Exposure to cigarette taxes as a teenager and the persistence of smoking into adulthood.

Are teenage and adult smoking causally related? Recent anti-tobacco policy is predicated on the assumption that preventing teenagers from smoking will ensure that fewer adults smoke, but direct evidence in support of this assumption is scant. Using data from three nationally representative sources and instrumenting for teenage smoking with cigarette taxes experienced at ages 14-17, we document a strong positive relationship between teenage and adult smoking: deterring 10 teenagers from smoking through raising cigarette taxes roughly translates into 5 fewer adult smokers. We conclude that efforts to reduce teenage smoking can have long-lasting consequences on smoking participation and, presumably, health.

Medical Malpractice Damage Caps and Provider Reimbursement.

A common state legislative maneuver to combat rising healthcare costs is to reform the tort system by implementing caps on noneconomic damages awardable in medical malpractice cases. Using the implementation of caps in several states and large database of private insurance claims, I estimate the effect of damage caps on the amount providers charge to insurance companies as well as the amount that insurance companies reimburse providers for medical services. The amount providers charge insurers is unresponsive to tort reform, but the amount that insurers reimburse providers decreases for some procedures. Copyright © 2015 John Wiley & Sons, Ltd.

JUE Insight: Were urban cowboys enough to control COVID-19? Local shelter-in-place orders and coronavirus case growth.

One of the most common policy prescriptions to reduce the spread of COVID-19 has been to legally enforce social distancing through shelter-in-place orders (SIPOs). This study examines the role of localized urban SIPO policy in curbing COVID-19 cases. Specifically, we explore (i) the comparative effectiveness of county-level SIPOs in urbanized as compared to non-urbanized areas, (ii) the mechanisms through which SIPO adoption in urban counties yields COVID-related health benefits, and (iii) whether late adoption of a statewide SIPO yields health benefits beyond those achieved from early adopting counties. We exploit the unique laboratory of Texas, a state in which the early adoption of local SIPOs by densely populated counties covered almost two-thirds of the state's population prior to adoption of a statewide SIPO on April 2, 2020. Using an event study framework, we document that countywide SIPO adoption is associated with an 8 percent increase in the percent of residents who remain at home full-time and between a 13 to 19 percent decrease in foot-traffic at venues that may contribute to the spread of COVID-19 such as restaurants, bars, hotels, and entertainment venues. These social distancing effects are largest in urbanized and densely populated counties. Then, we find that in early adopting urban counties, COVID-19 case growth fell by 21 to 26 percentage points two-and-a-half weeks following adoption of a SIPO, a result robust to controls for county-level heterogeneity in COVID-19 outbreak timing, coronavirus testing, the age distribution, and political preferences. We find that approximately 90 percent of the curbed growth in COVID-19 cases in Texas came from the early adoption of SIPOs by urbanized counties, suggesting that the later statewide shelter-in-place mandate yielded relatively few health benefits.

Is Healthcare Employment Resilient and "Recession Proof"?

Conventional wisdom often holds that the healthcare sector fares better than other sectors during economic downturns. However, little research has examined the relationship between local economic conditions and healthcare employment. Understanding how the healthcare sector responds to economic conditions is important for policymakers seeking to ensure an adequate supply of healthcare workers, as well as for those directing displaced workers into new jobs. We examine the impact of macroeconomic conditions on both the healthcare labor market and the pipeline of healthcare workers receiving healthcare degrees during 2005-2017 (the pre-COVID era). Our results indicate that the healthcare sector is stable across past business cycles. If anything, when areas experience more severe local economic downturns, healthcare employment increases. Much remains unknown about how the healthcare sector will fare during the current recession. Our study represents an important backdrop as policymakers consider ways to sustain the healthcare sector during current economic and public health turbulence.

Association Between Statewide COVID-19 Lottery Announcements and Vaccinations.

This case-control study assesses if announcements of cash drawings in 19 states were associated with increased vaccine uptake by comparing vaccination trends in states that announced drawings with states that did not using a difference-in-differences framework.

WHEN DO SHELTER-IN-PLACE ORDERS FIGHT COVID-19 BEST? POLICY HETEROGENEITY ACROSS STATES AND ADOPTION TIME.

This study explores the impact of Shelter-in-Place Orders (SIPOs) on health, with attention to heterogeneity in their impacts. First, using daily state-level social distancing data, we document that adoption of a SIPO was associated with a 9%-10% increase in the rate at which state residents remained in their homes full-time. Using daily state-level coronavirus case data, we find that approximately 3 weeks following the adoption of a SIPO, cumulative COVID-19 cases fell by approximately 53.5%. However, this average effect masks important heterogeneity across states-early adopters and high population density states appear to reap larger benefits from their SIPOs. (JEL H75, I12, I18).

Risk avoidance, offsetting community effects, and COVID-19: Evidence from an indoor political rally.

The Centers for Disease Control and Prevention (CDC) deem large indoor gatherings without social distancing the "highest risk" activity for COVID-19 contagion. On June 20, 2020, President Donald J. Trump held his first mass campaign rally following the US coronavirus outbreak at the indoor Bank of Oklahoma arena. In the weeks following the event, numerous high-profile national news outlets reported that the Trump rally was "more than likely" the cause of a coronavirus surge in Tulsa County based on time series data. This study is the first to rigorously explore the impacts of this event on social distancing and COVID-19 spread. First, using data from SafeGraph Inc, we show that while non-resident visits to census block groups hosting the Trump event grew by approximately 25 percent, there was no decline in net stay-at-home behavior in Tulsa County, reflecting important offsetting behavioral effects. Then, using data on COVID-19 cases from the CDC and a synthetic control design, we find little evidence that COVID-19 grew more rapidly in Tulsa County, its border counties, or in the state of Oklahoma than each's estimated counterfactual during the five-week post-treatment period we observe. Difference-in-differences estimates further provide no evidence that COVID-19 rates grew faster in counties that drew relatively larger shares of residents to the event. We conclude that offsetting risk-related behavioral responses to the rally-including voluntary closures of restaurants and bars in downtown Tulsa, increases in stay-at-home behavior, displacement of usual activities of weekend inflows, and smaller-than-expected crowd attendance-may be important mechanisms. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11166-021-09359-4.

The Prevalence of Cardiovascular Disease and Other Comorbidities Among American Indian and Alaska Native Adults with Diabetes.

AIMS: American Indians and Alaska Native (AI/ANs) peoples experience significant health disparities compared to the U.S. general population. We report comorbidities among AI/ANs with diabetes to guide efforts to improve their health status. METHODS: Drawing upon data for over 640,000 AI/ANs who used services funded by the Indian Health Service, we identified 43,518 adults with diabetes in fiscal year 2010. We reported the prevalence of comorbidities by age and cardiovascular disease (CVD) status. Generalized linear models were estimated to describe associations between CVD and other comorbidities. RESULTS: Nearly 15% of AI/AN adults had diabetes. Hypertension, CVD and kidney disease were comorbid in 77.9%, 31.6%, and 13.3%, respectively. Nearly 25% exhibited a mental health disorder; 5.7%, an alcohol or drug use disorder. Among AI/ANs with diabetes absent CVD, 46.9% had 2 or more other chronic conditions; the percentage among adults with diabetes and CVD was 75.5%. Hypertension and tobacco use disorders were associated with a 71% (95% CI for prevalence ratio: 1.63 - 1.80) and 33% (1.28 - 1.37) higher prevalence of CVD, respectively, compared to adults without these conditions. CONCLUSION: Detailed information on the morbidity burden of AI/ANs with diabetes may inform enhancements to strategies implemented to prevent and treat CVD and other comorbidities.

Association of Ambulance Use in New York City With the Implementation of the Patient Protection and Affordable Care Act.

Importance: Expanding insurance coverage may be associated with overuse of medical care because newly insured patients are insulated from having to pay the full cost. Objective: To examine the use of ambulance transport before and after the rollout of the Patient Protection and Affordable Care Act (ACA) in New York City (NYC), New York. Design, Setting, and Participants: In this case-control study, the volume of ambulance dispatches in NYC for minor injuries before and after the rollout of the ACA was examined. Data were drawn from a census of all ambulance dispatches in NYC between January 1, 2013, and July 31, 2016. Ambulance dispatches for more severe injuries, which are more difficult to characterize as unnecessary, were used as the control group. Analyses were conducted from August 17, 2017, to May, 10, 2019. Main Outcome and Measures: The main outcome was the number of ambulance dispatches for minor injuries, defined per month per dispatch zone. The implementation of the ACA was measured using an indicator variable of 1 for dispatches starting January 1, 2014, and 0 for dispatches before January 1, 2014. The number of ambulance dispatches for injuries and major injuries was used to account for secular trends. Injury severity was classified by the dispatchers based on information from the 911 callers with a severity score on a scale of 1 to 8, where 1 is the most severe; minor injuries had a score of 7; injuries, 5; and major injuries, 3. Results: There were 4 787 180 ambulance dispatches in NYC during the study. After the 2014 expansion of insurance coverage under the ACA, there was an increase in ambulance dispatches for minor injuries compared with dispatches for more severe injuries. Compared with the preimplementation mean (SD) of 20.75 (14.24) minor injury dispatches per dispatch zone per month, there were 7.71 (95% CI, 1.23-14.19) additional minor injury dispatches per dispatch zone per month compared with dispatches for other types of injuries, an increase of 37.2%. Given that NYC has 31 dispatch zones, this increase is equivalent to approximately 239 additional dispatches per month or 2868 additional dispatches per year for minor injuries. Conclusions and Relevance: There was a significant increase in use of ambulance transport for minor injuries in NYC after the ACA insurance expansion, suggesting that the change in health insurance structure was associated with increased use of emergency medical services in nonemergent situations. Future reforms to the US health insurance system should take into account the potential for increased use of emergency medical services in nonemergent situations, which the literature suggests may lead to congestion and slower response times.

The affordable care act and ambulance response times.

This study contributes to the literature on the capacity challenges faced by health care providers after insurance expansions by examining the Affordable Care Act (ACA) and ambulance response times. Exploiting temporal and geographic variation in the implementation of the ACA as well as pre-treatment differences in uninsured rates, we estimate that the expansions of private and Medicaid coverage under the ACA combined to slow ambulance response times by an average of 24%. We conclude that, through extending coverage to individuals who, in its absence, would not have availed themselves of emergency medical services, the ACA added strain to emergency response systems.

Comparison of Health Care Worker Satisfaction Before vs After Implementation of a Communication and Optimal Resolution Program in Acute Care Hospitals.

This case-control study investigates the association between a communication and optimal resolution program to address unexpected adverse patient outcomes and measures of health care worker satisfaction.

Recessions and health revisited: New findings for working age adults.

A series of influential papers have documented that state level mortality rates decrease during economic downturns. In this paper, we estimate the effect of education specific unemployment rates on mortality, which provide a more exact measure of the likelihood of being directly impacted by a recession. We find that the unemployment rate of an education group in a given state is positively related to mortality in that group. A 1% increase in the group-specific unemployment rate is associated with an approximately 0.015% increase in the group-specific mortality rate, which is consistent with the hypothesis that, while state-level unemployment may have indirect health benefits, being personally affected by a recession has a detrimental effect on health.

Mandated Health Insurance and Provider Reimbursement via Private Insurance: Evidence From the Massachusetts Health Reform.

In 2006, Massachusetts passed a reform that required individuals to purchase health insurance and provided subsidized health insurance to low-income individuals. The US Patient Protection and Affordable Care Act (ACA) was modeled after this reform, making Massachusetts an ideal place to look at potential outcomes from the ACA. Postreform, the proportion of the health-insured population in Massachusetts greatly increased, which potentially changed physician reimbursement for procedures as usage of care, particularly preventative care for children increased. We find that reimbursement for well-infant visits rose temporarily by approximately 4% the year after the reform but that the effective price increase did not persist. It is likely that this lack of persistence is due to an increase in the supply of physicians. This has important implications for the ACA, as expanding physician capacity is more difficult on a national level.

The impact of agglomeration economies on hospital input prices.

This paper examines the extent to which agglomeration of the hospital service industry enhances the productivity of producing health care. Specifically, we use a large set of private insurance claims from the FAIR Health database to show that an increasing spatial concentration of hospital services results in a decreased cost of obtaining intermediate medical services. We explicitly test whether the reduced cost at concentrated locations arises from the ability to share intermediate service providers. The identification relies on state variation in medical lab technician licensure requirements, which influence the cost of intermediate services only through the cost of running a lab. Our findings suggest that agglomeration of the hospital service industry attracts specialized medical labs, which in turn help to reduce the cost of producing laboratory tests.