Hit-and-run or hit-and-stay? Unintended effects of a stricter BAC limit.

Although they comprise a relatively small subset of all traffic deaths, hit-and-run (HR) fatalities are both contemptible and preventable. We analyze longitudinal data from 1982 to 2008 to examine the effects of blood alcohol concentration (BAC) laws on HR traffic fatalities. Our results suggest that lower BAC limits may have an unintended consequence of increasing HR fatalities, whereas a similar effect is absent for non-HR fatalities. Specifically, we find that the adoption of a 0.08 BAC limit is associated to an 8.3% increase in HR fatalities. This unintended effect is more pronounced in urban areas and during weekends, which are typical settings for HR incidents.

Trends in Health Care Utilization and Expenditures in the United States Across 5 Decades: 1977-2017.

BACKGROUND: Health care expenditures in the United States are high and rising, with significant increases over the decades. The delivery, organization, and financing of the health care system has evolved over time due to technological innovation, policy changes, patient preferences, altering payment mechanisms, shifting demographics, and other factors. OBJECTIVE: The objective of this study was to examine trends over time in health care utilization and expenditures in the United States. RESEARCH DESIGN: This analysis employs descriptive statistics to examine 5 decades of health care utilization and expenditure data from the Agency for Healthcare Research and Quality (AHRQ) for 1977-2017. MEASURES: Measures include utilization and expenditures (not charges) for inpatient, emergency department, outpatient physician, outpatient nonphysician, office-based physician, dental, and out-of-pocket retail prescription drugs. RESULTS: We demonstrate that while health care expenditures have increased significantly overall and by type of care, utilization trends are less pronounced. The population of the United States grew 53% between 1977 and 2017, while annual total expenditures on health care increased by 208%. Amidst attention to out-of-pocket exposure for unexpected medical care bills, out-of-pocket payments for care have declined from 32% in 1977 to 12% in 2017 but increased in amount. CONCLUSIONS: This article provides the first extended snapshot of the dynamics of health care utilization and expenditures in the United States. Aspects of health care are much different today than in previous decades, yet the inpatient setting still dominates the expenditures.

The relationships between marijuana use and exercise among young and middle-aged adults.

As decriminalization, increased access, and decreased perception of risk spurs the popularity of medical and recreational marijuana, more information is needed on possible links between marijuana use and social determinants of health. The goal of this study was to assess the relationships between marijuana use and exercise. Data sources included the two most recent waves of the National Longitudinal Study of Adolescent to Adult Health (Wave IV, 2008-2009; N = 14,784 and Wave V, 2016-2018; N = 12,043). The exercise variables included any form of exercise/sport during the past 7 days and the number of days participating in each of 7 types of exercise/sport. Marijuana-use variables comprised any current use and frequency of use during the past 30 days. Both fixed-effects and random-effects models were estimated with numerous control variables, along with binary and count measures of exercise. Results show that, particularly for fixed-effects models, marijuana use is not significantly related to exercise, counter to conventional wisdom that marijuana users are less likely to be active. Indeed, the only significant estimates suggest a positive relationship, even among heavier users during the past 30 days. These findings are at odds with much of the existing literature, which generally shows a negative relationship between marijuana use and exercise. As additional states legalize the medicinal and recreational use of marijuana, perhaps its impact on exercise, one of the leading social determinants of health, is not necessarily a primary concern.

The effect of genetic vs nongenetic parental care on adult children's income and wealth in later life: An evolutionary analysis.

OBJECTIVE: Using Wave IV of the National Longitudinal Study of Adolescent to Adult Health data set, this preregistered study set out to investigate the effect of parental care arrangements (eg, genetically related parents, adoptive, step/ foster, genetic nonparental relative, and no parental figure) on adult children's income and wealth in later life. METHODS: Consistent with the preregistration plan, multivariate analyses of covariance were first used to examine, separately, the effects of paternal and maternal care arrangements on children's income and wealth in later life. Further post hoc exploratory analyses were carried out to evaluate the robustness of the findings. RESULTS: The results indicate that individual earnings in later life are unrelated to paternal care arrangements, thus questioning a key tenet of kin selection theory. However, children raised by biological fathers and adoptive fathers still enjoy significant economic advantages over nongenetic father figures and homes without fathers in relation to household income and wealth. CONCLUSIONS: Prevailing theories suggest that children raised by relatives, nongenetically related parents, and no father or mother suffer from a lack of parental investment that should manifest itself in reduced earnings and assets in adulthood. These theories are only partially correct, with evidence pointing to no deleterious effect of variable parental arrangements on individual earnings.

The Application of a Hospital Medical Surge Preparedness Index to Assess National Pandemic and Other Mass Casualty Readiness.

EXECUTIVE SUMMARY: This article describes the use and findings of the Hospital Medical Surge Preparedness Index (HMSPI) tool to improve the understanding of hospitals' ability to respond to mass casualty events such as the COVID-19 pandemic. For this investigation, data from the U.S. Census Bureau, the Dartmouth Atlas Project, and the 2005 to 2014 annual surveys of the American Hospital Association (AHA) were analyzed. The HMSPI tool uses variables from the AHA survey and the other two sources to allow facility, county, and referral area index calculations. Using the three data sets, the HMSPI also allows for an index calculation for per capita ratios and by political (state or county) boundaries. In this use case, the results demonstrated increases in county and state HMSPI scores through the period of analysis; however, no statistically significant difference was found in HMSPI scores between 2013 and 2014. The HMSPI builds on the limited scientific foundation of medical surge preparedness and could serve as an objective and standardized measure to assess the nation's medical readiness for crises such as the COVID-19 pandemic and other large-scale emergencies such as mass shootings. Future studies are encouraged to refine the score, assess the validity of the HMSPI, and evaluate its relevance in response to future legislative and executive policies that affect preparedness measures.

Hormone Therapy and Discrimination in the Labor Market: Emerging Experimental Evidence on the Economics of Endocrinology.

BACKGROUND: Gender transitioning is increasingly common, but little is known about the extent to which individuals in transition and fully transitioned suffer from wage discrimination. Methods: Managers in the United States (n=204) were shown photos of white and Asian male and female "employees" at different stages of simulated hormone therapy and were asked to estimate their actual hourly wages based on appearance. RESULTS: The results suggest that Asian men and women "in transition" and fully transitioned do not suffer from significant wage discrimination. However, among the white stimuli, gender atypical ("in transition" and fully transitioned) men and women are estimated to earn significantly less than their gender typical (sexually dimorphic) counterparts, with some gender-specific nuances. CONCLUSIONS: The effects of hormone therapy may have a deleterious impact on the wages of white transgender individuals.

Psychological Distress and Coronavirus Fears During the Initial Phase of the COVID-19 Pandemic in the United States.

INTRODUCTION: The COVID-19 pandemic is a significant health and economic crisis around the world. The U.S. saw a rapid escalation in laboratory-confirmed cases of COVID-19 and related deaths in March, 2020. The financial consequences of a virtual economic shutdown to curb the spread of the coronavirus are widespread and debilitating, with over 30 million Americans (about 20% of the labor force) filing for unemployment benefits since mid-March. During these unprecedented times, it is important to understand the impact of the COVID-19 pandemic on psychological distress and overall fear associated with the virus. DATA: To gain an understanding of the overall levels and predictors of psychological distress experienced in the first month of the COVID-19 pandemic in the U.S., a survey was administered online to over 2,000 individuals residing in the country. The survey instrument was administered between March 22-26, 2020, during which time the country was suffering through a period of exponential growth in COVID-19 cases and fatalities. It was administered via MTurk, a popular crowdsourcing platform increasingly used by social scientists to procure large samples over a brief period of time. A short, valid screening instrument to measure psychological distress in individuals, the Kessler 10 scale was developed in the U.S. in the 1990s as an easy-to-administer symptom assessment. The first dependent variable is the respondents' summated Kessler 10 score. The second dependent variable is a 7-category measure of how afraid the subject is about the novel coronavirus. The final dependent variable is also a 7-category scale, this time measuring self-reported likelihood of contracting the coronavirus. A variety of socio-demographic variables and health status were collected to analyze factors associated with psychological distress and mental health. METHODS: Ordinary Least Squares (OLS) multiple regression was employed to analyze these data. RESULTS: We find that protective factors against psychological distress include age, gender (male), and physical health. Factors exacerbating psychological distress include Hispanic ethnicity and a previous mental illness diagnosis. Similar factors are significantly related to fear of the virus and self-assessed likelihood of contracting it. DISCUSSION: The COVID-19 pandemic is associated with high levels of psychological distress in the U.S. The Kessler 10 mean value in our sample is 21.12, which falls in the likely to experience mild mental illness category, yet is considerably higher compared to one of the largest and earliest benchmark studies validating the scale. Psychological distress is one element of overall mental health status that could be influenced by the COVID-10 pandemic. Other mental health conditions such as depression, anxiety, and substance use disorders could also be affected by the pandemic. We encourage researchers to examine these and other mental health disorders in future research on the COVID-19 pandemic. CONCLUSION: The relatively high mean score (21.12) for psychological distress during early stages of the pandemic suggests government officials, policy-makers, and public health advocates should act quickly to address emerging mental health problems.

Why Money Alone Can't (Always) "Nudge" Physicians: The Role of Behavioral Economics in the Design of Physician Incentives.

Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.

Self-reported Health Status Differs for Amazon's Mechanical Turk Respondents Compared With Nationally Representative Surveys.

BACKGROUND: Amazon's Mechanical Turk (MTurk) platform has become a data source for peer-reviewed academic research publications, with over 24,000 Google Scholar search results. Although well-developed and supportive in other disciplines, the literature in health and medicine comparing results from samples generated on MTurk to gold standard, nationally representative health and medical surveys is beginning to emerge. OBJECTIVE: To compare the demographic, socioeconomic, and self-reported health status variables in an MTurk sample to those from 2 prominent national probability surveys, including the Medical Expenditure Panel Survey (MEPS) and the Behavioral Risk Factor Surveillance System (BRFSS). RESEARCH DESIGN: We analyze weighted and unweighted tabulations of the MTurk, MEPS, and BRFSS. Wald tests identify statistical significance. MEASURES: Demographic, socioeconomic, and health status variables in an adult MTurk sample collected in 2016 (n=1916), the 2015 MEPS household survey component (n=21,210), and the 2015 BRFSS (n=283,502). RESULTS: Our findings indicate statistically significant differences in the demographic, socioeconomic, and self-perceived health status tabulations in the MTurk sample relative to the unweighted and weighted MEPS and BRFSS. The MTurk sample is more likely to be female (65.8% in MTurk, 50.9% in MEPS, 50.2% in BRFSS), white (80.1% in MTurk, 76.9% in MEPS, and 73.9% in BRFSS), non-Hispanic (91.1%, 82.4%, and 81.4%, respectively), younger, and less likely to report excellent health status (6.8% in MTurk, 28.3% in MEPS, and 20.2% in BRFSS). CONCLUSIONS: We find significant differences across variables that warrant hesitation in using MTurk data as a replacement for the gold standard datasets in health services research.

The economic costs of jail-based methadone maintenance treatment.

BACKGROUND: The US has the highest incarceration rate in the world and spends $40-$80 billion to house inmates per year. It is well-known that a significant correlation is present between substance use and crime, especially over recent years as opioid use disorder (OUD) has grown exponentially. To mitigate OUD, methadone maintenance treatment (MMT) has demonstrated effectiveness in numerous randomized and quasi-experimental studies. A potentially fruitful environment for MMT is correctional facilities, particularly short-term facilities, such as city and county jails. However, little is known about the economic implications of MMT within correctional facilities. OBJECTIVE: The aim of the present study was to estimate the economic costs of jail-based MMT using data from a novel, established MMT program located within a large urban jail in New Mexico. METHODS: Data were collected using administrative records and by interviewing program administrators using a modified version of the Drug Abuse Treatment Cost Analysis Program (DATCAP). Both sensitivity analysis and cost-structure analysis were conducted to gauge the robustness of the findings. RESULTS: The average (per patient) weekly cost of MMT is $115 and the total treatment cost for an average treatment episode is $689. These costs are generally in-line with non-jail-based MMT programs of similar size. Weekly cost estimates range from $86 to $185 depending on the size of the treatment facility, with larger programs exhibiting lower per-patient costs. CONCLUSION: Results provide a valuable economic benchmark to policy makers, criminal justice officials, and program administrators considering establishing and/or expanding MMT in jail settings.

The Role of Adolescent Friendship Group Integration and Cohesion in Weapon-Related Violent Crime as a Young Adult.

Weapon-related violent crime is a serious, complex, and multifaceted public health problem. The present study uses data from Waves I and III of Add Health (n = 10,482, 54% female) to examine how friendship group integration and cohesion in adolescence (ages 12-19) is associated with weapon-related criminal activity as a young adult (ages 18-26). Results indicate that greater cohesion in friendship groups is associated with significantly lower weapon-related criminal activity in young adulthood. In addition, for adolescent girls, a greater number of close friendship ties-an indicator of friendship group integration-is associated with less weapon-related criminal activity in young adulthood. These findings suggest that school-based initiatives to facilitate inclusive and cohesive adolescent peer communities may be an effective strategy to curb weapon-related criminal activity in young adulthood.

A Randomized Controlled Trial of a Telephone Intervention for Alcohol Misuse With Injured Emergency Department Patients.

STUDY OBJECTIVE: We conduct a randomized controlled trial to test efficacy of a telephone intervention for injured emergency department (ED) patients with alcohol misuse to decrease alcohol use, impaired driving, alcohol-related injuries, and alcohol-related negative consequences. METHODS: ED patients screening positive for alcohol misuse were randomized to a 3-session telephone brief motivational intervention on alcohol, delivered by a counselor trained in motivational interviewing during 6 weeks, or a control intervention of a scripted home fire and burn safety education delivered in 3 calls. Patients were followed for 12 months and assessed for changes in alcohol use, impaired driving, alcohol-related injuries, and alcohol-related negative consequences. RESULTS: Seven hundred thirty ED patients were randomized; 78% received their assigned intervention by telephone, and of those, 72% completed 12-month assessments. There were no differential benefits of telephone brief motivational intervention versus assessment and a control intervention in all 3 variables of alcohol use (frequency of binge alcohol use during the previous 30 days, maximum number of drinks at one time in the past 30 days, and typical alcohol use in the past 30 days), alcohol-impaired driving, alcohol-related injuries, and alcohol-related negative consequences. CONCLUSION: Despite the potential advantage of delivering a telephone brief motivational intervention in not disrupting ED clinical care, our study found no efficacy for it over an assessment and control intervention. Potential causes for our finding include that injury itself, alcohol assessments, or the control intervention had active ingredients for alcohol change.

A randomized trial to identify accurate and cost-effective fidelity measurement methods for cognitive-behavioral therapy: project FACTS study protocol.

BACKGROUND: This randomized trial will compare three methods of assessing fidelity to cognitive-behavioral therapy (CBT) for youth to identify the most accurate and cost-effective method. The three methods include self-report (i.e., therapist completes a self-report measure on the CBT interventions used in session while circumventing some of the typical barriers to self-report), chart-stimulated recall (i.e., therapist reports on the CBT interventions used in session via an interview with a trained rater, and with the chart to assist him/her) and behavioral rehearsal (i.e., therapist demonstrates the CBT interventions used in session via a role-play with a trained rater). Direct observation will be used as the gold-standard comparison for each of the three methods. METHODS/DESIGN: This trial will recruit 135 therapists in approximately 12 community agencies in the City of Philadelphia. Therapists will be randomized to one of the three conditions. Each therapist will provide data from three unique sessions, for a total of 405 sessions. All sessions will be audio-recorded and coded using the Therapy Process Observational Coding System for Child Psychotherapy-Revised Strategies scale. This will enable comparison of each measurement approach to direct observation of therapist session behavior to determine which most accurately assesses fidelity. Cost data associated with each method will be gathered. To gather stakeholder perspectives of each measurement method, we will use purposive sampling to recruit 12 therapists from each condition (total of 36 therapists) and 12 supervisors to participate in semi-structured qualitative interviews. DISCUSSION: Results will provide needed information on how to accurately and cost-effectively measure therapist fidelity to CBT for youth, as well as important information about stakeholder perspectives with regard to each measurement method. Findings will inform fidelity measurement practices in future implementation studies as well as in clinical practice. TRIAL REGISTRATION: NCT02820623 , June 3rd, 2016.

Got Munchies? Estimating the Relationship between Marijuana Use and Body Mass Index.

BACKGROUND: Although marijuana use is commonly associated with increased appetite and the likelihood of weight gain, research findings in this area are mixed. Most studies, however, report cross-sectional associations and rarely control for such important predictors as physical activity, socioeconomic status, and alcohol and other drug use. METHODS: Using data from Waves III (N = 13,038) and IV (N = 13,972) of the National Longitudinal Survey of Adolescent Health, we estimate fixed-effects models to more rigorously study the relationships between marijuana use and body mass index over time. Our analyses include numerous sensitivity tests using alternative estimation techniques and at Wave IV we investigate the relationship between marijuana use and an alternative measure of body size (waist circumference). RESULTS: Results show that daily female marijuana users have a BMI that is approximately 3.1% (p<0.01) lower than that of non-users, whereas daily male users have a BMI that is approximately 2.7% (p<0.01) lower than that of non-users. DISCUSSION: The present study indicates a negative association between marijuana use and BMI. Uncovering a negative association between marijuana use and weight status is a valuable contribution to the literature, as this result contradicts those from some previous studies, which were unable to address time-invariant unobserved heterogeneity. IMPLICATIONS FOR FUTURE RESEARCH: Future theory-based research is necessary to explore the metabolic and behavioral pathways underlying the negative associations between marijuana use and BMI. A broader understanding of such mechanisms along with causal estimates will be most helpful to both policymakers and clinicians.

Personal traits, cohabitation, and marriage.

This study examines how personal traits affect the likelihood of entering into a cohabitating or marital relationship using a competing risk survival model with cohabitation and marriage as competing outcomes. The data are from Waves 1, 3, and 4 of the National Longitudinal Study of Adolescent Health, a rich dataset with a large sample of young adults (N=9835). A personal traits index is constructed from interviewer-assessed scores on the respondents' physical attractiveness, personality, and grooming. Having a higher score on the personal traits index is associated with a greater hazard of entering into a marital relationship for men and women, but the score does not have a significant influence on entering into a cohabitating relationship. Numerous sensitivity tests support the core findings.

Economic Costs of a Postrelease Intervention for Incarcerated Female Substance Abusers: Recovery Management Checkups for Women Offenders (RMC-WO).

This study estimates the economic costs of Recovery Management Checkups for Women Offenders (RMC-WO), highlighting the unique mix of services and differential costs between two distinct phases of the intervention. Participants were randomly assigned to quarterly outcome monitoring (OM) only (n=242) or OM plus Recovery Management Checkups (OM-plus-RMC) (n=238). The OM-only condition has a total annual economic cost of $76,010, which equates to $81 quarterly per person. The average cost per OM interview completed is $86. OM-plus-RMC generates a total annual economic cost of $126,717, or $137 quarterly per person. The cost per interview completed is $147 and the cost per intervention session completed is $161. RMC-WO has a relatively modest additional cost compared with the average costs of post-release supervision, which can range from $3.42 ($1,250) per day (year) for probationers to $7.47 ($2,750) per day (year) for parolees. The clinical, economic, and policy implications of incorporating RMC-WO into existing corrections and/or community-based treatment settings are discussed.

Mental health and risky sexual behaviors: evidence from DSM-IV Axis II disorders.

BACKGROUND: Several economic studies link poor mental health and substance misuse with risky sexual behaviors. However, none have examined the relationships between DSM-IV Axis II mental health disorders (A2s) and risky sexual behaviors. A2 disorders are a poorly understood, yet prevalent and disabling class of mental health conditions. They develop early in life through an interaction of genetics and environment, and are persistent across the life course. Common features include poor impulse control, addiction, social isolation, and elevated sexual desires, although the defining features vary substantially across disorder. AIMS OF THE STUDY: To investigate the association between A2 disorders and three measures of risky sexual behavior. METHODS: We obtain data on adults age 20 to 50 years from Wave II of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC). Our outcome measures include early initiation into sexual activity, and past year regular use of alcohol before sex and sexually transmitted disease diagnosis. NESARC administrators use the Alcohol Use Disorder and Associated Disabilities Interview Schedule to classify respondents as meeting criteria for the ten A2 disorders recognized by the American Psychiatric Association. We construct several measures of A2 disorders based on the NESARC administrators' classifications. Given their comorbidity with A2 disorders, we explore the importance of Axis I disorders in the estimated associations. RESULTS: We find that A2 disorders are generally associated with an increase in the probability of risky sexual behaviors among both men and women. In specifications that disaggregate disorders into clusters and specific conditions, the significant associations are not uniform, but are broadly consistent with the defining features of the cluster or disorder. Inclusion of A1 disorders attenuates estimated associations for some risky sexual behaviors among men, but not for women. DISCUSSION: We find positive associations between A2 disorders and our measures of risky sexual behaviors. Our findings are subject to several data limitations, however. The NESARC lacks information on more advanced risky sexual behaviors and our measure of early initiation into sexual activity is retrospective. Identifying the causal effects of mental health and risky sexual behaviors is complicated due to bias from reverse causality and omitted variables. We believe these sources of bias are less of a concern in our study, however. Specifically, A2 disorders develop early in life and pre-date the risky sexual behaviors, thus negating reverse causality. Because the NESARC contains a rich set of personal characteristics, we are also able to minimize potential omitted variable bias. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: A2 disorders are significantly associated with risky sexual behaviors, which could lead to greater utilization and cost of health care services. IMPLICATION FOR HEALTH POLICIES: Health care providers should consider A2 disorders when developing health promotion recommendations as these disorders may place individuals at elevated risk for unsafe sexual behaviors. IMPLICATIONS FOR FURTHER RESEARCH: Future studies should examine the causal mechanisms between A2 disorders and risky sexual behaviors.

Adolescent alcohol use, sociability and income as a young adult.

We use data from the National Longitudinal Survey of Adolescent Health (Add Health) to study how sociability and adolescent alcohol use impact personal income as a young adult. We find that factors which enhance not only individual sociability but also social interaction at the community level are positively linked to future earnings of adolescents. Adolescents whose friends and friends of friends have greater sociability reap long-term labor market rewards into adulthood. After adjusting for individual and community sociability, the effect of teenage alcohol consumption on labor market earnings as young adults is reduced. Our results suggest that earnings premiums associated with adolescent alcohol consumption may be partially explained by social network dynamics.

Alcohol use and crime: findings from a longitudinal sample of U.S. adolescents and young adults.

BACKGROUND: A positive relationship between alcohol use and criminal activity has been well documented among adults, but fewer studies explore this relationship among adolescents. METHODS: Using data from 4 waves of the National Longitudinal Study of Adolescent Health (Add Health), we examine alcohol use patterns and criminal activity from adolescence to young adulthood. Fixed-effects models partially address the potential endogeneity of alcohol use, and, because numerous studies indicate that males are more likely than females to engage in drinking and criminal activity, the analyses are segmented by gender. RESULTS: We find a strong positive relationship between alcohol consumption, the commission of crimes, and criminal victimization for both genders. Various sensitivity analyses and robustness checks support this core finding. CONCLUSIONS: Our results have important policy implications, as public policy tools that aim to reduce drinking among adolescents could also reduce criminal activity. Moreover, effective alcohol abuse treatment may indirectly reduce delinquency and thus have greater long-term economic benefits than previously estimated.

Easing the pain of an economic downturn: macroeconomic conditions and excessive alcohol consumption.

Individuals can react to financial stress in a variety of ways, such as reducing discretionary spending or engaging in risky behaviors. This article investigates the effect of changing macroeconomic conditions (measured by the unemployment rate in the state of residence) on one type of risky behavior: excessive alcohol consumption. Using unique and recent panel data from waves 1 and 2 of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) and estimating fixed-effects models, we find that changes in the unemployment rate are positively related to changes in binge drinking, alcohol-involved driving, and alcohol abuse and/or dependence. Some differences are present among demographic groups, primarily in the magnitude of the estimated effects. These results contradict previous studies and suggest that problematic drinking may be an indirect and unfortunate consequence of an economic downturn.