The effects of the COVID-19 pandemic on the mental health of people with obesity.

Obesity is a risk factor for anxiety and depression. Obesity is also a risk factor for severe COVID-19 disease and therefore may have contributed to adverse mental health outcomes in this vulnerable population during the COVID-19 pandemic. We compare the trajectory of mental health outcomes of people with obesity with normal-weight people before and during the COVID-19 pandemic using nationally representative individual-level longitudinal data from the National Health Interview Survey and Difference-in-Difference regressions. Our results indicate that severe anxiety increased by 2.75 (95% CI: 0.0056-0.0494; p-value 0.014) percentage points, representing a 31.3% relative increase, and anxiety-related prescription drug usage increased by 2.75 (95% CI: 0.0076-0.0473; p-value<0.01) percentage points, representing a 19.2% relative increase among people with obesity, compared to normal-weight people. We conclude that people with obesity experienced an increase in the incidence of severe anxiety and anxiety-related prescription drug usage during the COVID-19 pandemic, which was not observed among normal-weight individuals. Furthermore, women, less-educated, and rural residents with obesity disproportionately bore the burden of the pandemic.

The effects of the American Rescue Plan Act on racial equity in health insurance coverage.

OBJECTIVE: To evaluate the effects on racial disparities in health insurance coverage from the changes in the Premium Tax Credit (PTC) implemented in March 2021 as part of the American Rescue Plan Act (ARPA). DATA SOURCES AND STUDY SETTING: We use nationally representative individual-level data from the Household Pulse Survey (HPS), which provides demographic, economic, and health insurance information for United States residents during the period April 2020-August 2022. STUDY DESIGN: While the PTC changes applied to all states, the 14 states that did not expand Medicaid received substantially more benefits than the expansion states since they had more uninsured individuals eligible for the PTC than the expansion states. In our analysis, the treatment (control) group includes all Medicaid nonexpansion (expansion) states. We use a difference-in-difference regression analysis to estimate the increase in the probability of insurance coverage after the expansion of the PTC. Furthermore, we conduct sensitivity and heterogeneity analyses. DATA COLLECTION/EXTRACTION METHODS: We focus on survey respondents ages 18-64. PRINCIPAL FINDINGS: The expanded PTC increased the probability of an individual having coverage through the Health Insurance Exchange (HIX) in a nonexpansion state by 0.95 (95% CI: 0.6136, 1.2900), 1.75 (95% CI: 1.1795, 2.3291), and 1.75 (95% CI: 1.1815, 2.3269) percentage points among White, Black, and Hispanic respondents, respectively. It also increased overall health insurance coverage among all groups. CONCLUSIONS: The expanded PTC boosted HIX and overall health insurance coverage and reduced racial disparities.

The effects of Medicaid expansion on job loss induced mental distress during the COVID-19 pandemic in the US.

The COVID-19 pandemic led to an unprecedented level of job losses in the U.S., where job loss is also associated with the loss of health insurance. This paper uses data from the 2020 Household Pulse Survey (HPS) and difference-in-difference (DD) regressions to estimate the effect of Medicaid expansion on anxiety and depression associated with job loss. Estimates show that the respondents who live in expansion states are 96.6% more likely to have Medicaid coverage, and 14.2% less likely to have moderate to severe mental distress following their job loss compared to those living in non-expansion states. The corresponding numbers associated with a family member's job loss are 36.3% and 7.6%, respectively. Next, we explore the mechanisms which suggest that the economic security provided by Medicaid is as important (if not more) as the access to or utilization of healthcare. The difference-in-difference-in-difference (DDD) estimates using just above and below the Medicare eligibility age (65) confirm these results.

Elections have (health) consequences: Depression, anxiety, and the 2020 presidential election.

In this paper, we examine the effect of the 2020 presidential election on anxiety and depression among Americans. We use data from the 2020 Household Pulse Survey (HPS), a nationally representative rapid response survey conducted weekly from April to July of 2020 and then bi-weekly until December of 2021. The high-frequency nature of the survey implies that we can identify week-to-week changes in mental health outcomes. We find that self-reported symptoms of moderate to severe anxiety and depression increased steadily up to the presidential election and declined after the election. The anxiety and depression levels are significantly higher around the 2020 election than in April 2020, when most of the U.S. was under mandatory or advisory stay-at-home orders due to the COVID-19 pandemic. Furthermore, anxiety and depression-specific office visits and usage of mental-health-specific prescription drugs show similar patterns. Robustness checks rule out alternative explanations such as a COVID-19 surge or vaccine development.

Do employers discriminate against obese employees? Evidence from individuals who are simultaneously self-employed and working for an employer.

We test whether the lower wages of obese employees result from employer discrimination using a novel empirical strategy. Using data from two nationally representative surveys from the US, we analyze the wages of individuals who are simultaneously self-employed and working for an employer. While lower productivity and customer discrimination against obese individuals may affect wages in both types of jobs, employer discrimination cannot affect the wages of solo entrepreneurs. Our estimates suggest that, even after controlling for productivity (proxied by their concurrent wage in self-employment), white women (men) who are obese earn 11.4% (9.7%) less than their healthy-weight counterparts in their paid employment jobs. We also find that white women (but not men) who are overweight earn 9.1% less than their healthy-weight counterparts. We do not find any evidence of significant bodyweight discrimination among black and Hispanic workers. These results suggest that white workers, especially white women, are likely to face bodyweight discrimination in their workplaces. We report the results for a series of robustness checks to rule out alternative explanations, such as reverse causality, differences in healthcare costs, and occupation-specific customer discrimination.

Impacts of shifting responsibility for high-cost individuals on Health Insurance Exchange plan premiums and cost-sharing provisions.

Insurance companies can respond to increases in expected per-capita healthcare expenditures by adjusting premiums, cost-sharing requirements, and/or plan generosity. We use a Difference-in-Difference model with Plan-level Fixed Effects to estimate the impacts of increases in expected expenditures generated by closure of state-operated High Risk Pools (HRPs). For Silver plans, we find that issuers responded to HRP closures by increasing both premiums and deductibles, and by increasing the ratios of premiums to deductibles. This adjustment to the structure of plan prices is consistent with the hypothesis that issuers will be reluctant to adjust deductibles, because consumers tend to overweight changes in deductibles over changes in premiums. The increase in the ratio of premiums to deductibles indicates that the increase in expected expenditures triggered an increase in the share of total risk-pool healthcare expenditures paid by low healthcare utilizers, and a decrease in the share paid by high utilizers.

Incentive design to boost health for juveniles with Medicaid coverage: Evidence from a field experiment.

Augmenting incentives for juveniles with separate incentives for parents could boost juvenile efforts to reduce BMI. However, financing a parent incentive by reducing the incentives offered to adolescents could attenuate the juvenile response. In a field experiment, Medicaid-covered juveniles enrolled in a cardiac wellness program were randomly assigned to two groups: juveniles in the focused-incentive group received all earned points; juveniles in the split-incentive group split earned points with a parent. The focused-incentive group was 12.8 percentage points more likely to achieve their stipulated goals compared to the split-incentive group at the end of the 3-month active phase of the program. In contrast, members of the split-incentive group outperformed their peers in the focused-incentive group during the second quarter, and the two incentives structures were equally effective at the year-end session. Additional quasi-experimental data indicates that members of both incentivized groups significantly outperformed (focused-incentive group by 8.48 percentage points and split-incentive group by 11.0 percentage points) a pre-experiment (non-incentivized) set of juveniles enrolled in the same program at year-end.

Evaluating an employee wellness program.

What criteria should be used to evaluate the impact of a new employee wellness program when the initial vendor contract expires? Published academic literature focuses on return-on-investment as the gold standard for wellness program evaluation, and a recent meta-analysis concludes that wellness programs can generate net savings after one or two years. In contrast, surveys indicate that fewer than half of these programs report net savings, and actuarial analysts argue that return-on-investment is an unrealistic metric for evaluating new programs. These analysts argue that evaluation of new programs should focus on contract management issues, such as the vendor's ability to: (i) recruit employees to participate and (ii) induce behavior change. We compute difference-in-difference propensity score matching estimates of the impact of a wellness program implemented by a mid-sized employer. The analysis includes one year of pre-implementation data and three years of post-implementation data. We find that the program successfully recruited a broad spectrum of employees to participate, and it successfully induced short-term behavior change, as manifested by increased preventive screening. However, the effects on health care expenditures are positive (but insignificant). If it is unrealistic to expect new programs to significantly reduce healthcare costs in a few years, then focusing on return-on-investment as the gold standard metric may lead to early termination of potentially useful wellness programs. Focusing short-term analysis of new programs on short-term measures may provide a more realistic evaluation strategy.

The value of an employment-based green card.

The need for and role of highly skilled immigrant workers in the U.S. economy is fiercely debated. Proponents and opponents agree that temporary foreign workers are paid a lower wage than are natives. This lower wage partly originates from the restricted mobility of workers while on a temporary visa. In this article, we estimate the wage gain to employment-based immigrants from acquiring permanent U.S. residency. We use data from the New Immigrant Survey (2003) and implement a difference-in-difference propensity score matching estimator. We find that for employer-sponsored immigrants, the acquisition of a green card leads to an annual wage gain of about $11,860.

Effects of school reformon education and labor market performance: Evidence from Chile's universal voucher system.

This paper studies the effects of school reform in Chile, which adopted a nationwide school voucher program along with school decentralization reforms in 1981. Since then, Chile has had a relatively unregulated, competitive market in primary and secondary education. It therefore provides a unique setting in which to study how these reforms affected school attainment and labor market outcomes. This paper develops and estimates a dynamic model of school attendance and work decisions using panel data from the 2002 and 2004 waves of the Encuesta de Protección Social survey. Some individuals in the sample completed their schooling before the voucher reforms were introduced, while others had the option of using the vouchers over part or all of their schooling careers. The impacts of the voucher reform are identified from differences in the schooling and work choices made and earnings returns received by similar aged individuals who were differentially exposed to the voucher system. Simulations based on the estimated model show that the voucher reform significantly increased the demand for private subsidized schools and decreased the demand for both public and nonsubsidized private schools. It increased high school (grades 9-12) graduation rates by 3.6 percentage points and the percentage completing at least two years of college by 2.6 percentage points. Individuals from poor and non-poor backgrounds on average experienced similar schooling attainment gains. The reform also increased lifetime utility and modestly reduced earnings inequality.

Are prenatal care resources distributed efficiently across high-risk and low-risk mothers?

The Institute for Clinical Systems Improvement recommends reducing the number of prenatal care visits recommended for low-risk women, citing evidence from a randomized clinical trial indicating that the reduction would not adversely impact infant health. We investigate the implicit hypothesis that prenatal care resources are not distributed efficiently across high-risk and low-risk women. Using clinic-reported prenatal care and an inclusive measure of infant health, we report evidence indicating inefficient resource utilization: prenatal care only boosts infant health when mothers have specific pre-existing diagnoses, but women with high potential to benefit from care do not obtain more care than other women.