Causal effects of mental health on food security.

Although mental health conditions are known to be associated with socioeconomic hardships, their causal effects remain largely unexplored. Using a sample of low-income families in the National Health Interview Survey (NHIS), we assess causal effects of serious mental illness (SMI) and related mental health conditions on family food security. We apply partial identification methods to account for fundamental endogeneity and measurement identification problems in a unified framework. To implement these methods, we combine a proxy measure of SMI in the NHIS with an estimate of the true rate of SMI from the Substance Abuse and Mental Health Services Administration. We also develop an innovative approach to approximate true prevalence rates when only self-reported prevalence rates are available. Applying relatively weak monotonicity assumptions on latent food security outcomes, we find that alleviating SMI would improve the food security rate by at least 9.5 percentage points, or 15 %. JEL codes: C21, I10, I38.

A Research Note on Transitions in Out-of-Pocket Spending on Dental Services.

OBJECTIVE: We analyze correlates of the direction and magnitude of changes in out-of-pocket (OOP) payments for dental care by older Americans over a recent 4-year period. METHODS: We analyzed data from the 2006 and 2008 waves of the Health and Retirement Study. We estimated multinomial logistic models of the direction and linear regression models of the amounts of OOP changes over survey periods. RESULTS: Financial-based factors were more strongly associated with the direction and magnitude of changing self-payments for dental care than were health factors. DISCUSSION: Findings suggested that dental coverage, income, and wealth and changes in these financial factors were more strongly correlated with the persistence of and changes in OOP payments for dental care over time than were health status and changes in health status. The sensitivity to dental coverage changes should be considered as insurance and retirement policy reforms are deliberated.

Dental use and expenditures for older uninsured Americans: the simulated impact of expanded coverage.

OBJECTIVE: To determine if providing dental insurance to older Americans would close the current gaps in dental use and expenditure between insured and uninsured older Americans. DATA SOURCES/STUDY SETTING: We used data from the 2008 Health and Retirement Survey (HRS) supplemented by data from the 2006 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: We compared the simulated dental use and expenditures rates of newly insured persons against the corresponding rates for those previously insured. DATA COLLECTION/EXTRACTION METHODS: The HRS is a nationally representative survey administered by the Institute for Social Research (ISR). The MEPS is a nationally representative household survey sponsored by the Agency for Healthcare Research and Quality (AHRQ). PRINCIPAL FINDINGS: We found that expanding dental coverage to older uninsured Americans would close previous gaps in dental use and expense between uninsured and insured noninstitutionalized Americans 55 years and older. CONCLUSIONS: Providing dental coverage to previously uninsured older adults would produce estimated monthly costs net of markups for administrative costs that comport closely to current market rates. Estimates also suggest that the total cost of providing dental coverage targeted specifically to nonusers of dental care may be less than similar costs for prior users.

Response error in reporting dental coverage by older Americans in the health and retirement study.

The aim of this research was to analyze the inconsistency in responses to survey questions within the Health and Retirement Study (HRS) regarding insurance coverage of dental services. Self-reports of dental coverage in the dental services section were compared with those in the insurance section of the 2002 HRS to identify inconsistent responses. Logistic regression identified characteristics of persons reporting discrepancies and assessed the effect of measurement error on dental coverage coefficient estimates in dental utilization models. In 18% of cases, data reported in the insurance section contradicted data reported in the dental use section of the HRS by those who said insurance at least partially covered (or would have covered) their (hypothetical) dental use. Additional findings included distinct characteristics of persons with potential reporting errors and a downward bias to the regression coefficient for coverage in a dental use model without controls for inconsistent self-reports of coverage. This study offers evidence for the need to validate self-reports of dental insurance coverage among a survey population of older Americans to obtain more accurate estimates of coverage and its impact on dental utilization.

Dental usage under changing economic conditions.

OBJECTIVE: The purpose of this article is to examine the relationship between changes in household finances (wealth and income) and changes in dental utilization at the onset of the recent recession in a population of older Americans. METHODS: Data from the Health and Retirement Study (HRS) were analyzed for U.S. individuals aged 51 years and older during the 2006 and 2008 waves of the HRS. We estimated logistic models of (a) starting and (b) stopping dental use between 2006 and 2008 survey periods as a function of changes in household wealth and income, controlling for other potentially confounding covariates. RESULTS: We found that only when household wealth falls by 50 percent or more were older adults less likely to seek dental care. Changes in household income and other changes in household wealth were not associated with changes in dental utilization among this population. CONCLUSIONS: Older Americans' dental care utilization appeared to be fairly resilient to changes in household finances; only when wealth fell by 50 percent or more did individuals decrease dental use. This finding might extend to other health-care services that are preventive, routine, and relatively inexpensive.

Patterns of older Americans' health care utilization over time.

OBJECTIVES: We analyzed correlates of older Americans' continuous and transitional health care utilization over 4 years. METHODS: We analyzed data for civilian, noninstitutionalized US individuals older than 50 years from the 2006 and 2008 waves of the Health and Retirement Study. We estimated multinomial logistic models of persistent and intermittent use of physician, inpatient hospital, home health, and outpatient surgery over the 2004-2008 survey periods. RESULTS: Individuals with worse or worsening health were more likely to persistently use medical care and transition into care and not transition out of care over time. Financial variables were less often significant and, when significant, were often in an unexpected direction. CONCLUSIONS: Older individuals' health and changes in health are more strongly correlated with persistence of and changes in care-seeking behavior over time than are financial status and changes in financial status. The more pronounced sensitivity to health status and changes in health are important considerations in insurance and retirement policy reforms.

The effect of dental insurance on dental care use and selection bias.

OBJECTIVES: We examine the effect of dental insurance coverage on the probability of having a dental care visit in light of selection bias. METHODS: We use data from the 2003 Medical Expenditure Panel Survey and use 3 different approaches to control for selection bias. First, we use a probit specification and include a rich set of independent variables that we posit control for unobserved attitudes toward risk and health care. Second, we use an instrumental variable model with family employment status as our instrument. Finally, we use a nonparametric approach to identify the upper and lower bounds of a dental insurance effect. We also ran a base probit model that did not include controls for attitudes toward risk and health care. RESULTS: The base probit, the probit including measure of attitudes, and the instrumental variable models provided similar estimates of the effect of dental insurance on the probability to seek dental care. This may indicate that selection bias may not be a concern. All estimates were within the bounds obtained through the nonparametric approach. CONCLUSIONS: Despite concerns of the potential endogeneity of dental insurance in models that estimate dental care use, we find evidence that these concerns may be unfounded.

Wealth effect and dental care utilization in the United States.

OBJECTIVE: The purpose of this article is to examine the relationship of wealth and income and the relative impact of each on dental utilization in a population of older Americans, using data from the Health and Retirement Study (HRS). METHODS: Data from the HRS were analyzed for US individuals aged 51 years and older during the 2008 wave of the HRS. The primary focus of the analysis is the relationship between wealth, income, and dental utilization. We estimate a multivariable model of dental use controlling for wealth, income, and other potentially confounding covariates. RESULTS: We find that both wealth and income each have a strong and independent positive effect on dental care use of older Americans (P < 0.05). A test of the interaction between income and wealth in our model failed to show that the impact on dental care utilization as wealth increases depends on a person's income level or, alternatively, that the impact on dental use as income increases depends on a person's household wealth status (P > 0.05). CONCLUSIONS: Relative to those living in the wealthiest US households, the likelihood of utilizing dental care appears to decrease with a decline in wealth. The likelihood of utilizing dental care also appears to decrease with a decline in income as well.

The influence of changes in dental care coverage on dental care utilization among retirees and near-retirees in the United States, 2004-2006.

OBJECTIVES: We examined dental care utilization transition dynamics between 2004 and 2006 in the context of changing dental coverage status. METHODS: We used data from the Health and Retirement Study for persons aged 51 years and older to estimate a multivariable model of dental care use transitions with controls for dental coverage and retirement transitions and other potentially confounding covariates. RESULTS: We found that Americans aged 51 years and older who lost dental coverage between the 2004 and 2006 survey periods were more likely to stop dental care use between periods, and those who gained coverage were more likely to start dental care use between periods, than those without coverage in both periods. CONCLUSIONS: Dental coverage transitions and status have a strong effect on transitions in dental care use. Given that retirement is a time when many experience a loss of dental coverage, older adults may be at risk for sporadic dental care and even stopping use, leading to worse dental and potentially overall health.

Dental care expenditures and retirement.

OBJECTIVES: To examine the relationship of dental care coverage, retirement, and out-of-pocket (OOP) dental expenditures in an aging population, using data from the Health and Retirement Study (HRS). METHODS: We estimate OOP dental expenditures among individuals who have dental utilization as a function of dental care coverage status, retirement, and individual and household characteristics. We also estimate a multivariate model controlling for potentially confounding variables. RESULTS: Overall, mean OOP dental expenditures among those with any spending were substantially larger for those without coverage than for those with coverage. However, controlling for coverage shows that there is little difference in spending by retirement status. CONCLUSIONS: Although having dental coverage is a key determinant of the level of OOP expenditures on dental care; spending is higher among those without coverage than those who have dental insurance. We also found that while retirement has no independent effect on OOP dental expenditures once controlling for coverage, dental coverage rates are much lower among retirees.

Dental care coverage and retirement.

OBJECTIVES: To examine the convergence of an aging population and a decreased availability of dental care coverage using data from the Health and Retirement Study (HRS). METHODS: We calculate national estimates of the number and characteristics of those persons age 51 years and above covered by dental insurance by labor force, retirement status, and source of coverage. We also estimate a multivariate model controlling for potentially confounding variables. RESULTS: We show that being in the labor force is a strong predictor of having dental coverage. For older retired adults not in the labor force, the only source for dental coverage is either a postretirement health benefit or spousal coverage. CONCLUSIONS: Dental care, generally not covered in Medicare, is an important factor in the decision to seek dental care. It is important to understand the relationship between retirement and dental coverage in order to identify the best ways of improving oral health and access to care among older Americans.

Dental care utilization and retirement.

OBJECTIVE: The authors examine the relationship of dental care coverage, retirement, and utilization in an aging population using data from the Health and Retirement Study (HRS). METHODS: The authors estimate dental care use as a function of dental care coverage status, retirement, and individual and household characteristics. They also estimate a multivariate model controlling for potentially confounding variables. RESULTS: The authors show that that the loss of income and dental coverage associated with retirement may lead to lower use rates but this effect may be offset by other unobserved aspects of retirement including more available free time leading to an overall higher use rate. CONCLUSIONS: The authors conclude from this study that full retirement accompanied by reduced income and dental insurance coverage produces lower utilization of dental services. However, they also show that retirement acts as an independent variable, whereas income, coverage, and free time (unobserved) act as intervening variables.

Dental care coverage transitions.

OBJECTIVE: To examine dental insurance transition dynamics in the context of changing employment and retirement status. STUDY DESIGN: Data from the Health and Retirement Study (HRS) were analyzed for individuals 51 years and older between the 2004 and 2006 waves of the HRS. METHODS: The primary focus of the analysis is the relationship between retirement and transitions in dental care coverage. We calculate and present bivariate relationships between dental coverage and retirement status transitions over time and estimate a multivariable model of dental coverage controlling for retirement and other potentially confounding covariates. RESULTS: Older adults are likely to lose their dental coverage on entering retirement compared with those who remain in the labor force between waves of the HRS. While more than half of those persons in the youngest group (51-64 years) were covered over this entire period, two-thirds of those in the oldest group (>or=75 years) were without coverage over the same period. We observe a high percentage of older persons flowing into and out of dental coverage over the period of our study, similar to flows into and out of poverty. CONCLUSIONS: Dental insurance is an important factor in the decision to seek dental care. Yet, no dental coverage is provided by Medicare, which provides medical insurance for almost all Americans 65 years and older. This loss of coverage could lead to distortions in the timing of when to seek care, ultimately leading to worse oral and overall health.

Using performance standards to evaluate social programs with incomplete outcome data. General issues and application to a higher education block grant program.

The idea of program evaluation is both simple and appealing. Program outcomes are measured and compared to some minimum performance standard or threshold. In practice, however, evaluation is difficult. Two fundamental problems of outcome measurement must be addressed. The first, which we call the problem of auxiliary outcomes, is that we do not observe outcome of interest. The second, which we call the problem of counterfactual outcomes, is that we do not observe the threshold standard. This article examines how performance standard should be set and applied in the face of these problems in measuring outcomes. The central message is that the proper way to implement standards varies with the prior information an evaluator can credibly bring to bear to compensate for incomplete outcome data. By combining available data with credible assumptions on treatments and outcomes, the performance of a program may be deemed acceptable, unacceptable, or indeterminate.