.5), individuals with HIV than those without (126.7 vs. 5.9), and individuals with chronic liver disease than those without (143.6 vs. 3.8). The total mean (SD)/median (interquartile range, IQR) per-patient cost for hepatitis A-related care was $2,520 ($10,899)/$156 ($74-$529) and the mean cost of hospitalization was 18.7 times higher than that of outpatient care ($17,373 vs. $928)., Limitations: The study data included only a commercially insured population and may not be representative of all individuals., Conclusions: In conclusion, hepatitis A is associated with a substantial economic burden among privately insured individuals in the US.

Aims: To assess US payers' per-patient cost of testing associated with next-generation sequencing (NGS) versus polymerase chain reaction (PCR) biomarker testing strategies among patients with metastatic non-small cell lung cancer (mNSCLC), including costs of testing, delayed care, and suboptimal treatment initiation., Methods: A decision tree model considered biomarker testing for genomic alterations using either NGS, sequential PCR testing, or hotspot panel PCR testing. Literature-based model inputs included time-to-test results, costs for testing/medical care, costs of delaying care, costs of immunotherapy [IO]/chemotherapy [CTX] initiation prior to receiving test results, and costs of suboptimal treatment initiation after test results (i.e. costs of first-line IO/CTX in patients with actionable mutations that were undetected by PCR that would have been identified with NGS). The proportion of patients testing positive for a targetable alteration, time to appropriate therapy initiation, and per-patient costs were estimated for NGS and PCR strategies combined., Results: In a modeled cohort of 1,000,000 members (25% Medicare, 75% commercial), an estimated 1,119 had mNSCLC and received testing. The proportion of patients testing positive for a targetable alteration was 45.9% for NGS and 40.0% for PCR testing. Mean per-patient costs were lowest for NGS ($8,866) compared to PCR ($18,246), with lower delayed care costs of $1,301 for NGS compared to $3,228 for PCR, and lower costs of IO/CTX initiation prior to receiving test results (NGS: $2,298; PCR:$5,991). Cost savings, reaching $10,496,220 at the 1,000,000-member plan level, were driven by more rapid treatment with appropriate therapy for patients tested with NGS (2.1 weeks) compared to PCR strategies (5.2 weeks)., Limitations: Model inputs/assumptions were based on published literature or expert opinion., Conclusions: NGS testing was associated with greater cost savings versus PCR, driven by more rapid results, shorter time to appropriate therapy initiation, and minimized use of inappropriate therapies while awaiting and after test results.

Aim: To assess, from a United States (US) payer's perspective, the cost-effectiveness of gels designed to separate the endometrial surfaces (intrauterine spacers) placed following intrauterine surgery., Materials and Methods: A decision tree model was developed to estimate the cost-effectiveness of intrauterine spacers used to facilitate endometrial repair and prevent the formation (primary prevention) and reformation (secondary prevention) of intrauterine adhesions (IUAs) and associated pregnancy- and birth-related adverse outcomes. Event rates and costs were extrapolated from data available in the existing literature. Sensitivity analyses were conducted to corroborate the base case results., Results: In this model, using intrauterine spacers for adhesion prevention led to net cost savings for US payers of $2,905 per patient over a 3.5-year time horizon. These savings were driven by the direct benefit of preventing procedures associated with IUA formation ($2,162 net savings) and the indirect benefit of preventing pregnancy-related complications often associated with IUA formation ($3,002). These factors offset the incremental cost of intrauterine spacer use of $1,539 based on an assumed price of $1,800 and the related increase in normal deliveries of $931. Model outcomes were sensitive to the probability of preterm and normal deliveries. Budget impact analyses show overall cost savings of $19.96 per initial member within a US healthcare plan, translating to $20 million over a 5-year time horizon for a one-million-member plan., Limitations: There are no available data on the effects of intrauterine spacers or IUAs on patients' quality of life. Resultingly, the model could not evaluate patients' utility related to treatment with or without intrauterine spacers and instead focused on costs and events avoided., Conclusion: This analysis robustly demonstrated that intrauterine spacers would be cost-saving to healthcare payers, including both per-patient and per-plan member, through a reduction in IUAs and improvements to patients' pregnancy-related outcomes.

Large cross‐country variation in long‐term‐care (LTC) policy in conjunction with household‐level data on caregiving provides a valuable laboratory for policy analysis. However, there is a lack of comprehensive cross‐country data on how care is provided. In order to close this gap, we draw on data from the Survey of Health, Ageing, and Retirement in Europe (SHARE) and the Health and Retirement Study (HRS) in the United States. Because care hours are missing for some care forms (especially for nursing‐home residents), we propose a selection model to impute these. The model allows selection into care forms to differ by country. Our estimates imply that nursing‐home residents have higher care needs, even when conditioning on observed characteristics. In contrast to the bulk of the literature, we also take into account care provision from persons in the same household, and we find that this contributes one‐third of all care hours. Informal‐care provision in Europe follows a steep North–South gradient, with the United States falling in between Central European and Southern European countries. The results are robust to alternative imputation schemes. [ABSTRACT FROM AUTHOR]

Recent research has demonstrated that public regulation of private economic activity often has regressive effects. Despite those effects, poorer Americans show strong support for a variety of regulations in public opinion surveys. I use the database of survey questions from 1981 to 2002, assembled by Martin Gilens, to identify 85 questions that deal with economic regulation. Poorer Americans support regulation on most issues, and they often favor regulatory intervention more than Americans at the median or upper income levels. I also use similar questions from surveys of economists to suggest the possibility of rational irrationality on the part of low-income Americans when they disagree with economists. [ABSTRACT FROM AUTHOR]

This paper examines the impacts of the affordable care act (ACA)—which substantially increased insurance coverage through regulations, mandates, subsidies, and Medicaid expansions—on behaviors related to future health risks after 3 years. Using data from the Behavioral Risk Factor Surveillance System and an identification strategy that leverages variation in pre-ACA uninsured rates and state Medicaid expansion decisions, we show that the ACA increased preventive care utilization along several dimensions, but increased risky drinking. These results are driven by the private portions of the law, as opposed to the Medicaid expansion. We also conduct subsample analyses by income and age. [ABSTRACT FROM AUTHOR]

This paper investigates the effect of the Affordable Care Act's Medicaid expansion on the retirement decision of low-educated adults aged 55-64. I employ a difference-in-differences strategy that exploits the timing and expansion decisions of states for adults without dependent children. I find that the expansions increase Medicaid enrollment for both men and women. The estimates also suggest that the expansions result in women retiring early, whereas there is no significant change in the retirement behavior of men. These findings imply that the effect of health insurance on women's retirement decisions may depend on men's labor market responses to health insurance. [ABSTRACT FROM AUTHOR]

This study examines the relationship between healthcare expenditure and disposable income in the 50 US states over the period 1966-2009 using fractional integration and cointegration techniques. The degree of integration and nonlinearity of both series are found to vary considerably across states, while the fractional cointegration analysis suggests that a long-run relationship exists between them in only 11 out of the 50 US states. The estimated long-run income elasticity of healthcare expenditure suggests that health care is a luxury good in these states. By contrast, the short-run elasticity obtained from the regressions in first differences is in the range (0, 1) for most US states, which suggests that health care is a necessity good instead. The implications of these results for health policy are also discussed. [ABSTRACT FROM AUTHOR]

This study examines whether financial literacy can help to reduce anxiety about life in old age. We hypothesized that financially literate people are more able to earn income and accumulate assets, leading them to have a less anxious life in old age. On the other hand, less financially literate people rely more on social security to secure themselves in the old age as they are not able to accumulate sufficient assets. By using US survey data, we provide evidence that assets significantly reduce anxiety about life in old age only for people who are more financially literate. For less financially literate people, social security plays an important role in reducing anxiety about life in old age. Besides these, having a child and doing regular exercise also reduced anxiety for all respondents but marital status reduced anxiety in respondents over 40 years of age. The results of our study are robust to measurement of financial literacy and endogeneity problems. [ABSTRACT FROM AUTHOR]

This paper is the first to provide an empirical analysis of the short run and long run effects of carbon dioxide (CO 2 ) emissions on health care spending across U.S. states. Accounting for the possibility of non-linearity in the data and the relationship among the variables, the analysis estimated various statistical models to demonstrate that CO 2 emissions led to increases in health care expenditures across U.S states between 1966 and 2009. Using quantile regressions, the analysis displayed that the effect of CO 2 emissions was stronger at the upper-end of the conditional distribution of health care expenditures. Results indicate the effect of CO 2 emissions on health care was relatively stronger for states that spend higher amounts in health care expenditures. The primary policy message of the paper is that there can be tangible health related benefits associated with policies that aim to reduce carbon emissions across U.S. states. [ABSTRACT FROM AUTHOR]

I study the effect of the 1973 expansions of Medicare coverage among individuals with end-stage renal disease (ESRD) on insurance coverage, health care utilization, and mortality. I find that the expansions increased insurance coverage by between 22 and 30 percentage points, in models that include trends in age, with the increase explained by Medicare coverage, and increased physician visits by 25-35 percent. These expansions also decreased mortality due to kidney disease in the under 65 population by between 0.5 and 1.0 deaths per 100,000. Lastly, I provide evidence for two mechanisms that affected mortality: an increase in access to and use of treatment, which may be due to changes in insurance coverage; and an increase in entry of dialysis clinics and transplant programs. [ABSTRACT FROM AUTHOR]

We explore the potential causes of the unhealthy body mass index (BMI) assimilation of US immigrants to native levels. Diet — measured by fat, carbohydrate, protein, and caloric intake — and exercise have mixed success in explaining immigrants’ BMI convergence. Assimilation differs by age. Middle-aged immigrants exhibit poor behaviors consistent with unhealthy BMI gains. Worse diets may contribute to BMI increases among young immigrants who increase their intake of saturated fats. There are differences in behaviors by income, as poorer immigrants exhibit greater convergence to unhealthy native eating habits. Home country conditions influence dietary assimilation, with heterogeneity across Mexican and non-Mexican immigrants. [ABSTRACT FROM AUTHOR]

In this paper we investigate the dual role of supply restrictions and drug treatment in combating the concurrent rise of opioid abuse and suicide in the United States over the last two decades. We find that supply-side interventions decrease suicides in places with strong addiction-help networks, implying that prescription drug abuse is associated with an inherent risk of suicide. Our findings support an important role for access to treatment services in policies designed to combat the opioid epidemic. [ABSTRACT FROM AUTHOR]

Exercise is an important part of a healthy lifestyle and influences a variety of health outcomes. Regions vary in their levels of exercise due to geography, climate, culture, and policy. The extent to which a country's policies are consistent with economic freedom has been found to be positively associated with greater participation in physical activity. We empirically investigate the relationship between economic freedom and exercise across U.S. states. Contrary to the cross‐country results, we find that states with higher levels of economic freedom have lower rates of participation in exercise. [ABSTRACT FROM AUTHOR]

There is a substantial literature assessing the impact of entry restrictions created by state certificate-of-need (CON) programs on hospital and nursing home markets, but comparatively little research has focused on CON for home health agencies (HHAs). We assessed the impact of state CON programs for HHAs, and for potential substitute service providers, on quality ratings for HHAs. HHA quality ratings were obtained from the Home Health Compare database developed by the Centers for Medicare and Medicaid Services (CMS) for the last quarter of 2010 through the last quarter of 2013. The HHA-level data were augmented with county-level area characteristics for each HHA in the CMS database. An ordered logit model was used to estimate the association between state CON restrictions and Low, Medium, and High quality categories, adjusted for HHA and area characteristics. The results indicated that HHAs in states with CON for HHAs were less likely to have High quality ratings, and more likely to have Medium quality ratings, compared to agencies in states without CON for home health. Additional research is needed to assess whether the apparent adverse impact of CON on HHA quality is related to diminished competition among HHAs in states with CON. [ABSTRACT FROM AUTHOR]

Any subsidy provision for healthcare premiums, including those embedded in Affordable Care Act (ACA), has the potential to result in some couples facing an implicit penalty when married relative to unmarried. To illustrate such consequences of means-tested subsidies of health insurance premiums, we construct hypothetical households earning different levels of income who are eligible for current subsidies in the USA. and compare the estimated implicit marriage penalty faced by these households to the one faced by low-income households who are eligible for various means-tested programmes (e.g. TANF, WIC, SNAP) for each of the 48 contiguous states. We find that, like very low-income households, marriage can potentially penalize couples who receive health insurance premium subsidies by decreasing their overall disposable income by as much as 14%. We find that the ACA increases the number of households subject to marriage penalties embedded in means-tested programmes for low-income couples. This distortion will exist for any future health insurance premium subsidies that are means tested at the household income level. [ABSTRACT FROM AUTHOR]

The purpose of this article is to analyze the relation between public health and the regulations of Maximum Residue Limit (MRL) of pesticides. Many authors underline the role of trade protectionism in fixing these limits, whereas these regulations should be intended for public health protection. We first establish the link between the MRL for a given chemical in plant products and its level of toxicity. In order to perform this analysis, we cross the FAS USDA MRL database and the classification of the long-term toxicological effects (LTE) for active substances provided by SAgE pesticide. We then compute a synthetic and polyvalent tool, namely, 'Health Score,' which provides a first overview of the link between LTE and MRL by country. Then this score is regressed in a logit model in order to identify the relationship between the countries' Health Score and the socioeconomic and political characteristics of such areas. Results highlight the importance of public health expenditures in determining the settings of MRL toward stricter levels. [ABSTRACT FROM AUTHOR]

The labor market institution of occupational licensing continues to grow in scope in the United States and abroad. In this paper, we estimate the effects of occupational licensing on opticians using data from the US Census and American Community Survey. Our results suggest that optician licensing is associated with opticians receiving as much as 16.9 percent more in annual earnings. In an examination of malpractice insurance premiums in all states and participation rates in optician certification programs in Texas, we find little evidence that optician licensing has enhanced the quality of services delivered to consumers. By and large, optician licensing appears to be reducing consumer welfare by raising the earnings of opticians without enhancing the quality of services delivered to consumers. [ABSTRACT FROM AUTHOR]

To equalize differences in health plan premiums due to differences in risk pools, the German legislature introduced a simple Risk Adjustment Scheme (RAS) based on age, gender and disability status in 1994. In addition, effective 1996, consumers gained the freedom to choose among hundreds of existing health plans, across employers and state-borders. This paper (a) estimates RAS pass-through rates on premiums, financial reserves, and expenditures and assesses the overall RAS impact on market price dispersion. Moreover, it (b) characterizes health plan switchers and investigates their annual and cumulative switching rates over time. Our main findings are based on representative enrollee panel data linked to administrative RAS and health plan data. We show that sickness funds with bad risk pools and high pre-RAS premiums lowered their total premiums by 42 cents per additional euro allocated by the RAS. Consequently, post-RAS, health plan prices converged but not fully. Because switchers are more likely to be white collar, young and healthy, the new consumer choice resulted in more risk segregation and the amount of money redistributed by the RAS increased over time. [ABSTRACT FROM AUTHOR]

Many competitive health insurance markets adjust payments to participating health plans according to their enrollees' risk - including based on diagnostic information. We investigate responses of German health plans to the introduction of morbidity-based risk adjustment in the Statutory Health Insurance in 2009, which triggers payments based on "validated" diagnoses by providers. Using the regulator's data from office-based physicians, we estimate a difference-in-difference analysis of the change in the share and number of validated diagnoses for ICD codes that are inside or outside the risk adjustment but are otherwise similar. We find a differential increase in the share of validated diagnoses of 2.6 and 3.6 percentage points (3-4%) between 2008 and 2013. This increase appears to originate from both a shift from not-validated toward validated diagnoses and an increase in the number of such diagnoses. Overall, our results indicate that plans were successful in influencing physicians' coding practices in a way that could lead to higher payments. [ABSTRACT FROM AUTHOR]

Evidence on insurers' behavior in environments with both risk selection and market power is largely missing. We fill this gap by providing one of the first empirical accounts of how insurers adjust plan features when faced with potential changes in selection. Our strategy exploits a 2012 reform allowing Medicare enrollees to switch to 5-star contracts at anytime. This policy increased enrollment into 5-star contracts, but without risk selection worsening. Our findings show that this is due to 5-star plans lowering both premiums and generosity, thus becoming more appealing for most beneficiaries, but less so for those in worse health conditions. [ABSTRACT FROM AUTHOR]

A 2010 national policy change due to the Affordable Care Act allowed dependent children to remain on parental health insurance policies until age 26. Evidence shows the mandate increased insurance coverage among affected young adults and also increased premiums for family health insurance policies. In this paper, we investigate the use of dependent tax exemptions as a mechanism families could use to pay for increased costs associated with expanded coverage. Using data on households from the Medical Expenditure Panel Survey, we use a difference-in-difference methodology comparing changes in the likelihood of being claimed as a dependent on a tax return for the 19-25 year olds affected by the coverage mandate compared to 16-18 year olds that were unaffected. We find a significant increase in dependent tax exemptions among 19-25 year olds following implementation of the dependent coverage mandate. Family income gains from switching an exemption from a young adult child to the parent would shift a substantial portion of young adult insurance coverage costs (ultimately medical costs) to other taxpayers. Though we point to family health insurance cost as a likely driver of the increased dependent tax exemptions, we cannot rule out a role for other outcomes also affected by the mandate, including labor market changes among 19-25 year olds. We further compare the overall social costs and benefits of the mandate and show that absent significant health improvement to date, welfare gains likely depend on the positive contribution of young adults to insurance pools in terms of lower average costs. [ABSTRACT FROM AUTHOR]

We bring together estimates of patterns of medical spending in all nine countries considered in this issue - Canada, Denmark, England, France, Germany, Japan, the Netherlands, Taiwan and the United States. Comparing estimates across countries reveals three principal findings. First, medical spending in the calendar year of death accounts for 5-10 per cent of aggregate medical spending for the whole population and 9-20 per cent for those aged 65 and over. Spending in Taiwan is a little higher, at 16 per cent for the whole population and 29 per cent for the over-65s. Second, there is a mostly negative correlation between patient income and medical spending within all countries, except Japan and Taiwan for the over-65s and Taiwan and the US for the under-25s. Third, medical spending in all countries is concentrated in a small share of the population and is persistent over time, although the degree of concentration and persistence varies across countries. [ABSTRACT FROM AUTHOR]

Little is known about the impact of drug abuse/dependence on health insurance coverage, especially by race groups and income levels. In this study, we examine the disparities in health insurance predictors and investigate the impact of drug use (alcohol abuse/dependence, nicotine dependence, and illicit drug abuse/dependence) on lack of insurance across different race and income groups. To perform the analysis, we used insurance data (8057 uninsured and 28,590 insured individual adults) from the National Surveys on Drug Use and Health (NSDUH 2011). To analyze the likelihood of being uninsured we performed weighted binomial logistic regression analyses. The results show that the overall prevalence of lacking insurance was 19.6 %. However, race differences in lack of insurance exist, especially for Hispanics who observe the highest probability of being uninsured (38.5 %). Furthermore, we observe that the lowest income level bracket (annual income <$20,000) is associated with the highest likelihood of being uninsured (37.3 %). As the result of this investigation, we observed the following relationship between drug use and lack of insurance: alcohol abuse/dependence and nicotine dependence tend to increase the risk of lack of insurance for African Americans and whites, respectively; illicit drug use increases such risk for whites; alcohol abuse/dependence increases the likelihood of lack of insurance for the group with incomes $20,000-$49,999, whereas nicotine dependence is associated with higher probability of lack of insurance for most income groups. These findings provide some useful insights for policy makers in making decisions regarding unmet health insurance coverage. [ABSTRACT FROM AUTHOR]

Among the newest policies developed to reduce smoking and improve health are smoking bans. Using individual-level birth certificate data from the Natality Detail File between 1995 and 2009 and data on county smoking bans, we investigate the impacts of smoking bans on infant birth weight, length of gestation, 5-minute APGAR score, and cleft palate. Smoking bans are not associated with significant improvements in infant health. Instead, we find small increases in low birth weight and very low birth weight in infants born to young mothers who live in counties that adopted at least one type of ban during the study period. [ABSTRACT FROM AUTHOR]

We evaluate the effect of postnatal participation in the Women, Infants, and Children (WIC) programme on breastfeeding decisions using the data from the IFPS II. We find that the infant’s WIC participation positively affects the hazard of discontinuing breastfeeding, both partial and exclusive (and is thus associated with abbreviated breastfeeding duration). No significant association is found between the mother’s participation and the hazards of stopping exclusive or partial breastfeeding. Such differential effects might be a result of the programme’s policy, according to which the infant, but not the mother needs to be enrolled to receive free formula. [ABSTRACT FROM PUBLISHER]

In 23 states and Washington D.C., alcohol retailers are required by law to post alcohol warning signs (AWS) that warn against the risks of drinking during pregnancy. Using the variation in the adoption of these laws across states and within states over time, I find a statistically significant reduction in prenatal alcohol use associated with AWS. I then use this plausibly exogenous change in drinking behavior to establish a causal link between prenatal alcohol exposure and birth outcomes. I find that AWS laws are associated with decreases in the odds of very low birth weight and very pre-term birth. [ABSTRACT FROM AUTHOR]

This study assesses the impact of county-level public health spending on rates of sexually transmitted disease (STD) in California. Across a variety of empirical specifications, increases in own-county public health spending reduce rates of gonorrhea and syphilis. Indeed, a $1 increase in per capita public health spending reduces the gonorrhea (syphilis) rate by approximately 0.30 (0.60) percent. Spillover effects are also associated with public health spending, as increases in border-county spending reduce STD rates. To varying degrees of significance, county STD rates are also sensitive to lagged STD rates, county racial composition, whether or not a public university is located within the county, and a yearly time trend. [ABSTRACT FROM AUTHOR]

U.S. labor market estimates of the value of a statistical life (VSL) were the first revealed preference estimates of the VSL in the literature and continue to constitute the majority of such market estimates. The VSL estimates in U.S. studies consequently may have established a reference point for the estimates that researchers analyzing data from other countries are willing to report and that journals are willing to publish. This article presents the first comparison of the publication selection biases in U.S. and international estimates using a sample of 68 VSL studies with over 1000 VSL estimates throughout the world. Publication selection biases vary across the VSL distribution and are greater for the larger VSL estimates. The estimates of publication selection biases distinguish between U.S. and international studies as well as between government and non-government data sources. Empirical estimates that correct for the impact of these biases reduce the VSL estimates, particularly for studies based on international data. This pattern of publication bias effects is consistent with international studies relying on U.S. estimates as an anchor for the levels of reasonable estimates. U.S. estimates based on the Census of Fatal Occupational Injuries constitute the only major set of VSL studies for which there is no evidence of statistically significant publication selection effects. Adjusting a baseline bias-adjusted U.S. VSL estimate of $9.6 million using estimates of the income elasticity of the VSL may be a sounder approach for generating international estimates of the VSL than relying on direct estimates from international studies. [ABSTRACT FROM AUTHOR]

I provide novel evidence on the effectiveness of two vaccination policies - simple non-binding recommendations to vaccinate versus mandates requiring vaccination prior to childcare or kindergarten attendance - in the context of the only disease whose institutional features permit a credible examination of both: hepatitis A. Using provider-verified immunization data I find that recommendations significantly increased hepatitis A vaccination rates among young children by at least 20 percentage points, while mandates increase rates by another 8 percentage points. These policies also significantly reduced population hepatitis A incidence. My results suggest a range of policy options for addressing suboptimally low population vaccination rates. [ABSTRACT FROM AUTHOR]

The article explores the relationship between capita health care expenditure and disposable income series in the U.S. between 1966 and 2009. Topics discussed include the concept of the Triples Test to test the asymmetry between capita health care expenditure and disposable income series, results from the application of the Triples Test on the Center for Medicare and Medicaid Services Health Expenditures, and problems with using linear models for income and health expenditure analysis.

By providing affordable healthcare to many Americans for the first time, the Affordable Care Act increases demand for public mental health services. It is, however, unclear if states' provision standards for supply of mental health services will be able to accommodate this demand increase. Both the demand and supply of public mental health services vary within states; it is necessary to measure both locally. In this paper, we estimate the prevalence of mental illness within 30 geographical regions in the state of Virginia, a representative example of how many states organize their public mental health systems and how mental illness prevalence can be measured locally. Our methodology extends the analysis in Stern (Health Serv. Outcomes Res. Methods 14:109-155, 2014) by covering an entire state and accounting for peoples' insurance status. The latter allows us to compare estimates of demand for public mental health services among those 30 geographical regions. We find that over 66,000 uninsured and Medicaid-insured individuals in Virginia are not provided with public mental health services. The deficit varies locally, with several regions having no deficit and others having 5000 or more untreated people. We also estimate that a large portion of the unserved people with mental illness are uninsured but would be insured for mental health services through Medicaid if Virginia were to accept the Medicaid expansion associated with the Affordable Care Act. These results provide evidence that there is significant variation in the demand for and public health systems' ability to supply mental health services within states. This implies states can better serve populations relying on mental health care by allocating scarce public mental health dollars to localities reflecting their need. [ABSTRACT FROM AUTHOR]

Purpose As of 2011, the average US state had 37 health insurance benefit mandates, laws requiring health insurance plans to cover a specific treatment, condition, provider, or person. This number is a massive increase from less than one mandate per state in 1965, and the topic takes on a new significance now, when the federal government is considering many new mandates as part of the “essential health benefits” required by the Affordable Care Act. The paper aims to discuss these issues.Design/methodology/approach The authors use fixed effects estimation on 1996-2010 data to determine why some states pass more mandates than others.Findings The authors find that the political strength of health care providers is the strongest determinant of mandates.Originality/value A large body of literature has attempted to evaluate the effect of mandates on health, health insurance, and the labor market. However, previous papers did not consider the political processes behind the passage of mandates. In fact, when they estimate the laws’ effect, almost all papers on the subject assume that mandates are passed at random. The paper opens the way to estimating the causal effect of mandates on health insurance and the labor market using an instrumental variables strategy that incorporates political information about why mandates get passed. [ABSTRACT FROM AUTHOR]

The regulation of nursing homes in the U.S. often includes mandates that require a minimum nurse staffing level. In this paper, we exploit new minimum nurse staffing regulations by the states of New Mexico and Vermont that were implemented in the early 2000s to determine how nursing homes responded in terms of staffing, quality, and the decision to exit the market. Our identification strategy exploits the fact that some nursing homes had pre-regulatory staffing levels near the new requirement and did not need to change staffing levels. We compare these nursing homes to a group that faced binding constraints (low-staffed) and those that were significantly over the constraint (high-staffed). Low-staffed nursing homes increase staffing levels but also use less expensive nurse types to satisfy the new standard. High-staffed nursing homes decrease staffing and use fewer contracted staff. Overall, dispersion in staffing is reduced, but we find little effect by pre-regulatory staffing level on non-staffing measures of quality and the decision to exit the market. [ABSTRACT FROM AUTHOR]

Does tort reform reduce defensive medicine and thus healthcare spending? Several (though not all) prior studies, using a difference-in-differences (DiD) approach, find lower Medicare spending for hospital care after states adopt caps on non-economic or total damages ("damage caps"), during the "second" reform wave of the mid-1980s. We re-examine this issue in several ways. We study the nine states that adopted caps during the "third reform wave," from 2002 to 2005. We find that damage caps have no significant impact on Medicare Part A spending, but predict roughly 4% higher Medicare Part B spending. We then revisit the 1980s caps, and find no evidence of a post-adoption drop (or rise) in spending for these caps. [ABSTRACT FROM AUTHOR]

We use the Australian National Health Survey to estimate the impact of private hospital insurance on the propensity for hospitalization as a private patient. We account for the potential endogeneity of supplementary private hospital insurance purchases and calculate moral hazard based on a difference-of-means estimator. We decompose the moral hazard estimate into adiversioncomponent that is due to an insurance-induced substitution away from public patient care towards private patient care, and anexpansioncomponent that measures a pure insurance-induced increase in the propensity to seek private patient care. Our results suggest that on average, private hospital insurance causes a sizable and significant increase in the likelihood of hospital admission as a private patient. However, there is little evidence of an expansion effect; the treatment effect of private hospital insurance on private patient care is driven almost entirely by the substitution away from public patient care towards private patient care. We discuss the implications for policies that aim to expand supplementary private insurance coverage for the purpose of reducing excess demand on the public healthcare system. [ABSTRACT FROM AUTHOR]

After a brief reprieve, healthcare spending in the United States is expected to once again rise rapidly, continuing the trend of the past half-century. To inform the debate about whether policymakers should take action to contain high and rising medical care costs, we use panel data on all 50 states for the period 1993 to 2009 to estimate a healthcare spending model. Our framework, which includes a structural spending equation and a health production function, identifies the pathways through which medical technology and income affect healthcare costs and the potential health benefits they produce. We find evidence that medical technology and income are important factors fueling rising healthcare costs in the United States. However, our results also indicate they generate large health benefits in the form of lower mortality that may outweigh the costs and increase social economic welfare. [ABSTRACT FROM AUTHOR]

Since 2000 several papers have examined the efficiency of healthcare delivery systems worldwide. These papers have extended the literature using drastically different input and output combinations from one another, with little theoretical or empirical support backing these specifications. Issues arise that many of these inputs and outputs are available for a subset of OECD countries each year. Using a common estimator and the different specifications proposed leads to the result that efficiency rankings across papers can diverge quite significantly, with several countries being highly efficient in one specification and highly inefficient in another. Broad input-output measures that are collected annually provide consistent efficiency rankings across specifications, compared to specifications that utilize specific measures collected infrequently. This paper also finds that broad output measures that are not quality-adjusted, such as life expectancy, seem to be a suitable alternative for infrequently collected quality-adjusted output measures, such as disability adjusted life years. [ABSTRACT FROM AUTHOR]

In many markets, including the new U.S. Marketplaces, health insurance plans are paid by risk-adjusted capitation, sometimes combined with reinsurance and other payment mechanisms. This paper proposes a framework for evaluating the de facto insurer incentives embedded in these complex payment systems. We discuss fit, power and balance, each of which addresses a distinct market failure in health insurance. We implement empirical metrics of fit, power, and balance in a study of Marketplace payment systems. Using data similar to that used to develop the Marketplace risk adjustment scheme, we quantify tradeoffs among the three classes of incentives. We show that an essential tradeoff arises between the goals of limiting costs and limiting cream skimming because risk adjustment, which is aimed at discouraging cream-skimming, weakens cost control incentives in practice. A simple reinsurance system scores better on our measures of fit, power and balance than the risk adjustment scheme in use in the Marketplaces. [ABSTRACT FROM AUTHOR]

The food environment in the United States is complex. Sixteen socio-economic-demographic variables from various public data sources are studied with a machine learning algorithm to ascertain the causality structure associated with the food environment in the United States. High levels of unemployment and poverty are direct causes of high levels of food insecurity, while low income causes high levels of food insecurity via increased levels of poverty. Unemployment is a common cause for both increased levels of food insecurity and poverty. We find that food insecurity and participation in Supplemental Nutrition Assistance Program (SNAP) are related, yet no direct causality is observed. Contrary to past studies which find that SNAP participation decreased the occurrences of poverty, in contemporaneous time, we find that poverty and SNAP participation are related through several back-door paths, via food insecurity, unemployment, race and food taxes. Obesity and SNAP participation are indirectly related via several back-door paths, namely, race income, poverty and food insecurity and unemployment. Also, food insecurity and obesity are related by several back-door paths. Low income, high food taxes, and race (being Black and non-Hispanic) are direct causes of obesity. The complex causality structure in the US food environment reveals that policy variables cannot be treated independently of their rich causal structure. Government agencies responsible for designing policies for food assistance, poverty alleviation, combating food insecurity and obesity need to consider the interrelationships among these variables. [ABSTRACT FROM AUTHOR]

In recent decades, most states' Medicaid programs have introduced disease management programs for chronically ill beneficiaries. Interventions assist beneficiaries and their health care providers to appropriately manage chronic health condition(s) according to established clinical guidelines. Cost containment has been a key justification for the creation of these programs despite mixed evidence they actually save money. This study evaluates the effects of a disease management program in Georgia by exploiting a natural experiment that delayed the introduction of high-intensity services for several thousand beneficiaries. Expenditures for medical claims decreased an average of $89 per person per month for the high- and moderate-risk groups, but those savings were not large enough to offset the total costs of the program. Impacts varied by the intensity of interventions, over time, and across disease groups. Heterogeneous treatment effect analysis indicates that decreases in medical expenditures were largest at the most expensive tail of the distribution. [ABSTRACT FROM AUTHOR]