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This paper evaluates the financial and economic consequences of being denied an abortion. We link credit report data to the Turnaway Study, which collected high-quality, longitudinal data on women receiving or being denied a wanted abortion in the United States. We compare financial outcomes over a ten-year period for women who had pregnancies just above and below a gestational age limit allowing for a wanted abortion. Outcomes evolved similarly for the two groups prior to the abortion encounter. Following the encounter, women who were denied an abortion experience a large increase in financial distress that remains for several years. (JEL G51, I18, J13, J16)

This article estimates changes in all-cause mortality due to the COVID-19 pandemic by socioeconomic characteristics and occupation for nonelderly adults in the US, using large-scale, national survey data linked to administrative mortality records. Mortality increases were largest for adults living in correctional facilities or in health care-related group quarters, those without health insurance coverage, those with family incomes below the federal poverty level, and those in occupations with limited work-from-home options. For almost all subgroups, mortality increases were higher among non-Hispanic Black respondents than among non-Hispanic White respondents. Hispanic respondents with health insurance, those not living in group quarters, those with work-from-home options, and those in essential industries also experienced larger increases in mortality during the COVID-19 crisis compared with non-Hispanic Whites in those categories. Occupations that experienced the largest mortality increases were related to installation, maintenance, and repair and production. This research highlights the relevance of individual economic, social, and demographic characteristics during the COVID-19 crisis.

We use large-scale federal survey data linked to administrative death records to investigate the relationship between Medicaid enrollment and mortality. Our analysis compares changes in mortality for near-elderly adults in states with and without Affordable Care Act Medicaid expansions. We identify adults most likely to benefit using survey information on socioeconomic status, citizenship status, and public program participation. We find that prior to the ACA expansions, mortality rates across expansion and nonexpansion states trended similarly, but beginning in the first year of the policy, there were significant reductions in mortality in states that opted to expand relative to nonexpanders. Individuals in expansion states experienced a 0.132 percentage point decline in annual mortality, a 9.4% reduction over the sample mean, as a result of the Medicaid expansions. The effect is driven by a reduction in disease-related deaths and grows over time. A variety of alternative specifications, methods of inference, placebo tests, and sample definitions confirm our main result.

The period before pregnancy is critically important for the health of a woman and her infant, yet not all women have access to health insurance during this time. We evaluated whether increased access to health insurance under the Affordable Care Act Medicaid expansions affected ten preconception health indicators, including the prevalence of chronic conditions and health behaviors, birth control use and pregnancy intention, and receipt of preconception health services. By comparing changes in outcomes for low-income women in expansion and nonexpansion states, we document greater preconception health counseling, prepregnancy folic acid intake, and postpartum use of effective birth control methods among low-income women associated with Medicaid expansion. We do not find evidence of changes on the other preconception health indicators examined. Our findings indicate that expanding Medicaid led to detectable improvements on a subset of preconception health measures.

Some states have not adopted the Affordable Care Act (ACA) Medicaid expansions due to concerns that the expansions may impair access to care and utilization for those who are already insured. We investigate such negative spillovers using a large panel of Medicare beneficiaries. Across many subgroups and outcomes, we find no evidence that the expansions reduced utilization among Medicare beneficiaries and can rule out all but very small changes in utilization or spending. These results indicate that the expansions in Medicaid did not impair access to care or utilization for the Medicare population. (JEL G22, H51, I13, I18, I38)

We provide a brief overview of the Turnaway Study, the first study to collect longitudinal data on individual women who received versus were denied a wanted abortion in the United States. The study team collected data on nearly 1,000 women seeking an abortion from 30 facilities around the country and followed them for 5 years. We discuss some of the main findings from the study related to the health, labor, and human capital outcomes of the women who were denied abortions and gave birth. We conclude by describing future opportunities to learn from the study with new linkages to administrative data.

A growing body of literature examining the effects of the Affordable Care Act (ACA) on nonelderly adults provides promising evidence of improvements in health outcomes through insurance expansions. Our review of forty-three studies that employed a quasi-experimental research design found encouraging evidence of improvements in health status, chronic disease, maternal and neonatal health, and mortality, with some findings corroborated by multiple studies. Some studies further suggested that the beneficial effects have grown over time and thus may continue to grow if the ACA insurance expansions remain in force. However, not all studies reported a significant positive relationship between ACA provisions that expanded insurance coverage and health status. We highlight the challenges facing researchers, including the importance of nonmedical factors in determining individual health and the use of outcome data predominantly drawn from self-reports. In closing, we identify opportunities to enhance researchers' understanding of the relationship between the ACA insurance expansions and health outcomes using new data sources, including electronic health records.

This article estimates changes in all-cause mortality due to the COVID-19 pandemic by socioeconomic characteristics and occupation for nonelderly adults in the US, using large-scale, national survey data linked to administrative mortality records. Mortality increases were largest for adults living in correctional facilities or in health care-related group quarters, those without health insurance coverage, those with family incomes below the federal poverty level, and those in occupations with limited work-from-home options. For almost all subgroups, mortality increases were higher among non-Hispanic Black respondents than among non-Hispanic White respondents. Hispanic respondents with health insurance, those not living in group quarters, those with work-from-home options, and those in essential industries also experienced larger increases in mortality during the COVID-19 crisis compared with non-Hispanic Whites in those categories. Occupations that experienced the largest mortality increases were related to installation, maintenance, and repair and production. This research highlights the relevance of individual economic, social, and demographic characteristics during the COVID-19 crisis.

The period prior to pregnancy is critically important for the health of a woman and her infant, yet not all women have access to health insurance during this time. We evaluated whether increased access to health insurance under the ACA Medicaid expansions affected ten preconception health indicators, including the prevalence of chronic conditions and health behaviors, birth control use and pregnancy intention, and receipt of preconception health services. By comparing changes in outcomes for low-income women in expansion and non-expansion states, we document greater preconception health counseling, prepregnancy folic acid intake, and postpartum use of effective birth control methods among low-income women in expansion states associated with Medicaid expansion. We do not find evidence of changes on the other preconception health indicators examined. Our findings indicate that expanding Medicaid led to detectable improvements on a subset of preconception health measures.

A growing body of literature examining the effects of the Affordable Care Act (ACA) on nonelderly adults provides promising evidence of improvements in health outcomes through insurance expansions. Our review of forty-three studies that employed a quasi-experimental research design found encouraging evidence of improvements in health status, chronic disease, maternal and neonatal health, and mortality, with some findings corroborated by multiple studies. Some studies further suggested that the beneficial effects have grown over time and thus may continue to grow if the ACA insurance expansions remain in force. However, not all studies reported a significant positive relationship between ACA provisions that expanded insurance coverage and health status. We highlight the challenges facing researchers, including the importance of nonmedical factors in determining individual health and the use of outcome data predominantly drawn from self-reports. In closing, we identify opportunities to enhance researchers' understanding of the relationship between the ACA insurance expansions and health outcomes using new data sources, including electronic health records.

Restrictions on abortion are pervasive, yet relatively little is known about the financial and economic impact of being denied an abortion on pregnant women who seek one. This paper evaluates the economic consequences of being denied an abortion on the basis of the gestational age of the pregnancy. Our analysis relies on new linkages to administrative credit report data for participants in the Turnaway Study, the first study to collect high-quality, longitudinal data on women receiving or being denied a wanted abortion in the United States. Some women had pregnancies close to the facility’s gestational age limit, but below it, and received a wanted abortion (Near Limit Group). A second group of women had pregnancies just over the facility’s gestational age limit and were turned away without receiving an abortion (Turnaway Group). We link study participants to ten years of credit report data including several years prior to their recruitment into the study. Using these data, we compare differences in credit report outcomes for the two groups of women over time using an event study design. We find that the trajectories for these outcomes are similar for the two groups of women prior to the abortion encounter. However, following their visit to the abortion provider, we find evidence of a large and persistent increase in financial distress for the women who were denied an abortion that is sustained for several years. Being denied an abortion increases the amount of debt 30 days or more past due by 78 percent and increases negative public records, such as bankruptcies and evictions, by 81 percent. We conduct additional analyses that use a regression discontinuity design to compare outcomes for women just above and just below the gestation limit at each clinic and find results that are consistent with the event study analyses. We explore the mechanisms behind these findings by taking advantage of existing survey data collected for the study participants and compare the effects sizes we document to those experienced by similar women following a “typical” birth. Our results highlight important financial and economic consequences of restrictions on abortion access.

Exploiting a discontinuity in childhood Medicaid eligibility based on date of birth, we find that more years of childhood eligibility are associated with fewer hospitalizations in adulthood. For blacks, we find a 7–15% decrease in hospitalizations and a suggestive 2–5% decrease in emergency department visits, but no similar effect for non-blacks. The effects are pronounced for utilization related to chronic illnesses and for patients living in low-income zip codes. Calculations suggest that lower rates of hospitalizations during one year in adulthood for blacks offset between 2 and 4 percent of the initial costs of expanding Medicaid for all children.

In this study, we evaluate how an expansion of Medicaid coverage for pregnant women and infants affected the adult outcomes ofindividuals who gained access to coverage in utero and during the first year oflife. We find that cohorts whose mothers gained eligibilityfor prenatal coverage under Medicaid have lower rates ofchronic conditions as adults and fewer hospitalizations related to diabetes and obesity. We also find that the expansions increased high school graduation rates. Our results indicate that expanding Medicaid prenatal coverage had long-term benefits for the next generation. [ABSTRACT FROM AUTHOR]

Over the past 30 years, the criteria used to diagnose many illnesses have been relaxed, resulting in millions more relatively healthy individuals receiving treatment. This paper explores the impact of receiving a diagnosis of a common disease among such “marginally ill” patients. We apply a regression discontinuity design to the cutoff in blood sugar levels used to classify patients as having diabetes. We find that a marginally diagnosed patient with diabetes spends $1,097 more on drugs and diabetes-related care annually after diagnosis, but find no corresponding changes in self-reported health or healthy behaviors. These increases in spending persist over the 6-year period we observe the patients. These marginally diagnosed patients experience improved blood sugar after the first year of diagnosis, but this improvement does not persist in subsequent years. Other clinical measures of health, such as BMI, blood pressure, cholesterol, and mortality show no improvement. The diagnosis rates for preventable disease-related conditions such as diabetic retinopathy, neuropathy, and kidney disease increase following a diagnosis, likely due to more intensive screening. Our results imply that a small relaxation in the diagnosis cutoff would increase total spending on diabetes-related care by about $2.4 billion annually and minimally impact patient health.

BACKGROUND Health care administrators often lack feasible methods to prospectively identify new pediatric patients with high health care needs, precluding the ability to proactively target appropriate population health management programs to these children. OBJECTIVE To develop and validate a predictive model identifying high-cost pediatric patients using parent-reported health (PRH) measures that can be easily collected in clinical and administrative settings. DESIGN Retrospective cohort study using 2-year panel data from the 2001 to 2011 rounds of the Medical Expenditure Panel Survey. SUBJECTS A total of 24,163 children aged 5-17 with family incomes below 400% of the federal poverty line were included in this study. MEASURES Predictive performance, including the c-statistic, sensitivity, specificity, and predictive values, of multivariate logistic regression models predicting top-decile health care expenditures over a 1-year period. RESULTS Seven independent domains of PRH measures were tested for predictive capacity relative to basic sociodemographic information: the Children with Special Health Care Needs (CSHCN) Screener; subjectively rated health status; prior year health care utilization; behavioral problems; asthma diagnosis; access to health care; and parental health status and access to care. The CSHCN screener and prior year utilization domains exhibited the highest incremental predictive gains over the baseline model. A model including sociodemographic characteristics, the CSHCN screener, and prior year utilization had a c-statistic of 0.73 (95% confidence interval, 0.70-0.74), surpassing the commonly used threshold to establish sufficient predictive capacity (c-statistic>0.70). CONCLUSIONS The proposed prediction tool, comprising a simple series of PRH measures, accurately stratifies pediatric populations by their risk of incurring high health care costs.

Objective To evaluate impacts of state Medicaid expansions for low-income parents on the health insurance coverage, pregnancy intention, and use of prenatal care among mothers who became pregnant. Data sources/study setting Person-level data for women with a live birth from the 1997-2012 Pregnancy Risk Assessment Monitoring System. Data collection/extraction methods The sample was restricted to women who were already parents using information on previous live births and combined with information on state Medicaid policies for low-income parents. Study design I used a measure of expanded generosity of state Medicaid eligibility for low-income parents to estimate changes in health insurance, pregnancy intention, and prenatal care for pregnant mothers associated with Medicaid expansion. Principal findings I found an increase in prepregnancy health insurance coverage and coverage during pregnancy among pregnant mothers, as well as earlier initiation of prenatal care, associated with the expansions. Among pregnant mothers with less education, I found an increase in the adequacy of prenatal care utilization. Conclusions Expanded Medicaid coverage for low-income adults has the potential to increase a woman's health insurance coverage prior to pregnancy, as well as her insurance coverage and medical care receipt during pregnancy.

We examine multi-generational impacts of positive in utero health interventions using a new research design that exploits sharp increases in prenatal Medicaid eligibility that occurred in some states. Our analyses are based on U.S. Vital Statistics Natality files, which enables linkages between individuals' early life Medicaid exposure and the next generation's health at birth. We find robust evidence that the health benefits associated with treated generations' early life program exposure extend to later offspring. Our results suggest that the returns on early life health investments may be substantively underestimated.

Expanded health insurance coverage for pregnant immigrant women who are in the United States lawfully as well as those who are in the country without documentation may address barriers in access to pregnancy-related care. We present new evidence on the impact of states' public health insurance expansions for pregnant immigrant women (both state-funded and expansions under the Children's Health Insurance Program) on their prenatal care use, mode of delivery, and infant health. Our quasi-experimental design compared changes in immigrant women's outcomes in states expanding coverage to changes in outcomes for nonimmigrant women in the same state and to women in nonexpanding states. We found that prenatal care use increased among all immigrant women following coverage expansion and that cesarean section increased among immigrant women with less than a high school diploma. We found no effects on the incidence of low birthweight, preterm birth, being small for gestational age, or infant death. State public insurance programs that cover pregnant immigrant women appear to have improved prenatal care utilization without observable changes in infant health or mortality.

By September 2015, a total of 29 states and Washington, D.C., were participating in Medicaid expansions under the Affordable Care Act. We examined whether Medicaid expansions were associated with changes in insurance coverage, health care use, and health among low-income adults.We compared changes in outcomes during the 2 years after implementation of the Medicaid expansion (2014 and 2015) relative to the 4 years before expansion (2010 through 2013) in states with and without expansions, using data from the National Health Interview Survey. The sample consisted of 60,766 U.S. citizens who were 19 to 64 years of age and had incomes below 138% of the federal poverty level. Outcomes included insurance coverage, access to and use of medical care in the past 12 months, and health status as reported by the respondents.A total of 29 states and Washington, D.C., expanded Medicaid by September 1, 2015. In year 2 after implementation, uninsurance rates were reduced in expansion states relative to nonexpansion states (difference-in-differences estimate, -8.2 percentage points; P0.001) and rates of Medicaid coverage were increased (difference-in-differences estimate, 15.6 percentage points; P0.001). Expansions were not associated with significant changes in the likelihood of a doctor visit or overnight hospital stay or health status as reported by the respondent. However, as compared with nonexpansion states, expansion states had a decrease in reports of inability to afford needed follow-up care (difference-in-differences estimate, -3.4 percentage points; P=0.002) and in reports of worry about paying medical bills (difference-in-differences estimate, -7.9 percentage points; P=0.002) and an increase in reports of medical care being delayed because of wait times for appointments (difference-in-differences estimate, 2.6 percentage points; P=0.02).Medicaid expansion was associated with increased insurance coverage and access to care during the second year of implementation, but it was also associated with longer wait times for appointments, which suggests that challenges in access to care persist.

I examined the impact of state expansions in eligibility for Medicaid family planning services on the utilization of Papanicolaou (Pap) tests, clinical breast examinations, HIV testing, and routine doctor check-ups among women aged 21 to 44 years using the Behavioral Risk Factor Surveillance System (1993–2009). Using a natural experiment approach, I found significant increases in Pap tests and clinical breast examinations among women eligible for services under the expansions but no significant change in HIV testing or routine doctor check-ups.

Healthy tooth development starts early in life, beginning even before birth. We present new evidence suggesting that a historic public health insurance expansion for pregnant women and children in the United States in the 1980s and 1990s may have had long-lasting effects on the oral health of the children gaining eligibility. We estimated the relationship between adult oral health and the extent of state public health insurance eligibility for pregnant women, infants, and children throughout childhood separately for non-Hispanic whites, non-Hispanic blacks, and Hispanics. We found that expanded Medicaid coverage geared toward pregnant women and children during their first year of life was linked to better oral health in adulthood among non-Hispanic blacks. Our results also suggested that there might be a benefit to expanded public health insurance eligibility for children at ages 1-6 among non-Hispanic blacks and Hispanics. Medicaid expansions appear to have had long-lasting effects for certain low-income children and helped narrow racial/ethnic disparities in adult oral health.

Policy-makers have argued that providing public health insurance coverage to the uninsured lowers long-run costs by reducing the need for expensive hospitalizations and emergency department visits later in life. In this paper, we provide evidence for such a phenomenon by exploiting a legislated discontinuity in the cumulative number of years a child is eligible for Medicaid based on date of birth. We find that having more years of Medicaid eligibility in childhood is associated with fewer hospitalizations and emergency department visits in adulthood for blacks. Our effects are particularly pronounced for hospitalizations and emergency department visits related to chronic illnesses and those of patients living in low-income neighborhoods. Furthermore, we find evidence suggesting that these effects are larger in states where the difference in the number of Medicaid-eligible years across the cutoff birthdate is greater. Calculations suggest that lower rates of hospitalizations and emergency department visits during one year in adulthood offset between 3 and 5 percent of the initial costs of expanding Medicaid.

International capital mobility and economic restructuring have brought training and skills acquisition to the forefront of policy dialogues. Taiwan has gone beyond most countries in promoting vocational education and setting strict quotas for schooling. Although the education plans do not have separate targets for men and women, they have gendered outcomes. Estimates of earnings premiums using ordinary least squares and quantile regression techniques indicate that only men have gained consistently higher premiums from vocational school compared to general schooling. Women who were denied access to the university system have forgone college premiums that exceed those of men. Also, the commerce track, in which women cluster, yields an earnings penalty compared to general schooling, while the technical track, in which men predominate, yields an earnings premium. Policy reforms based on relaxing education quotas and enforcing equal opportunity legislation would provide women with more rewarding educa...

Medicaid agencies are increasingly adopting care coordination and management strategies for their high-need beneficiaries, often with the twin goals of enhancing quality of care and reducing costs (Verdier, Byrd, and Stone 2009; Kim et al. 2013). This trend is likely to accelerate as states implement the Affordable Care Act's (ACA) new options to coordinate the care of chronically ill Medicaid beneficiaries (Kaiser Family Foundation 2011) and, in at least 28 states, expand Medicaid coverage to a larger population (Advisory Board 2013). To target high-need individuals, care management initiatives typically apply a case-finding approach that uses predictive models to stratify patients along likely future health care utilization (Knutson, Bella, and Llanos 2009; Verdier, Byrd, and Stone 2009). There is a mismatch, however, between the data requirements of these models, which rely on historical medical claims, and the data available to Medicaid programs for both new and “churning” beneficiaries, of whom states expect increasing numbers under the ACA (Knutson, Bella, and Llanos 2009). This article proposes and tests a practical alternative to a claims-based algorithm for identifying high-need Medicaid beneficiaries, one that relies upon well-validated self-reported health (SRH) measures that states or managed care organizations (MCOs) may potentially collect during the initial application and enrollment process.

Although the link between the fetal environment and later life health and achievement is well-established, few studies have evaluated the extent to which public policies aimed at improving fetal health can generate benefits that persist into adulthood. In this study, we evaluate how a rapid expansion of prenatal and child health insurance through the Medicaid program affected adult outcomes of individuals born between 1979 and 1993 who gained access to coverage in utero and as children. We conduct this analysis by exploiting state- and cohort-level variation in the timing and generosity of Medicaid expansions using a simulated eligibility instrumental variables model. We find that cohorts whose mothers gained eligibility for prenatal coverage under Medicaid have lower rates of obesity as adults and fewer hospitalizations related to endocrine, nutritional and metabolic diseases, and immunity disorders as adults. We also find that the prenatal expansions increased high school graduation rates among affected cohorts. We find effects of public eligibility in other periods of childhood on self-reported health and hospitalizations later in life, but these effects are smaller in magnitude. Our results indicate that expanding Medicaid prenatal coverage had sizeable long-term benefits for the next generation.

This paper uses a policy discontinuity to identify the immediate and long-term effects of public health insurance coverage during childhood. Our identification strategy exploits a unique feature of several early Medicaid expansions that extended eligibility only to children born after September 30, 1983. This feature resulted in a large discontinuity in the lifetime years of Medicaid eligibility of children at this birthdate cutoff. Those with family incomes at or just below the poverty line had close to five more years of eligibility if they were born just after the cutoff than if they were born just before. We use this discontinuity in eligibility to measure the impact of public health insurance on mortality by following cohorts of children born on either side of this cutoff from childhood through early adulthood. We examine changes in rates of mortality by the underlying causes of death, distinguishing between deaths due to internal and external causes. We also examine outcomes separately for black and white children. Our analysis shows that black children were more likely to be affected by the Medicaid expansions and gained twice the amount of eligibility as white children. We find a substantial effect of public eligibility during childhood on the later life mortality of black children at ages 15-18. The estimates indicate a 13-20 percent decrease in the internal mortality rate of black teens born after September 30, 1983. We find no evidence of an improvement in the mortality of white children under the expansions.