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Policy makers are pursuing strategies to integrate Medicare and Medicaid coverage for people enrolled in both programs, who are known as dual eligibles. Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans that exclusively serve this population, with several features intended to enhance care and facilitate integration with Medicaid. This study compared access to, use of, and satisfaction with care among dual eligibles enrolled in D-SNPs versus those enrolled in two other forms of Medicare coverage: other Medicare Advantage (MA) plans not exclusively serving dual eligibles and traditional Medicare. Compared with those in traditional Medicare, dual eligibles generally reported greater access to care, preventive service use, and satisfaction with care in D-SNPs. However, we found fewer differences in these outcomes among dual eligibles in D-SNPs versus other MA plans. Compared with non-Hispanic White dual eligibles, dual eligibles of color (for example, those identifying as Black or Hispanic) were less likely to report receiving better care in D-SNPs versus other Medicare coverage. These findings suggest that D-SNPs altogether have not provided consistently superior or more equitable care, and they highlight areas where federal and state policy could strengthen incentives for D-SNPs to improve care.

Various U.S. states and municipalities raised their mandated minimum wages between 2017 and 2019. In some areas, minimum wages became high enough to bind for more professional workers, such as lower paid staff at nursing facilities. We add to the small prior literature on the effects of minimum wages on nursing facility staffing using novel establishment-level data on daily hours worked; these data allow us to examine changes in staffing hours along margins previously unexplored in the minimum wage literature. We find no evidence that minimum wage increases reduced hours worked among lower-paid nurses in nursing facilities. In contrast, we find that increases in state and local minimum wages increased hours worked per resident day by nursing assistants; increases occurred for the average of all days throughout the month and on weekend days. We also find that a higher minimum wage increased the share of days in the month that facilities meet at least 75% of the minimum recommended levels of staffing for nursing assistants. These results lessen concerns that minimum wage hikes may reduce the quality of resident care at nursing facilities.

Because Medicare beneficiaries can qualify for Medicaid through several pathways, duals who newly enroll in Medicaid may have experienced various financial and/or health changes that impact their Medicaid eligibility. Alternatively, new enrollment could reflect changes in awareness of the program among those previously eligible. Using monthly enrollment data linked to Health and Retirement Study survey data, we examine financial and health changes that occur around the time new Medicaid participants enter the program, and we compare those with changes experienced by both those continuously enrolled in Medicaid and those not enrolled. We find that Medicaid entry is often timed with a marked increase in out-of-pocket medical expenses, a substantial decrease in assets for some, and increases in activities of daily living (ADL) limitations. We also observe financial changes among persons continuously enrolled in Medicaid. Our results inform discussions about Medicaid eligibility policies and potential gaps in the protection that Medicaid offers from financial risk.

For many low-income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out-of-pocket costs and additional benefits. We examine whether Medicaid participation by low-income adults age 65 and up increased as a result of Medicaid expansions to working-age adults under the Affordable Care Act (ACA). Previous literature documents so-called “welcome mat” effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working-age adults increased Medicaid participation among low-income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an “on-ramp” effect; that is, low-income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non-expansion states. This on-ramp effect is an important mechanism behind welcome mat effects among some older adults.

Objective To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. Data source 2010-2013 Medicare Current Beneficiary Survey. Study design Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. Principal findings Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. Conclusions Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.

Medicaid is an important source of supplemental coverage for older Medicare beneficiaries with low income. Research has shown that Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with increased Medicaid coverage for previously eligible older adults with low income, but there has been little research on whether their health care use increased or whether such changes differed by beneficiaries' health status.To assess whether the ACA Medicaid expansion to working-age adults was associated with increased Medicaid enrollment and health care use among older adults with low income with and without chronic condition limitations.This cross-sectional study used data from the National Health Interview Survey from 2010 to 2017 for adults 65 years or older with low income (≤100% of the federal poverty level). Data were analyzed from November 2020 to March 2022.Residence in a state with Medicaid expansion for working-age adults.The main outcomes were Medicaid coverage and health care use, measured by physician office visits and inpatient hospital care. Survey weights were used in calculating descriptive statistics and regression estimates. In multivariate analysis, difference-in-differences models were used to compare changes in outcomes over time between respondents in Medicaid expansion states and respondents in nonexpansion states.Of 21 859 adults included in the study, 7153 had chronic condition limitations (4983 [70.1%] female; mean [SD] age, 76.0 [0.1] years) and 14 706 did not have chronic condition limitations (9609 [66.3%] female; mean [SD] age, 74.85 [0.08] years). Of those with chronic condition limitations, 2707 (36.7%) were enrolled in Medicaid, 2816 (39.4%) had an office visit in the past 2 weeks, and 2152 (30.7%) used inpatient hospital care in the past year. Medicaid expansion was associated with differential increases in the likelihood of having Medicaid (4.92 percentage points; 95% CI, 0.25-9.60 percentage points;In this cross-sectional study, ACA Medicaid expansion for working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were dually eligible for Medicare and Medicaid.

PURPOSE To examine whether geographic information systems (GIS)-based physician-to-population ratios (PPRs) yield determinations of geographic primary care shortage areas that differ from those based on bounded-area PPRs like those used in the Health Professional Shortage Area (HPSA) designation process. METHODS We used geocoded data on primary care physician (PCP) locations and census block population counts from 1 US state to construct 2 shortage area indicators. The first is a bounded-area shortage indicator defined without GIS methods; the second is a GIS-based measure that measures the populations' spatial proximity to PCP locations. We examined agreement and disagreement between bounded shortage areas and GIS-based shortage areas. FINDINGS Bounded shortage area indicators and GIS-based shortage area indicators agree for the census blocks where the vast majority of our study populations reside. Specifically, 95% and 98% of the populations in our full and urban samples, respectively, reside in census blocks where the 2 indicators agree. Although agreement is generally high in rural areas (ie, 87% of the rural population reside in census blocks where the 2 indicators agree), agreement is significantly lower compared to urban areas. One source of disagreement suggests that bounded-area measures may "overlook" some shortages in rural areas; however, other aspects of the HPSA designation process likely mitigate this concern. Another source of disagreement arises from the border-crossing problem, and it is more prevalent. CONCLUSIONS The GIS-based PPRs we employed would yield shortage area determinations that are similar to those based on bounded-area PPRs defined for Primary Care Service Areas. Disagreement rates were lower than previous studies have found.

Do Medicaid expansions to working-age adults affect healthcare spending and utilization among older Medicare beneficiaries? Although economic theory provides conflicting predictions about the presence and direction of such spillover effects, it does identify circumstances when spillovers can reduce Medicare spending. Using data on Medicaid expansions during the 2000s and microdata from the Medicare Current Beneficiary Survey, we find that a 1 percentage point rise in the share of working-age adults eligible for Medicaid has modest effects on the average Medicare beneficiary's spending, but reduces average spending by $477 among dual eligibles. Importantly, we find no evidence of adverse health effects. (JEL G22, H75, I12, I13, I18, I38, J14)

Background There is concern that medical marijuana laws (MMLs) could negatively affect adolescents. To better understand these policies, we assess how adolescent exposure to MMLs is related to educational attainment. Methods Data from the 2000 Census and 2001–2014 American Community Surveys were restricted to individuals who were of high school age (14–18) between 1990 and 2012 (n = 5,483,715). MML exposure was coded as: (i) a dichotomous “any MML” indicator, and (ii) number of years of high school age exposure. We used logistic regression to model whether MMLs affected: (a) completing high school by age 19; (b) beginning college, irrespective of completion; and (c) obtaining any degree after beginning college. A similar dataset based on the Youth Risk Behavior Survey (YRBS) was also constructed for confirmatory analyses assessing marijuana use. Results MMLs were associated with a 0.40 percentage point increase in the probability of not earning a high school diploma or GED after completing the 12th grade (from 3.99% to 4.39%). High school MML exposure was also associated with a 1.84 and 0.85 percentage point increase in the probability of college non-enrollment and degree non-completion, respectively (from 31.12% to 32.96% and 45.30% to 46.15%, respectively). Years of MML exposure exhibited a consistent dose response relationship for all outcomes. MMLs were also associated with 0.85 percentage point increase in daily marijuana use among 12th graders (up from 1.26%). Conclusions Medical marijuana law exposure between age 14 to 18 likely has a delayed effect on use and education that persists over time.

Previous studies show that survey-based reports of Medicaid participation are measured with error, but no prior study has examined measurement error in an important segment of the Medicaid population—low-income adults enrolled in Medicare. Using the Medicare Current Beneficiary Survey, we examine whether respondent self-reports of Medicaid enrollment match administrative records and present several key findings. First, among low-income Medicare beneficiaries, the false negative rate is 11.5% when the self-report is interpreted as full Medicaid and 3.7% when the self-report is interpreted as full or partial Medicaid. Second, the likelihood of a false negative report is systematically associated with respondent traits. Third, systematic measurement error results in biased coefficient estimates in models of Medicaid participation defined from self-reports, and the bias is more significant when the researcher interprets self-reports as full Medicaid coverage only. Researchers should use caution when interpreting survey reports as pertaining to full Medicaid coverage only.

To incentivize hospitals to provide better quality care at a lower cost, the Affordable Care Act of 2010 included the Hospital Readmissions Reduction Program (HRRP), which reduces payments to hospitals with excess 30-day readmissions for Medicare patients treated for certain conditions. We use triple difference estimation to identify the HRRP's effects in Virginia hospitals; this method estimates the difference in changes in readmission over time between patients targeted by the policy and a comparison group of patients and then compares those difference-in-differences estimates in patients treated at hospitals with readmission rates above the national average (i.e., those at risk for penalties) and patients treated at hospitals with readmission rates below or equal to the national average (those not at risk). We find that the HRRP significantly reduced readmission for Medicare patients treated for acute myocardial infarction (AMI). We find no evidence that hospitals delay readmissions, treat patients with greater intensity, or alter discharge status in response to the HRRP, nor do we find changes in the age, race/ethnicity, health status, and socioeconomic status of patients admitted for AMI. Future research on the specific mechanisms behind reduced AMI readmissions should focus on actions by healthcare providers once the patient has left the hospital. Copyright © 2016 John Wiley & Sons, Ltd.

Physician acceptance is an important dimension of access to care, especially for Medicaid patients. We constructed two new measures to quantify primary care physician (PCP) acceptance of Medicaid patients using geocoded Virginia physician addresses and population data and geospatial methods. For each Census block group, we measured the shares of “accessible PCPs” accepting any Medicaid patients or new Medicaid patients. Accessible PCPs were defined as those located within 30-minute travel from patient locations and patient locations were proxied by Census block group geographic centroids. We found that the shares of accessible PCPs accepting Medicaid varied within Virginia, and were significantly lower in urban communities where larger fractions of the population were Hispanic, even controlling for unobserved market-level traits associated with Medicaid acceptance. Policy makers and Medicaid program officials should continue to improve nonfinancial access to primary care, especially by addressing access barriers in communities with high shares of minority residents.

To examine whether geographic information systems (GIS)-based physician-to-population ratios (PPRs) yield determinations of geographic primary care shortage areas that differ from those based on bounded-area PPRs like those used in the Health Professional Shortage Area (HPSA) designation process.We used geocoded data on primary care physician (PCP) locations and census block population counts from 1 US state to construct 2 shortage area indicators. The first is a bounded-area shortage indicator defined without GIS methods; the second is a GIS-based measure that measures the populations' spatial proximity to PCP locations. We examined agreement and disagreement between bounded shortage areas and GIS-based shortage areas.Bounded shortage area indicators and GIS-based shortage area indicators agree for the census blocks where the vast majority of our study populations reside. Specifically, 95% and 98% of the populations in our full and urban samples, respectively, reside in census blocks where the 2 indicators agree. Although agreement is generally high in rural areas (ie, 87% of the rural population reside in census blocks where the 2 indicators agree), agreement is significantly lower compared to urban areas. One source of disagreement suggests that bounded-area measures may "overlook" some shortages in rural areas; however, other aspects of the HPSA designation process likely mitigate this concern. Another source of disagreement arises from the border-crossing problem, and it is more prevalent.The GIS-based PPRs we employed would yield shortage area determinations that are similar to those based on bounded-area PPRs defined for Primary Care Service Areas. Disagreement rates were lower than previous studies have found.

Objective To investigate the association between older adults’ potentially avoidable hospitalization rates and both a geographic measure of primary care physician (PCP) access and a standard bounded-area measure of PCP access. Data Sources State physician licensure data from the Virginia Board of Medicine. Patient-level hospital discharge data from Virginia Health Information. Area-level data from the American Community Survey and the Area Health Resources Files. Virginia Information Technologies Agency road network data. US Census Bureau TIGER/Line boundary files. Study Design We use enhanced two-step floating catchment area methods to calculate geographic PCP accessibility for each ZIP Code Tabulation Area in Virginia. We use spatial regression techniques to model potentially avoidable hospitalization rates. Data Collection/Extraction Geographic accessibility was calculated using ArcGIS. Physician locations were geocoded using TAMU GeoServices and ArcGIS. Principal Findings Increased geographic access to PCPs is associated with lower rates of potentially avoidable hospitalization among older adults. This association is robust, allowing for spatial spillovers in spatial lag models. Conclusions Compared to bounded-area density measures, unbounded geographic accessibility measures provide more robust evidence that avoidable hospitalization rates are lower in areas with more PCPs per person. Results from our spatial lag models reveal the presence of positive spatial spillovers.

Despite the importance of the nursing profession for healthcare delivery, costs, and quality, there is relatively little research on how provider payments to hospitals affect the labor market for nurses. This study deals with the hospital wage index (HWI) adjustment to Medicare hospital payments, an area-level adjustment intended to compensate hospitals in high-cost labor markets. Since the HWI adjustment is based on hospital-reported labor costs, some argue that it incentivizes hospitals in concentrated markets to pay higher wages to nurses and other workers (the “circularity” critique). We investigate this critique using market-level data on the relative wages reported by nurses and hospital-level data on the average hourly wage for healthcare workers. For identification, we exploit a 2005 change in the geographic area used to define labor markets, which resulted in exogenous changes in the ability of some hospitals to influence their area’s wage index. We find that worker-reported relative nurse wages and hospital-reported healthcare worker wages are higher in some locations where hospitals experienced increased opportunities to game the circularity of the wage index, but these effects appear to be driven by pre-existing wage growth. Medicare’s HWI adjustment method does not appear to suffer from inefficiency due to circularity.

Objective To describe the amount of hospital outpatient care provided to the uninsured and its association with Medicare payment rate cuts following the implementation of Medicare's Outpatient Prospective Payment System. Data Sources/Study Setting We use hospital outpatient discharge records from Florida from 1997 through 2008. Study Design We estimate multivariate regression models of hospital outpatient care provided to the uninsured in separate samples of nonprofit and for-profit hospitals. Principal Findings Hospital outpatient departments provide significant amounts of care to the uninsured. As Medicare payment rates fall, total charges and the share of charges for outpatient visits by the uninsured decrease at nonprofit hospitals. At for-profit hospitals, the share of outpatient care provided to uninsured patients increases, but there is no significant change in the number of uninsured discharges. Conclusions Nonprofit and for-profit hospitals respond differently to reductions in Medicare payments; thus, studies of the impact of legislated Medicare payment cuts on care of the uninsured should account for differences in hospital ownership in communities. Given that outpatient care to the uninsured includes preventive and diagnostic care procedures, reductions in this care following payment cuts may adversely affect long-run health and health care costs in communities dominated by nonprofit hospitals.

A number of studies report that U.S. state mortality rates, particularly for the elderly, decline during economic downturns. Further, several prior studies use microdata to show that as state unemployment rates rise, physical health improves, unhealthy behaviors decrease, and medical care use declines. We use data on elderly mortality rates and data from the Medicare Current Beneficiary Survey from a time period that encompasses the start of the Great Recession. We find that elderly mortality is countercyclical during most of the 1994-2008 period. Further, as unemployment rates rise, seniors report worse mental health and are no more likely to engage in healthier behaviors. We find suggestive evidence that inpatient utilization increases perhaps because of an increased physician willingness to accept Medicare patients. Our findings suggest that either elderly individuals respond differently to recessions than do working age adults, or that the relationship between unemployment and health has changed.

Effective in 2000, Medicare's Outpatient Prospective Payment System (OPPS) sets pre-determined reimbursement rates for hospital outpatient services, replacing the prior cost-based methods of reimbursement. Using Florida outpatient discharge data, we study the effect of OPPS on hospital outpatient volume. We find that on average Medicare rate cuts either decreased or had no significant effect on Medicare volume, but increased private fee-for-service (FFS) volume. We also find that responses vary with the hospital's "exposure" to Medicare payment changes, where exposure is measured as the baseline Medicare patient share. Compared to less exposed hospitals, highly exposed hospitals responded with larger increases in private FFS volume and with smaller decreases (in some cases, even increases) in Medicare volume when payment rates fell. Our results are consistent with provider demand inducement.

Objectives. Using a sample of elementary and middle school students, we examined the associations between body mass index (BMI), obesity, and measures of the proximity of fast food and full service restaurants to students' residences. We controlled for socioeconomic status using a novel proxy measure based on housing values. Methods. We used BMI and obesity measures based on height and weight data collected as part of a school health assessment along with geocoded data on addresses of residences and food establishments. We constructed a proxy measure of socioeconomic status from public records of residential property assessments. These data were used to estimate logistic regression models of overweight and ordinary least squares models of BMI. Results. Students residing in homes with higher assessment values were significantly less likely to be obese, and had significantly lower BMIs. Upon controlling for socioeconomic status and other characteristics, the associations of BMI and obesity with proximity to food service establishments were reduced. Nonetheless, students who resided within one-tenth or one-quarter of a mile from a fast food restaurant had significantly higher values of BMI. The proximity of full service restaurants to residences did not have a significant positive association with either BMI or overweight. Conclusion. Public health efforts to limit access to fast food among nearby residents could have beneficial effects on child obesity. Public data on property value assessments may serve as useful approximations for socioeconomic status when address data are available.

Observational studies frequently support the popular belief that religion is associated with more other-regarding behavior; however, such studies are well known to be susceptible to the confounding effects of unobserved determinants of cooperation and trust. We test whether religious affiliation and participation in religious services are associated with behavior in public goods and trust games. Contrary to popular wisdom, religious affiliation is unrelated to individual behavior. However, we do find some weak evidence that among subjects attending religious services, increased participation is associated with behavior in both public goods and trust games.

We examine the stability of risk preference within subjects by comparing measures obtained from two elicitation methods, an economics experiment with real monetary rewards and a survey with questions on hypothetical gambles. The survey questions have been validated by numerous empirical studies of investment, insurance demand, smoking and alcohol use, and recent studies have shown the experimental measure is associated with several real-world risky behaviors. For the majority of subjects, we find that risk preferences are not stable across elicitation methods. In interval regression models, subjects’ risk preference classifications from survey questions on job-based gambles are not associated with risk preference estimates from the experiment. However, we find that risk classifications from inheritance-based gambles are significantly associated with the experimental measure. We identify some subjects for whom risk preference estimates are more strongly correlated across elicitation methods, suggesting that unobserved subject traits like comprehension or effort influence risk preference stability.

Recent studies report that economic inequality is associated with reduced government expenditures on social programs. Several prominent social scientists, including Putnam [2000], attribute this relationship to the detrimental Òpsychosocial effectsÓ of group heterogeneity on cooperation. We test the hypothesis that inequality within a group reduces individual contributions in a canonical public goods experiment. Unlike previous examinations of inequality and public good provision, our design introduces inequality by manipulating the levels and distributions of fixed payments given to subjects for participating in the experiment. When made salient through public information about each individualÕs standing within the group, inequality in the distribution of fixed payments reduces contributions to the public good for all group members.

Several non-experimental studies claim that heterogeneity among individuals reduces trust. A few experimental studies have examined the effects of naturally-occurring differences among subjects on trusting behavior, and in contrast, most have not supported these claims. We adopt a novel approach by inducing heterogeneity among subjects in a canonical trust experiment. We accomplish this by varying the show-up payments given to subjects for participating in the experiment. We find that this induced inequality does not consistently affect first- or second-mover behavior in the classic trust game in the manner predicted by either previous theoretical work or empirical studies of survey-based measures of trust. Further, the effect of inequality on trust, in terms of both sign and significance, depends on whether show-up payments are awarded publicly or privately.

Recent studies have found that two state-level measures of social capital, average levels of civic participation and trust, are associated with improvements in individual health status. In this study we employ these measures, together with the Putnam index of state social capital, to examine several key aspects of the relationship between state social capital and individual health. We find that for all three measures, the association with health status persists after carefully adjusting for household income and that for two measures, mistrust and the Putnam index, the size of this association warrants further attention. Using the Putnam index, we find particular support for the hypothesis that social capital has a more pronounced salutary effect for the poor. Our findings generate both support for the social capital and health hypothesis and a number of implications for future research.

This paper describes a classroom game that illustrates the effects of asymmetric information and adverse selection in health insurance markets. The first part of this game simulates a market in which buyers can purchase insurance from sellers; in some periods, government regulation of the insurance market prevents sellers from using information about buyer type to determine premiums. The results demonstrate the classic prediction that asymmetric information will result in adverse selection. Here, low risk buyers will forego the purchase of insurance at a measurable loss of potential earnings. In the second part of the game, sellers and buyers can trade two different types of health insurance policies, one moderate and another generous. The results from this part show that adverse selection can lead to an inefficient sorting of buyers across plans under government-mandated community rating and limits on premium increases. Under these circumstances, no buyers will purchase the generous insurance plan. The paper provides a series of questions to stimulate class discussion on the causes and consequences of adverse selection for consumers and insurers, and solutions that can be implemented in employer and government-sponsored programs.

Recent empirical studies from across the social and behavioral sciences find that social capital is associated with various measures of well-being, including economic growth (Stephen Knack and Phillip Keefer 1997) and mortality (Ichiro Kawachi, Bruce P. Kennedy and Kimberly Lochner 1997). These findings have inspired subsequent studies by economists examining the determinants of individual level measures of social capital (e.g., Alberto Alesina and Elianna La Ferrara 2002). However, experimental evidence from trust games conducted by Edward L. Glaeser, David I. Laibson, Jose A. Scheinkman and Christine L. Soutter (2001) calls into question the efficacy of the most prevalent measures of social capital employed in the literature. In contrast, we show that these same measures are significantly associated with contributions in a public goods experiment and perform as well as the alternative measures of social trust suggested by Glaeser, et al. Because social capital is thought to influence wellbeing through its effect on public good provision, our results bolster previous empirical work on the causes and consequences of social capital.(This abstract was borrowed from another version of this item.)

Objective To illustrate the potential sensitivity of ecological associations between mortality and certain socioeconomic factors to different methods of age-adjustment.

There is a sharp division among health policy researchers regarding the extent to which income inequality is a public health problem: some advocate the health benefits of egalitarian social policies (e.g., Wilkinson 1996, and Daniels, Kennedy, and Kawachi 2000), while others caution that there is little credible evidence that inequality is a determinant of public health (e.g., Milyo and Mellor 1999; Deaton 2001a; and Mackenbach 2002).1 The main point of contention is how to weigh the relative merits of empirical studies that report findings consistent with the claim that inequality has important and deleterious consequences for individual and population health (e.g., Lochner et al. 2001, and the studies collected in Kawachi, Kennedy; Wilkinson 2000) against several recent empirical studies that find no such connection between inequality and health (e.g., Meara 1999; Deaton 2001b; Deaton and Lubotsky 2002; Deaton and Paxson 2001; Mellor and Milyo 2001 and 2002; Miller 2001; Gravelle, Wildman, and Sutton 2002; and Sturm and Gresenz 2002). In our opinion, two important methodological improvements in these latter studies are the inclusion of more detailed information on individual characteristics as control variables and the use of procedures that control for unobservable fixed-state or regional effects. Nevertheless, research studies on both sides of this literature share a common shortcoming. With only two exceptions, every study of which we are aware investigates the contemporaneous association between income inequality and health outcomes, or the contemporaneous association between changes in inequality and changes in health outcomes. This is surprising, since the pathways by which inequality is conjectured to affect health clearly involve some persistent exposure, or seem to suggest a chain of events that might span years. For example, Wilkinson (1996) has argued that income disparities create psychosocial stress that eventually leads to heart disease or other stress-related maladies, while Kawachi et al. (1997) have speculated that inequality erodes social capital, which in turn eventually creates a political climate that is less supportive of policies that would improve public health. Consequently, explorations of the contemporaneous association between income inequality and health may fail to show evidence of a relationship that requires sufficient time to observe, and the question of whether prolonged exposure to income inequality is a determinant of either individual or population health remains unanswered by most of the extant quantitative research. Blakely et al. (2000 and 2002) are the only attempts to date to address this shortcoming. The former study examines whether lagged and contemporaneous levels of state-level inequality (measured by the Gini coefficient) are associated with self-reported health status in a pooled cross-section of respondents to the Current Population Survey (CPS) in 1995 and 1997. The latter is a follow-on study that examines the association between lagged metropolitan area inequality and self-reported health status using CPS data for 1996 and 1998. Blakely et al. (2002) find that the association between metropolitan area inequality and health status is much weaker than for state-level income inequality; this is consistent with what has been found for contemporaneous associations between inequality and health status in the CPS (Mellor and Milyo 2002). In addition, the apparent importance of state inequality supports the causal pathway articulated by Kawachi et al. (1997): inequality erodes social capital, which in turn hinders political support for policies that improve public health. Blakely et al. (2000) argue that lagged state inequality is more strongly associated with health status than contemporaneous inequality. For individuals older than 44 years of age, they find that the association between health status and the state-level Gini coefficient is strongest when the inequality measure is lagged 15 years, although they cannot reject the null hypothesis that the association is identical to that found with either shorter lags or the contemporaneous Gini, nor do they find any significant association for individuals younger than 45 years of age. Nevertheless, the authors conclude that these results are suggestive that exposure to inequality 15 years prior is an important determinant of current health status. We agree that these findings are intriguing, but unfortunately the model on which they are based does not control for many of the same factors omitted in the earlier literature. When included in more recent studies, these factors produce results that do not support the claim that inequality adversely affects health. For example, Blakely et al. (2000) do not control for certain individual covariates that are available in the CPS (e.g., education, marital status, and health insurance coverage). More importantly, the authors do not control for regional variations in health status, despite the fact that even textbook accounts of population health in the United States note the importance of regional differences in a variety of inputs in the health production function, such as lifestyle (e.g., Phelps 1997). This oversight is problematic because of the fact that income inequality is also known to be related to factors that vary regionally across the United States. For example, the size and age-composition of households, the prevalence of households with one adult or one working adult, immigration, and the number of jobs in the manufacturing sector have all been documented to be determinants of regional variations in income inequality (Husted 1991; Levernier, Rickman, and Partridge 1995; Partridge, Partridge, and Rickman 1998; Bernard and Jensen 2000). The failure to control for these regional effects may generate biased estimates of the effect of state-level income inequality on either individual or population health (Mellor and Milyo 2002). In this article, we test whether the adverse consequences of lagged inequality are robust to the inclusion of other individual characteristics, and to the control of regional factors. In addition, we examine the strength of this association in multiple years of the CPS, using lags ranging from 5 to 29 years. In the second part of this article we use state-level data on all-cause mortality and cause-specific death rates to examine the lagged effect of income inequality on other health outcomes. Our results indicate that once we account for regional differences, there is insufficient evidence to support the claim that exposure to income disparities poses a risk to individual or population health.

TYPE="ORG" OID="af2" CNY="US">Irving B. Harris Graduate School of Public Policy Studies, University of Chicago

We test whether religion affects adult subjects' decisions in a repeated public goods experiment. Contribution levels are not influenced by religious affiliation or participation. However, the decline with repetition is smaller among religious subjects, suggesting that religion may sustain cooperation.

A number of recent studies suggest that income and social inequality (as opposed to poverty itself) have detrimental consequences on people's health. These studies argue that while the poor may suffer the most from inequality, the rich also suffer. On closer inspection, however, it emerges that the basic arguments and evidence that inequality has a causal effect on health are wanting in many respects.

To contain outpatient health care spending, the Centers for Medicare & Medicaid Services (CMS) replaced the prior cost-based system for reimbursing hospital outpatient services in August 2000 with the Outpatient Prospective Payment System (OPPS). Under OPPS, CMS groups hospital outpatient services into ambulatory payment classifications (APCs) based on clinical and cost similarity and sets a common payment rate for all services in the same APC (CMS 2010a). Hospitals are reimbursed at the predetermined rate for services in a given APC instead of the actual costs incurred. Evidence suggests that OPPS reduced the generosity of Medicare payments for outpatient care overall (Becker unpublished data) and reduced Medicare payments for the most common outpatient surgical procedures (He and Mellor 2012). We examine whether the outpatient reimbursement cuts triggered by OPPS led hospitals to shift Medicare services from the outpatient setting into the inpatient setting. Although prior research has examined the effect of inpatient reimbursement on the setting of care (e.g., Coulam and Gaumer 1991), no prior study has examined whether OPPS-induced payment changes altered the setting of care. As the first to examine OPPS's effects outside the outpatient department, we provide insight on OPPS's potential to control health care costs broadly defined. Because OPPS caused reimbursement rates to rise or fall to varying degrees depending on the procedure and the hospital's historical payment, analyzing its effects requires procedure-specific payment rates at the hospital-level, pre- and post-OPPS.1 This study focuses on inguinal hernia repair surgeries performed in Florida hospitals from 1997 through 2008. One of the most common surgeries in the United States, inguinal hernia repair is performed in both inpatient and outpatient settings. Evidence shows that outcomes and satisfaction are similar in both settings even among older patients (Mitchell and Harrow 1994; Mattila et al. 2011). This suggests that providers may have the discretion to treat patients in either setting. Furthermore, the diagnosis of inguinal hernia is usually made by physical examination alone, so hernia repair surgery is unlikely to be affected by OPPS-induced changes in the payment of other procedures. This facilitates identification of the causal effect of changes in hernia outpatient reimbursement rates. We find that the average hospital experienced 4–10 percent cuts in Medicare payment rates for inguinal hernia repair surgeries over the 5-year period that OPPS was fully phased-in. Hospital fixed-effects regression results suggest that OPPS-induced cuts in outpatient hernia repair reimbursements decreased the volume of some outpatient hernia repair surgeries; however, we find no evidence that hospitals increased the number of inpatient hernia surgeries in response to outpatient payment cuts. Because hospitals’ ability to substitute hernia repair surgery across settings likely exceeds that of other common outpatient procedures, we conclude that outpatient cost containment efforts like OPPS are not seriously threatened by substitution to the inpatient setting.

Prior studies suggest that hospital care is countercyclical among Medicare beneficiaries, and if anything, procyclical among the non-elderly. In this paper, we provide the first physician-level analysis of changes in healthcare provision to Medicare and privately insured patients across the business cycle. Using Florida discharge data aggregated to the physician level, we find that as county unemployment rates increase, physicians treat fewer privately insured patients in both inpatient and outpatient settings. In contrast, physicians who are more exposed to income losses during recessions provide more care to Medicare patients as the unemployment rate rises. Further analysis suggests that easing capacity constraints may contribute to this rise in Medicare volume; however, even in areas that are not capacity constrained, care provided to Medicare patients remains countercyclical among physicians with a large share of privately insured patients. This pattern is consistent with demand inducement in response to a negative income shock.

How do sudden, large wealth losses affect mental health? Most prior studies of the causal effects of material well-being on health use identification strategies involving income increases; these studies as well as prior research on stock market accumulations may not inform this question if the effect of wealth on health is asymmetric. We use exogenous variation in the interview dates of the 2008 Health and Retirement Study to assess the impact of large wealth losses on mental health among older U.S. adults. We compare cross-wave changes in wealth and health for respondents interviewed before and after the October 2008 stock market crash. We find that the crash reduced wealth and increased depressive symptoms and the use of anti-depressants. These results suggest that sudden wealth losses cause immediate declines in mental health; for example, a loss of $50,000 of non-housing wealth increases the likelihood of feeling depressed by 1.35 percentage points, or by 8%.

This article empirically tests the proposition that the gender-race composition of an employee's occupation significantly affects the likelihood of promotion. Using data obtained from the personnel files of a financial services firm, we find that a high concentration of white females in an occupation adversely affects the probability of promotion, but only for white females and minorities in that occupation. A similar, attenuated pattern exists in occupations with either high concentrations of minority females or high concentrations of minority males. Additional empirical evidence suggests that the system of rules governing the promotion of white males differs significantly from that of the other three gender-race groups.

Many studies document disparities between Blacks and Whites in the treatment of acute myocardial infarction on controlling for patient demographic factors and comorbid conditions. Other studies provide evidence of disparities between Hispanics and Whites in cardiac care. Such disparities may be explained by differences in the hospitals where minority and nonminority patients obtain treatment and by differences in the traits of physicians who treat minority and nonminority patients. We used 1997-2005 Florida hospital inpatient discharge data to estimate models of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting in Medicare fee-for-service patients 65 years and older. Controlling for hospital fixed effects does not explain Black–White disparities in cardiac treatment but largely explains Hispanic–White disparities. Controlling for physician fixed effects accounts for some extent of the racial disparities in treatment and entirely explains the ethnic disparities in treatment.

During the US recession of 2007–09, overall health care spending growth fell, but Medicare spending growth increased. Using state-level data from the period 1991–2009, we show that these divergent trends were also observed within states. Furthermore, increases in state unemployment rates were associated with higher Medicare spending per capita and increased hospital use by Medicare beneficiaries. For example, a one-percentage-point point rise in the unemployment rate was associated with a $40 (0.7 percent) increase in Medicare spending per capita. Our results suggest that economic downturns contribute to Medicare spending and use. One of many possible explanations may be that health care providers have greater capacity, inclination, and financial incentive to treat Medicare patients during recessions as a result of slackening demand from the non-Medicare population.

Using data from a financial services firm, the determinants of salary growth are estimated in a two-stage model with special attention given to the roles of gender and race. While the analysis reveals no overt bias in salary growth decisions, there is evidence of institutional bias within one branch of the firm. In that branch the proportion of white females in an occupation is negatively related to salary growth for all but white males. Additional analysis suggests that rules governing promotion and salary growth differ for white males, white females, and minority workers within this branch. Interestingly, the same analysis of a second branch leads to quite different conclusions.

Several recent studies demonstrate a positive effect of cigarette prices and taxes on obesity among adults, especially those who smoke. If higher cigarette costs affect smokers' weights by increasing calories consumed or increasing food expenditures, then cigarette taxes and prices may also affect obesity in children of smokers. This study examines the link between child body mass index (BMI) and obesity status and cigarette costs using data from the National Longitudinal Survey of Youth-79 (NLSY79). Controlling for various child, mother, and household characteristics as well as child-fixed effects, I find that cigarette taxes and prices increase BMI in the children of smoking mothers. Interestingly, and unlike previous research findings for adults, higher cigarette taxes do not increase the likelihood of obesity in children. These findings are consistent with a causal mechanism in which higher cigarette costs reduce smoking and increase food expenditures and consumption in the household. Copyright © 2010 John Wiley & Sons, Ltd.

Previous studies have shown that adolescent religious participation is negatively associated with risky health behaviors such as cigarette smoking, alcohol consumption, and illicit drug use. One explanation for these findings is that religion directly reduces risky behaviors because churches provide youths with moral guidance or with strong social networks that reinforce social norms. An alternative explanation is that both religious participation and risky health behaviors are driven by some common unobserved individual trait. We use data from the National Longitudinal Study of Adolescent Health and implement an instrumental variables approach to identify the effect of religious participation on smoking, binge drinking, and marijuana use. Following Gruber (2005), we use a county-level measure of religious market density as an instrument. We find that religious market density has a strong positive association with adolescent religious participation, but not with secular measures of social capital. Upon accounting for unobserved heterogeneity, we find that religious participation continues to have a significant negative effect on illicit drug use. On the contrary, the estimated effects of attendance in instrumental variables models of binge drinking and smoking are statistically imprecise. Copyright © 2010 John Wiley & Sons, Ltd. Language: en

Previous studies have shown that active consent procedures result in sampling bias in surveys dealing with adolescent risk behaviors such as cigarette smoking and illicit drug use. To examine sampling bias from active consent procedures when the survey topic pertains to childhood obesity and associated health behaviors, the authors pair data obtained from both active and passive consent procedures. The authors find that parents of children who are overweight or at risk for being overweight are significantly less likely to give active consent. In addition, parents of children enrolled in lower grades are more reluctant to consent to participate.

A rapidly growing empirical literature from across the social sciences relates social capital to a diverse array of indicators of well-being, including economic growth (Knack & Keefer, 1997), labor force participation (Aguilera, 2002), violent crime (Galea, Karpati, & Kennedy, 2002), political corruption (La Porta et al., 1997), and even self-reported happiness (Bjornskov, 2003). Of all the phenomena thought to be affected by social capital, health and health-related outcomes have received the greatest attention, evidenced in part by the contributions in this volume. Yet, despite repeated findings of a statistical association between social capital and various health outcomes and risk factors, as well as the existence of plausible causal pathways linking social capital to individual health,3 many health economists are skeptical of the importance of social capital for health (e.g., Mellor & Milyo, 2005).

We conduct a large-scale economics experiment paired with a survey to examine the association between individual risk preference and health-related behaviors among adults aged 18-87 years. Risk preference is measured by the lottery choice experiment designed by Holt and Laury [Holt, C.A., Laury, S.K., 2002. Risk aversion and incentive effects. The American Economic Review 92(5), 1644-1655]. Controlling for subject demographic and economic characteristics, we find that risk aversion is negatively and significantly associated with cigarette smoking, heavy drinking, being overweight or obese, and seat belt non-use. In additional specifications, we find that risk aversion is negatively and significantly associated with the likelihood a subject engaged in any of five risky behaviors and the number of risky behaviors reported.

We test whether religious affiliation and participation in religious services are associated with behavior in public goods and trust games. Overall, religious affiliation is unrelated to individual behavior. However, we find some weak evidence that among subjects attending religious services, increased participation is associated with behavior in both public goods and trust games.

We test whether party affiliation or ideological leanings influence subjects' behavior in public goods experiments and trust games. In general, party is unrelated to behavior, and ideology is not related to contributions in the public goods experiment. However, there is some evidence that self-described liberals are both more trusting and more trustworthy.

Several non-experimental studies report that income inequality and other forms of population-based heterogeneity reduce levels of trust in society. However, recent work by Glaeser et al. (2000) calls into question the reliability of widely used survey-based measures of trust. Specifically, survey responses regarding trust attitudes did not reflect subjects' actual behavior in a trust game. In this paper, we conduct a novel experimental test of the effects of inequality on trust and trustworthiness. Our experimental design induces inequality by varying the show-up fees paid to subjects, in contrast to previous experiments that focus on broad cultural or national differences in trust. We do not find robust support for the hypothesis that inequality per se dampens trusting behavior among all subjects; however, we do find some evidence that trust and trustworthiness are influenced by an individual's relative position in the group. Finally, we confirm previous findings that common survey-based measures of social trust are not associated with actual trusting behavior.