Unconditional cash transfers and mental health symptoms among parents with low incomes: Evidence from the 2021 child tax credit.

The COVID-19 pandemic increased anxiety and depression in the U.S. population, particularly among low-income households, parents, and Black and Hispanic adults. To address the negative impacts of the pandemic, Congress temporarily expanded the Child Tax Credit (CTC) in 2021, providing a near-universal, unconditional cash transfer to families with children. Using a quasi-experimental, parameterized difference-in-differences research design, we examine the effects of the 2021 monthly CTC on symptoms of anxiety and depression in a large, national sample of parents with low incomes (N∼15,000). We study potential differences in the associations by race/ethnicity and consider whether CTC effects were stronger after a longer treatment period (for instance, due to greater dosage or delayed effects). We find some evidence that the monthly credit reduced parental anxiety and depression symptoms, although the results were not robust throughout all model specifications. Analyses stratified by race/ethnicity show stronger associations for non-Hispanic Black parents than for non-Hispanic White parents or Hispanic parents, although differences were small. We also find the credit reduced anxiety (but not depression) symptoms after three months of payments, suggesting that it took some time for the CTC to affect mental health symptoms. Overall, this study suggests that recurring cash transfers to families in poverty in the U.S. may have small beneficial effects on parental mental health.

Emergency unemployment benefits and health care spending during Covid.

OBJECTIVE: To estimate the impact of the $600 per week Federal Pandemic Unemployment Compensation (FPUC) payments on health care services spending during the Covid pandemic and to investigate if this impact varied by state Medicaid expansion status. DATA SOURCES: This study leverages novel, publicly available data from Opportunity Insights capturing consumer credit and debit card spending on health care services for January 18-August 15, 2020 as well as information on unemployment insurance claims, Covid cases, and state policy changes. STUDY DESIGN: Using triple-differences estimation, we leverage two sources of variation-within-state change in the unemployment insurance claims rate and the introduction of FPUC payments-to estimate the moderating effect of FPUC on health care spending losses as unemployment rises. Results are stratified by state Medicaid expansion status. EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: For each percentage point increase in the unemployment insurance claims rate, health care spending declined by 1.0% (<0.05) in Medicaid expansion states and by 2.0% (<0.01) in nonexpansion states. However, FPUC partially mitigated this association, boosting spending by 0.8% (<0.001) and 1.3% (<0.05) in Medicaid expansion and nonexpansion states, respectively, for every percentage point increase in the unemployment insurance claims rate. CONCLUSIONS: We find that FPUC bolstered health care spending during the Covid pandemic, but that both the negative consequences of unemployment and moderating effects of federal income supports were greatest in states that did not adopt Medicaid expansion. These results indicate that emergency federal spending helped to sustain health care spending during a period of rising unemployment. Yet, the effectiveness of this program also suggests possible unmet demand for health care services, particularly in states that did not adopt Medicaid expansion.

A Universal Child Allowance: A Plan to Reduce Poverty and Income Instability Among Children in the United States.

To reduce child poverty and income instability, and eliminate extreme poverty among families with children in the United States, we propose converting the Child Tax Credit and child tax exemption into a universal, monthly child allowance. Our proposal is based on principles we argue should undergird the design of such policies: universality, accessibility, adequate payment levels, and more generous support for young children. Whether benefits should decline with additional children to reflect economies of scale is a question policymakers should consider. Analyzing 2015 Current Population Survey data, we estimate our proposed child allowance would reduce child poverty by about 40 percent, deep child poverty by nearly half, and would effectively eliminate extreme child poverty. Annual net cost estimates range from $66 billion to $105 billion.

Racial and Ethnic Disparities in the Lifetime Prevalence of Homelessness in the United States.

Homelessness in the United States is often examined using cross-sectional, point-in-time samples. Any experience of homelessness is a risk factor for adverse outcomes, so it is also useful to understand the incidence of homelessness over longer periods. We estimate the lifetime prevalence of homelessness among members of the Baby Boom cohort (n = 6,545) using the 2012 and 2014 waves of the Health and Retirement Study (HRS), a nationally representative survey of older Americans. Our analysis indicates that 6.2 % of respondents had a period of homelessness at some point in their lives. We also identify dramatic disparities in lifetime incidence of homelessness by racial and ethnic subgroups. Rates of homelessness were higher for non-Hispanic blacks (16.8 %) or Hispanics of any race (8.1 %) than for non-Hispanic whites (4.8 %; all differences significant with p < .05). The black-white gap, but not the Hispanic-white gap, remained significant after adjustment for covariates such as education, veteran status, and geographic region.

Is a mid-level dental provider model acceptable to potential patients?

OBJECTIVE: This study aims to assess patient attitudes toward mid-level dental providers, known as dental therapists (DTs), by surveying those likely to be their patients. The recent adoption of accreditation standards by the Commission on Dental Accreditation has reignited a debate surrounding the state-by-state legalization of DTs in the United States; while the dental profession is divided on DTs, it is important to understand how potential patients may view the DT model. METHODS: A questionnaire that asks about oral health experience, and comfort with the model of a dually trained dental therapist-hygienist, based on a provided definition, was administered to 600 patients and their waiting room companions at a large urban university-based dental clinic. RESULTS: Forty percent of respondents indicated they would be comfortable being treated by a DT for all 7 of the procedures referenced, and over 75% were comfortable with each of 5 procedures. Having caps or crowns placed was the only treatment about which respondents were evenly divided. Factors associated with greater odds of comfort with various procedures include being uninsured and being under the age of 65. Uninsured patients were 1.5 to 2 times more likely than privately insured patients to accept a DT. CONCLUSIONS: The introduction of mid-level dental providers is a strategy that those lacking regular care appear on the whole to be comfortable with.

Low-Income Parents' Perceptions of Oral Health and Acceptance of Mid-level Dental Providers.

PURPOSE: The purpose of this study was to explore low-income parents' perceptions of oral health and of mid-level dental providers as a means of improving access to care. As states increasingly consider adding mid-level providers to the dental workforce, understanding the views of potential patients toward such providers is important, since the success of this strategy will depend, in part, upon the willingness of potential patients to be treated by them. METHODS: Because little is known about the social acceptability of mid-level dental providers, the researchers employed a qualitative methodology, conducting in-depth interviews with 20 low-income parents in order to assess their perceptions of oral health, access to and need for dental care, and potential acceptance of mid-level dental providers. Interview transcripts were analyzed by a team of researchers using interpretive research methods. RESULTS: Respondents' descriptions of experiences with oral health and dental care demonstrate their strong desire to maintain their families' oral health, as well as their perception that they face significant barriers to receiving needed care. The vast majority of respondents expressed positive inclinations toward the introduction of mid-level dental providers, particularly once they understood that such providers would be fully trained professionals. Though in reality the cost to a patient would likely not vary, many respondents expressed increased interest in treatment by mid-level providers if it were less expensive than treatment by dentists, indicating the significant barrier that cost posed for many in the sample. CONCLUSION: The low-income parents in this sample would likely seek care from mid-level dental providers if such providers were introduced in the U.S. The success of mid-level providers in meeting the needs of this population would potentially be even greater if public education clearly explained their training and professionalism.

Toward a better understanding of dental appointment-keeping behavior.

OBJECTIVE: Broken appointments cause adverse outcomes in healthcare systems: They interrupt continuity of care, waste resources, affect workflow, and reduce population-wide access to care. A better understanding of dental appointment-keeping behavior would support efforts toward designing novel interventions aimed at reducing rates of broken appointments. METHODS: The authors conducted a conceptual review of quantitative and qualitative research on dental appointment-keeping in the United States. RESULTS: Research in this area is limited. Providers tend to use a blunt instrument to improve appointment-keeping: a system of reminder calls. There is evidence that patients with higher rates of broken dental appointments are the very ones who are most in need of care. Appointment-keeping barriers are multifactorial and related to social issues. They can be described as falling into three overlapping categories: psychological barriers, structural barriers, and health literacy barriers. CONCLUSIONS: Appointment-keeping interventions could simultaneously address social factors that exacerbate illness and improve workflow and finances. There arises an opportunity to design innovative patient-centered interventions tailored to particular barriers.

The Origins of Minnesota's Mid-Level Dental Practitioner: Alignment of Problem, Political and Policy Streams.

PURPOSE: Using John Kingdon's agenda-setting model, this paper explores how Minnesota came to legislate a mid-level dental practitioner to its oral health workforce. Using a pluralist framework embracing the existence of various interests and convictions, this analysis highlights the roles of issue formation, agenda setting and politics in policymaking. METHODS: Using Kingdon's agenda-setting model as a theoretical lens, and applying case study methodology, this paper analyzes how Minnesota came to legislate a mid-level dental practitione to its oral health workforce. Data have come from scholarly research, governmental and foundation agency reports, interviews with leaders involved in the mid-level dental practitioner initiative, news articles, and Minnesota statute. RESULTS: After 2 years of contentious and challenging legislative initiatives, the problem, policy and political streams converged and aligned with the compromise passage of a bill legalizing mid-level dental practitioner practice. The Minnesota Dental Therapist Law was the first-in-the-nation licensing law to develop a new dental professional workforce model to address access to oral health care. CONCLUSION: The Minnesota mid-level dental practitioner initiative demonstrates the important convergence and alignment of the access to oral health care problem and the subsequent collaboration between political interest groups and policymakers. Through partnerships and pluralist compromise, mid-level dental practitioner champions were able to open the policy window to move this legislation to law, enhancing the oral health workforce in Minnesota.

Safety Net Care and Midlevel Dental Practitioners: A Case Study of the Portion of Care That Might Be Performed Under Various Setting and Scope-of-Practice Assumptions.

OBJECTIVES: We sought to determine the proportion of dental care provided at safety net-type clinics that might be performed by midlevel practitioners. METHODS: Data were obtained on 157,328 procedures performed in 2012 at the clinics associated with a Midwestern dental school. Based on procedure codes, we determined the overall proportion, as well as the proportion of visits and patients' care, that could have been performed by 3 types of practitioners. RESULTS: Overall, 48% to 66% of all procedures could have been performed by a midlevel dental practitioner. Nearly half of all visits, and roughly a third of all patients, could have been entirely cared for by a practitioner trained in prophylaxis and with evaluation capabilities. Such practitioners could handle roughly 80% of the visits at the community-based clinic and more than half of the visits at the hospital-based clinic. CONCLUSIONS: A midlevel practitioner with training in prophylaxis has the potential to alleviate much of the burden on the dental safety net because much of the need among vulnerable populations falls well within their scope of practice.

The origins of Minnesota's mid-level dental practitioner: alignment of problem, political and policy streams.

PURPOSE: Using John Kingdon's agenda-setting model, this paper explores how Minnesota came to legislate a mid-level dental practitioner to its oral health workforce. Using a pluralist framework embracing the existence of various interests and convictions, this analysis highlights the roles of issue formation, agenda setting and politics in policymaking. METHODS: Using Kingdon's agenda-setting model as a theoretical lens, and applying case study methodology, this paper analyzes how Minnesota came to legislate a mid-level dental practitione to its oral health workforce. Data have come from scholarly research, governmental and foundation agency reports, interviews with leaders involved in the mid-level dental practitioner initiative, news articles, and Minnesota statute. RESULTS: After 2 years of contentious and challenging legislative initiatives, the problem, policy and political streams converged and aligned with the compromise passage of a bill legalizing mid-level dental practitioner practice. The Minnesota Dental Therapist Law was the first-in-the-nation licensing law to develop a new dental professional workforce model to address access to oral health care. CONCLUSION: The Minnesota mid-level dental practitioner initiative demonstrates the important convergence and alignment of the access to oral health care problem and the subsequent collaboration between political interest groups and policymakers. Through partnerships and pluralist compromise, mid-level dental practitioner champions were able to open the policy window to move this legislation to law, enhancing the oral health workforce in Minnesota.

U.S. Dental school deans' attitudes about mid-level providers.

The introduction of mid-level providers to the U.S. dental workforce is currently a topic of heated debate. As little is known about the opinions of those who educate oral health professionals on the subject of such practitioners, a survey of U.S. dental school deans was undertaken to gauge their attitudes about alternative workforce models in the dental profession. The survey was sent to deans of the then-fifty-eight U.S. schools of dentistry; forty-four responded for a 76 percent response rate. Over three-fourths of the respondents agreed that the scope of practice for both dental hygienists and dental assistants should be expanded; significantly, over half agreed that the future of dentistry should include a dental therapist-type practitioner. Moreover, three-fourths agreed that such practitioners or expanded-duty hygienists would improve access to care for the underserved, and between half and two-thirds agreed that the quality of care delivered by these professionals would not be a problem. The attitudes of the deans about mid-level providers falls somewhere between that reported for U.S. dentists generally, who tend to be skeptical, and for dentists in other countries, who, once they have worked in a system with dental therapists, tend to be supportive.

Dental therapists might not have a strong impact on overall caries incidence, but they may be more effective than dentists in terms of reducing the level of untreated caries.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. Wright JT, Graham F, Hayes C, Ismail AI, Noraian KW, Weyant RJ, Tracy SL, Hanson NB, Frantsve-Hawley J. J Am Dent Assoc 2013;144(1):75-91. REVIEWERS: Elizabeth Phillips, PhD, H. Luke Shaefer, PhD PURPOSE/QUESTION: In populations where midlevel providers conduct irreversible procedures, is there a change in disease increment, untreated dental disease, or cost-effectiveness of dental care? SOURCE OF FUNDING: None reported TYPE OF STUDY/DESIGN: Systematic review LEVEL OF EVIDENCE: Level 2: Limited-quality, patient-oriented evidence STRENGTH OF RECOMMENDATION GRADE: Grade B: Inconsistent or limited quality patient-oriented evidence.

Covered today, sick tomorrow? Trends and correlates of children's health insurance instability.

Many children with health insurance will experience gaps in coverage over time, potentially reducing their access to and use of preventive health care services. This article uses the Survey of Income and Program Participation to examine how the stability of children's health insurance changed between 1990 and 2005 and to identify dynamic aspects of family life associated with transitions in coverage. Children's health insurance instability has increased since the early 1990s, due to greater movement between insured and uninsured states and between private and public insurance coverage. Changes in the employment and marital status of the family head are highly associated with an increased risk of a child losing and gaining public and private coverage, largely in hypothesized directions. The exception is that marital dissolution and job loss are associated with an increased probability of a child losing public insurance, despite there being no clear policy explanation for such a relationship.

Improving access to oral health care services among underserved populations in the U.S.: is there a role for mid-level dental providers?

Nearly one-third of U.S. citizens lack access to basic preventive and primary oral health care services, which is primarily the result of the high costs of care and the uneven geographic distribution of dental providers. This article examines the case for and against one possible solution to address these barriers to oral health care: the introduction of a mid-level dental provider (MDP) position within the dental field.

Transitions from private to public health coverage among children: estimating effects on out-of-pocket medical costs and health insurance premium costs.

OBJECTIVE: To assess the effects of transitions from private to public health insurance by children on out-of-pocket medical expenditures and health insurance premium costs. DATA SOURCES: Data are drawn from the 1996 and 2001 panels of the Survey of Income and Program Participation. We construct a nationally representative, longitudinal sample of children, ages 0-18, and their families for the period 1998-2003, a period in which states raised public health insurance eligibility rates for children. STUDY DESIGN: We exploit the Survey of Income and Program Participation's longitudinal design to identify children in our sample who transition from private to public health insurance. We then use a bootstrapped instrumental variable approach to estimate the effects of these transitions on out-of-pocket expenditures and health insurance premium costs. PRINCIPAL FINDINGS: Children who transition from private to public coverage are relatively low-income, are disproportionately likely to live in single-mother households, and are more likely to be Black or of Hispanic origin. Child health status is highly predictive of transitions. We estimate that these transitions provide a cash-equivalent transfer of nearly U.S.$1,500 annually for families in the form of reduced out-of-pocket and health insurance premium costs. CONCLUSIONS: Transitions from private to public health coverage by children can bring important social benefits to vulnerable families. This suggests that instead of being a net societal cost, such transitions may provide an important social benefit.

Who transitions from private to public health insurance?: Lessons from expansions of the State Children's Health Insurance Program.

This paper examines families of children who transition from private to public health insurance. These transitions include, but are not limited to, transitions that constitute crowd-out. We pool longitudinal panels from the Survey of Income and Program Participation (SIPP) covering 1990 to 2005. The annual rate of children who transition from private to public coverage more than doubled over this period, although it remains small. Transitioning children in recent years are typically in working families with median incomes of around 200% of poverty. Children who transition from private to public coverage are more likely to belong to minority groups, to have lower incomes, and to be in poorer health than children remaining privately insured. Public coverage now provides important protections for low-income working families, especially those with children in poor health. These findings underscore the need to implement post-health-reform policies with an eye towards possible adverse selection into public programs.