The short-term effects of the earned income tax credit on health care expenditures among US adults.

OBJECTIVE: To test the hypothesis that the earned income tax credit (EITC)-the largest US poverty alleviation program-affects short-term health care expenditures among US adults. DATA SOURCES: Adult participants in the 1997-2012 waves of the US Medical Expenditure Panel Survey (MEPS) (N = 1 282 080). STUDY DESIGN: We conducted difference-in-differences analyses, comparing health care expenditures among EITC-eligible adults in February (immediately following EITC refund receipt) with expenditures during other months, using non-EITC-eligible individuals to difference out seasonal variation in health care expenditures. Outcomes included total out-of-pocket expenditures as well as spending on specific categories such as outpatient visits and inpatient hospitalizations. We conducted subgroup analyses to examine heterogeneity by insurance status. PRINCIPAL FINDINGS: EITC refund receipt was not associated with short-term changes in total expenditures, nor any expenditure subcategories. Results were similar by insurance status and robust to numerous alternative specifications. CONCLUSIONS: EITC refunds are not associated with short-term changes in health care expenditures among US adults. This may be because the refund is spent on other expenses, because of income smoothing, or because of similar refund-related variation in health care expenditures among noneligible adults. Future studies should examine whether other types of income supplementation affect health care expenditures, particularly among individuals in poverty.

The effects of state-level earned income tax credits on suicides.

This study examines the relationship between state-level earned income tax credit (EITC) laws in the United States on suicides. Following findings in previous work showing that the EITC is associated with lower depression rates and reduced number of risky biomarkers, I estimated the effects of state EITC generosity on suicide rates. Using data for the years 1996 to 2016, a period with 74 state-level EITC policy changes, I find that introducing a high state EITC rate reduces suicide rates for adults aged 25 or above by 3.91%. The results are consistent across four different measures of EITC generosity.

Digital Manipulation of Images of Models' Appearance in Advertising: Strategies for Action Through Law and Corporate Social Responsibility Incentives to Protect Public Health.

CONTEXT: Widespread digital retouching of advertising imagery in the fashion, beauty, and other consumer industries promotes unrealistic beauty standards that have harmful effects on public health. In particular, exposure to misleading beauty imagery is linked with greater body dissatisfaction, worse mood, poorer self-esteem, and increased risk for disordered eating behaviors. Moreover, given the social, psychological, medical, and economic burden of eating disorders, there is an urgent need to address environmental risk factors and to scale up prevention efforts by increasing the regulation of digitally altered advertising imagery. METHODS: This manuscript summarizes the health research literature linking digital retouching of advertising to increased risk of eating disorders, disordered weight and appearance control behaviors, and body dissatisfaction in consumers, followed by a review of global policy initiatives designed to regulate digital retouching to reduce health harms to consumers. Next, we turn to the US legal context, reporting on findings generated through legal research via Westlaw and LexisNexis, congressional records, federal agency websites, law review articles, and Supreme Court opinions, in addition to consulting legal experts on both tax law and the First Amendment, to evaluate the viability of various policy initiatives proposed to strengthen regulation on digital retouching in the United States. FINDINGS: Influencing advertising practices via tax incentives combined with corporate social responsibility initiatives may be the most constitutionally feasible options for the US legal context to reduce the use of digitally alternated images of models' bodies in advertising. CONCLUSIONS: Policy and corporate initiatives to curtail use of digitally altered images found to be harmful to mental and behavioral health of consumers could reduce the burden of eating disorders, disordered weight and appearance control behaviors, and body dissatisfaction and thereby improve population health in the United States.

The Effect of the Earned Income Tax Credit on Housing and Living Arrangements.

As rents have risen and wages have not kept pace, housing affordability in the United States has declined over the last 15 years, impacting the housing and living arrangements of low-income families. Housing subsidies improve the housing situations of low-income families, but less than one in four eligible families receive a voucher. In this article, we analyze whether one of the largest anti-poverty programs in the United States-the Earned Income Tax Credit (EITC)-affects the housing (eviction, homelessness, and affordability) and living arrangements (doubling up, number of people in the household, and crowding) of low-income families. Using the Current Population Survey, the American Community Survey/decennial census, and the Fragile Families and Child Wellbeing Study, we employ a parameterized difference-in-differences strategy to examine whether policy-induced expansions to the EITC affect the housing and living arrangements of single mothers. Results suggest that a $1,000 increase in the EITC improves housing by reducing housing cost burdens, but it has no effect on eviction or homelessness. Increases in the EITC also reduce doubling up (living with additional, nonnuclear family adults)-in particular, doubling up in someone else's home-and reduce three-generation/multigenerational coresidence, suggesting that mothers have a preference to live independently. We find weak evidence for a reduction in overall household size, yet the EITC does reduce household crowding. Although the EITC is not an explicit housing policy, expansions to the EITC are generally linked with improved housing outcomes for single mothers and their children.

Does the earned income tax credit increase children's weight? The impact of policy-driven income on childhood obesity.

I exploit substantial increases in the earned income tax credit to study how a policy-driven change in family income affects childhood obesity. Using the National Longitudinal Survey of Youth 1979, my difference-in-differences estimates indicate that the probability of being obese increased by 3 percentage points among children whose families experienced a greater income shock. A further investigation suggests that a reduction in maternal time with children played a greater role in children's weight gain than income. The paper's finding shows that a program that is not designed for health purposes, such as earned income tax credit, can have unintended effects on health outcomes.

Extending Marketplace Tax Credits Would Make Coverage More Affordable for Middle-Income Adults.

ISSUE: Affordability of health coverage is a growing challenge for Americans facing rising premiums, deductibles, and copayments. The Affordable Care Act's tax credits make marketplace insurance more affordable for eligible lower-income individuals. However, individuals lose tax credits when their income exceeds 400 percent of the federal poverty level, creating a steep cliff. GOALS: To analyze the effects of extending eligibility for tax credits to individuals with incomes above 400 percent of the federal poverty level. METHODS: We used RAND's COMPARE microsimulation model to examine changes in insurance coverage and health care spending. KEY FINDINGS AND CONCLUSIONS: Extending tax-credit eligibility increases insurance enrollment by 1.2 million, at a total federal cost of $6.0 billion. Those who would benefit from the tax-credit extension are mostly middle-income adults ages 50 to 64. These new enrollees would be healthier than current enrollees their age, which would improve the risk pool and lower premiums. Eliminating the cliff at 400 percent of the federal poverty level is one policy option that may be considered to increase affordability of insurance.

Effect of the Earned Income Tax Credit on Hospital Admissions for Pediatric Abusive Head Trauma, 1995-2013.

OBJECTIVES: Policies that increase household income, such as the earned income tax credit (EITC), have shown reductions on risk factors for child maltreatment (ie, poverty, maternal stress, depression), but evidence is lacking on whether the EITC actually reduces child maltreatment. We examined whether states' EITCs are associated with state rates of hospital admissions for abusive head trauma among children aged <2 years. METHODS: We conducted difference-in-difference analyses (ie, pre- and postdifferences in intervention vs control groups) of annual rates of states' hospital admissions attributed to abusive head trauma among children aged <2 years (ie, using aggregate data). We conducted analyses in 14 states with, and 13 states without, an EITC from 1995 to 2013, differentiating refundable EITCs (ie, tax filer gets money even if taxes are not owed) from nonrefundable EITCs (ie, tax filer gets credit only for any tax owed), controlling for state rates of child poverty, unemployment, high school graduation, and percentage of non-Latino white people. RESULTS: A refundable EITC was associated with a decrease of 3.1 abusive head trauma admissions per 100 000 population in children aged <2 years after controlling for confounders ( P = .08), but a nonrefundable EITC was not associated with a decrease ( P = .49). Tax refunds ranged from $108 to $1014 and $165 to $1648 for a single parent working full-time at minimum wage with 1 child or 2 children, respectively. CONCLUSIONS: Our findings with others suggest that policies such as the EITC that increase household income may prevent serious abusive head trauma.

The Tax Exclusion for Employer-Sponsored Insurance Is Not Regressive-But What Is It?

Conventional wisdom says that the tax exclusion for employer-sponsored health insurance (ESI) is "regressive and therefore unfair." Yet, by the standard definition of regressive tax policy, the conventional view is almost certainly false. It confuses the absolute size of the tax exclusion with its proportional effect on income. The error results from paying attention only to the marginal tax rate applied to ESI benefits as a portion of income and ignoring the fact that benefits are normally a much larger share of income for people with lower wages. This article explains the difference and then considers other distributional effects of ESI. It suggests that ESI-for those who receive it-further redistributes toward those with lesser means or greater need. The most evident effect is by need, favoring employees with families over those without. Yet there is good reason to believe there is also a redistribution by income, with the package of wages plus benefits being less unequal than wages alone would be. Therefore reformers should be much more careful before criticizing either ESI or its subsidy through the tax code as "unfair," especially as the likelihood of enacting something better in the United States seems quite low.

Modification of Treatment of Certain Health Organizations. Final regulations.

This document contains final regulations that provide guidance to Blue Cross and Blue Shield organizations, and certain other organizations, on computing and applying the medical loss ratio and the consequences for not meeting the medical loss ratio threshold. The final regulations reflect the enactment of a technical correction to section 833(c)(5) of the Internal Revenue Code by the Consolidated and Further Continuing Appropriations Act of 2015. The final regulations affect Blue Cross and Blue Shield organizations, and certain other organizations involved in providing health insurance.

Invited Commentary: Using Financial Credits as Instrumental Variables for Estimating the Causal Relationship Between Income and Health.

Social epidemiologists are interested in determining the causal relationship between income and health. Natural experiments in which individuals or groups receive income randomly or quasi-randomly from financial credits (e.g., tax credits or cash transfers) are increasingly being analyzed using instrumental variable analysis. For example, in this issue of the Journal, Hamad and Rehkopf (Am J Epidemiol. 2016;183(9):775-784) used an in-work tax credit called the Earned Income Tax Credit as an instrument to estimate the association between income and child development. However, under certain conditions, the use of financial credits as instruments could violate 2 key instrumental variable analytic assumptions. First, some financial credits may directly influence health, for example, through increasing a psychological sense of welfare security. Second, financial credits and health may have several unmeasured common causes, such as politics, other social policies, and the motivation to maximize the credit. If epidemiologists pursue such instrumental variable analyses, using the amount of an unconditional, universal credit that an individual or group has received as the instrument may produce the most conceptually convincing and generalizable evidence. However, other natural income experiments (e.g., lottery winnings) and other methods that allow better adjustment for confounding might be more promising approaches for estimating the causal relationship between income and health.