Effects of the Colorectal Cancer Control Program.

Although colorectal cancer (CRC) screening is highly effective, screening rates lag far below recommended levels, particularly for low-income people. The Colorectal Cancer Control Program (CRCCP) funded $100 million in competitively awarded grants to 25 states from 2009-2015 to increase CRC screening rates among low-income, uninsured populations, in part by directly providing and paying for screening services. Using data from the 2001-2015 Behavioral Risk Factor Surveillance System (BRFSS) and a difference-in-differences strategy, we find no effects of CRCCP on the use of relatively cheap fecal occult blood tests (FOBT). We do, however, find that the CRCCP significantly increased the likelihood that uninsured 50-64-year-olds report ever having a relatively expensive endoscopic CRC screening (sigmoidoscopy or colonoscopy) by 2.9 percentage points, or 10.7%. These effects are larger for women, minorities, and individuals who did not undertake other types of preventive care. We do not find that the CRCCP led to significant changes in CRC cancer detection. Our results indicate that the CRCCP was effective at increasing CRC screening rates among the most vulnerable.

Effects of the Affordable Care Act Dependent Coverage Mandate on Health Insurance Coverage for Individuals in Same-Sex Couples.

A large body of research documents that the 2010 dependent coverage mandate of the U.S. Affordable Care Act was responsible for significantly increasing health insurance coverage among young adults. No prior research has examined whether sexual minority young adults also benefitted from the dependent coverage mandate despite previous studies showing lower health insurance coverage among sexual minorities. Our estimates from the American Community Survey, using difference-in-differences and event study models, show that men in same-sex couples aged 21-25 experienced a significantly greater increase in the likelihood of having any health insurance after 2010 than older, 27- to 31-year-old men in same-sex couples. This increase is concentrated among employer-sponsored insurance, and it is robust to permutations of periods and age groups. Effects for women in same-sex couples and men in different-sex couples are smaller than the associated effects for men in same-sex couples. These findings confirm the broad effects of expanded dependent coverage and suggest that eliminating the federal dependent mandate could reduce health insurance coverage among young adult sexual minorities in same-sex couples.

The Direct Effects of Legal Same-Sex Marriage in the United States: Evidence From Massachusetts.

I provide evidence on the direct effects of legal same-sex marriage in the United States by studying Massachusetts, the first state to legalize it in 2004 by court order. Using confidential Massachusetts data from 2001-2013, I show that the ruling significantly increased marriage among lesbians, bisexual women, and gay men compared with the associated change for heterosexuals. I find no significant effects on coupling. Marriage take-up effects are larger for lesbians than for bisexual women or gay men and are larger for households with children than for households without children. Consistent with prior work in the United States and Europe, I find no reductions in heterosexual marriage.

Disparities in Health Insurance Coverage and Access to Care for Children By Mother's Sexual Orientation.

OBJECTIVE: Few population-based studies have examined the health care experiences of children with sexual minority parents. The purpose of this study was to compare health insurance status, access to care, and health services utilization for children by mother's sexual orientation. METHODS: We used data on children with lesbian mothers (n = 195), bisexual mothers (n = 299), and heterosexual mothers (n = 23,772) in the 2013-2017 National Health Interview Survey. Logistic regression models were used to compare health insurance status, access to care, and health services utilization while adjusting for demographic and socioeconomic characteristics of the child, mother, and household. RESULTS: After controlling for sociodemographic factors, there were no statistically significant differences in health insurance coverage, access to care, or health services utilization between children of lesbian mothers and children of heterosexual mothers. Compared to children with heterosexual mothers, children with bisexual mothers were more likely to have public health insurance (OR 2.33; 95% CI 1.07-7.68), delayed medical care due to cost (OR 2.33; 95% CI 1.12-4.86), unmet medical care due to cost (OR 2.86; 95% CI 1.07-7.68), and a visit to the emergency room (OR 1.74; 95% CI 1.27-2.39) in the prior year after controlling for child-level characteristics. Some of these differences were attenuated after controlling for maternal demographics and household characteristics. CONCLUSIONS FOR PRACTICE: Children with bisexual mothers experience barriers to routine medical care. Addressing socioeconomic dimensions of health care access and targeted outreach to bisexual parents will help promote health equity for children growing up in sexual minority households.

Effects of state education requirements for substance use prevention.

We provide the first evidence on the effects of state laws requiring students to receive education about alcohol, tobacco, and other drugs using data on over a million youths from the 1976-2010 Monitoring the Future study. In difference-in-differences and event-study models, we find robust evidence that these laws significantly reduced recent alcohol and marijuana use among high school seniors by 1.6-2.8 percentage points, or about 8-10% of the overall decline over this period. Our results suggest that information interventions can reduce youth substance use.

New Evidence on the Price Effects of Cigarette Tax Competition.

Multiple studies have shown that cigarette taxes are more than fully passed through to cigarette prices and that access to a nearby state with a lower cigarette tax also reduces local cigarette prices. We study two other sources of tax competition: nearby Native American reservations and online sales. Using quarterly data on local cigarette prices from 1976-2003, we show that the opening of a Native American casino within 25 miles of a city center is associated with a $0.016-$0.027 lower per-pack price, while a 50 percentage point increase in internet penetration is associated with a $0.22-$0.25 per-pack price reduction. These effects are not observed for other local prices for which there is no potential tax savings. Our results further our understanding of how tax competition affects local cigarette prices and provide context to studies linking Native American reservations and internet penetration to cigarette smuggling.

Effects of a Driver Cellphone Ban on Overall, Handheld, and Hands-Free Cellphone Use While Driving: New Evidence from Canada.

We provide new evidence on the effects of increasingly common driver cellphone bans on self-reported overall, handheld, and hands-free cellphone use while driving by studying Ontario, Canada, which instituted a 3-month education campaign in November 2009 followed by a binding driver cellphone ban in February 2010. Using residents of Alberta as a control group in a difference-in-differences framework, we find visual and regression-based evidence that Ontario's cellphone ban significantly reduced overall and handheld cellphone use. We also find that the policies significantly increased hands-free cellphone use. The reductions in overall and handheld use are driven exclusively by women, whereas the increases in hands-free use are much larger for men. Our results provide the first direct evidence that cellphone bans have the unintended effect of inducing substitution to hands-free devices.

Bad lighting: Effects of youth indoor tanning prohibitions.

Indoor tanning beds (ITBs) emit UV light at high intensity and have been classified as carcinogenic to humans by the World Health Organization since 2009. We are the first to study the role of state laws prohibiting youths from indoor tanning using a difference-in-differences research design. We find that youth ITB prohibitions reduced population search intensity for tanning-related information. Among white teen girls, ITB prohibitions reduced self-reported indoor tanning and increased sun protective behaviors. We also find that youth ITB prohibitions significantly reduced the size of the indoor tanning market by increasing tanning salon closures and reducing tanning salon sales.

Effects of the affordable care Act's Medicaid expansion on health insurance coverage for individuals in same-sex couples.

OBJECTIVE: To examine whether the Affordable Care Act's (ACA's) Medicaid expansions affected health insurance coverage for individuals in same-sex couples. DATA SOURCES AND STUDY SETTING: We used data on adults aged 18-64 years in same-sex couples (n = 33,512) from the 2008-2018 American Community Survey (ACS). STUDY DESIGN: To estimate the effect of the impact of the state Medicaid expansions under the ACA on health insurance coverage for sexual minorities, we utilize a standard difference-in-differences approach to leverage the variation across geography and time in expanding Medicaid. DATA COLLECTION: Secondary and publicly available ACS data were obtained from IPUMS at the University of Minnesota. PRINCIPAL FINDINGS: We find that Medicaid expansion significantly increased health insurance coverage among low-income men and women in same-sex couples by 4.9 (standard error [SE] = 1.75) and 6.5 (SE = 1.96) percentage points, respectively. We find increases in the likelihood of having Medicaid and reductions in private health insurance from an employer or privately purchased insurance. Effects on Medicaid take-up are consistently larger for low-income women in same-sex couples as compared to low-income men in same-sex couples. CONCLUSIONS: We provide the first evidence on the relationship between state Medicaid expansions under the ACA and health insurance coverage among sexual minority adults, a group that has been understudied in past research. Our results confirm that sexual minority adults benefitted from the ACA's Medicaid expansions with respect to increased health insurance coverage.

Exposure to the Above the Influence antidrug advertisements and adolescent marijuana use in the United States, 2006-2008.

OBJECTIVES: We examined the relationship between exposure to the Above the Influence antidrug campaign in 210 US media markets and adolescent marijuana and alcohol use from 2006 to 2008. METHODS: We analyzed monthly advertising exposure (targeted rating points) data from the Office of National Drug Control Policy and drug use data from the Monitoring the Future study. We estimated multivariate logistic regression models of marijuana use for students in grades 8, 10, and 12, with controls for individual, family, and media market characteristics and year and regional fixed effects. RESULTS: For eighth-grade adolescent girls, greater exposure to antidrug advertisements was associated with lower rates of past-month marijuana use (adjusted odds ratio [AOR] = 0.67; 95% confidence interval [CI] = 0.52, 0.87) and lower rates of lifetime marijuana use (AOR = 0.76; 95% CI = 0.62, 0.93), but not alcohol use (AOR = 1.00; 95% CI = 0.84, 1.19). Associations were not significant for adolescent boys or for students in grades 10 and 12. CONCLUSIONS: Antidrug advertising may be an effective way to dissuade eighth-grade adolescent girls from initiating marijuana use.

Cigarette taxes and smoking among sexual minority adults.

We provide the first quasi-experimental evidence on the relationship between cigarette taxes and smoking among sexual minority adults, a group that has been understudied in past research. We use large samples of individuals in same-sex households (a large share of whom are sexual minorities in same-sex romantic relationships) from the 1996-2018 Behavioral Risk Factor Surveillance System. We find that cigarette taxes significantly reduced smoking among men and women in same-sex households, and the effects we find for men in same-sex households are very robust and significantly larger than the associated effects for men in different-sex households (the vast majority of whom are heterosexual married or partnered men). For men in same-sex households, we find no unintended consequences of higher cigarette taxes on other risky behaviors, and in fact we find that cigarette taxes are associated with significant improvements in self-rated health for men in same-sex households. These results suggest that the sizable disparities in adult smoking rates between heterosexual and sexual minority men would have been even larger in the absence of stricter tobacco control policy. However, in line with previous research indicating that cigarette taxes have 'lost their bite', we find no significant relationship between cigarette taxes and sexual minority smoking in more recent years.

Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000-2007.

OBJECTIVES: We used data from the Behavioral Risk Factor Surveillance System to compare health insurance coverage, access to care, and women's cancer screenings for individuals in same-sex versus different-sex relationships. METHODS: We estimated logistic regression models by using data on 5265 individuals in same-sex relationships and 802,659 individuals in different-sex relationships. RESULTS: Compared with women in different-sex relationships, women in same-sex relationships were significantly less likely to have health insurance coverage, were less likely to have had a checkup within the past year, were more likely to report unmet medical needs, and were less likely to have had a recent mammogram or Pap test. Compared with men in different-sex relationships, men in same-sex relationships were significantly less likely to have health insurance coverage and were more likely to report unmet medical needs, although they were more likely to have had a checkup in the past year. CONCLUSIONS: In the largest and most recent nationally representative sample, we found important differences in health insurance coverage and access to care between individuals in same-sex relationships and those in different-sex relationships for both men and women.

Effects of venue-specific state clean indoor air laws on smoking-related outcomes.

A large literature has documented relationships between state clean indoor air laws (SCIALs) and smoking-related outcomes in the United States. These laws vary within states over time and across venues such as schools, government buildings, and bars. Few studies, however, have evaluated whether the effects of SCIALs are plausibly concentrated among workers who should have been directly affected because they worked at locations covered by the venue-specific restrictions. We fill this gap in the literature using data on private sector workers, government employees, school workers, eating and drinking place workers, and bartenders from the 1992-2007 Tobacco Use Supplements to the Current Population Survey. Our quasi-experimental models indicate robust effects of SCIALs restricting smoking in bars: these laws significantly increased the presence of workplace smoking restrictions as reported by bartenders and reduced the fraction of bartenders who smoke. We do not, however, find that SCIALs in private workplaces, government workplaces, schools, or restaurants increased the presence of workplace smoking restrictions among groups of workers working in venues covered by these laws. This suggests that the smoking reductions associated with SCIALs in previous research are unlikely to have been directly caused by effects of workplace smoking restrictions on workers.

Turing's children: Representation of sexual minorities in STEM.

We provide nationally representative estimates of sexual minority representation in STEM fields by studying 142,641 men and women in same-sex couples from the 2009-2018 American Community Surveys. These data indicate that men in same-sex couples are 12 percentage points less likely to have completed a bachelor's degree in a STEM field compared to men in different-sex couples. On the other hand, there is no gap observed for women in same-sex couples compared to women in different-sex couples. The STEM degree gap between men in same-sex and different-sex couples is larger than the STEM degree gap between all white and black men but is smaller than the gender gap in STEM degrees. We also document a smaller but statistically significant gap in STEM occupations between men in same-sex and different-sex couples, and we replicate this finding by comparing heterosexual and gay men using independently drawn data from the 2013-2018 National Health Interview Surveys. These differences persist after controlling for demographic characteristics, location, and fertility. Finally, we document that gay male representation in STEM fields (measured using either degrees or occupations) is systematically and positively associated with female representation in those same STEM fields.

The effects of mandatory seatbelt laws on seatbelt use, motor vehicle fatalities, and crash-related injuries among youths.

We provide the first comprehensive assessment of the effects of mandatory seatbelt laws on self-reported seatbelt use, highway fatalities, and crash-related injuries among high school age youths using data from the Centers for Disease Control's (CDC) national, state, and local Youth Risk Behavior Surveys (YRBS) and the Fatality Analysis Reporting System (FARS) from 1991 to 2005, a period spanning over 20 changes in state seatbelt laws. Our quasi-experimental approaches isolate the independent effects of seatbelt laws net of demographic characteristics, area and year fixed effects, and smooth area-specific trends. Across all data sources, we find consistent evidence that state mandatory seatbelt laws - particularly those permitting primary enforcement - significantly increased seatbelt use among high school age youths by 45-80%, primarily at the extensive margin. Unlike previous research for adults, however, we find evidence against the selective recruitment hypothesis: seatbelt laws had consistently larger effects on those most likely to be involved in traffic accidents (drinkers, alcohol-involved drivers). We also find that mandatory seatbelt laws significantly reduced traffic fatalities and serious injuries resulting from fatal crashes by 8 and 9%, respectively. Our results suggest that if all states had primary enforcement seatbelt laws then regular youth seatbelt use would be nearly universal and youth fatalities would fall by about 120 per year.

Workplace drug testing and worker drug use.

OBJECTIVE: To examine the nature and extent of the association between workplace drug testing and worker drug use. DATA SOURCES: Repeated cross-sections from the 2000 to 2001 National Household Surveys on Drug Abuse (NHSDA) and the 2002 National Survey on Drug Use and Health (NSDUH). STUDY DESIGN: Multivariate logistic regression models of the likelihood of marijuana use are estimated as a function of several different workplace drug policies, including drug testing. Specific questions about penalty severity and the likelihood of detection are used to further evaluate the nature of the association. PRINCIPAL FINDINGS: Individuals whose employers perform drug tests are significantly less likely to report past month marijuana use, even after controlling for a wide array of worker and job characteristics. However, large negative associations are also found for variables indicating whether a firm has drug education, an employee assistance program, or a simple written policy about substance use. Accounting for these other workplace characteristics reduces-but does not eliminate-the testing differential. Frequent testing and severe penalties reduce the likelihood that workers use marijuana. CONCLUSIONS: Previous studies have interpreted the large negative correlation between workplace drug testing and employee substance use as representing a causal deterrent effect of drug testing. Our results using more comprehensive data suggest that these estimates have been slightly overstated due to omitted variables bias. The overall pattern of results remains largely consistent with the hypothesis that workplace drug testing deters worker drug use.

Effects of State Cervical Cancer Insurance Mandates on Pap Test Rates.

OBJECTIVE: To evaluate the effects of state insurance mandates requiring insurance plans to cover Pap tests, the standard screening for cervical cancer that is recommended for nearly all adult women. DATA SOURCES: Individual-level data on 600,000 women age 19-64 from the CDC's Behavioral Risk Factor Surveillance System. STUDY DESIGN: Twenty-four states adopted state mandates requiring private insurers in the state to cover Pap tests from 1988 to 2000. We performed a difference-in-differences analysis comparing within-state changes in Pap test rates before and after adoption of a mandate, controlling for the associated changes in other states that did not adopt a mandate. PRINCIPAL FINDINGS: Difference-in-differences estimates indicated that the Pap test mandates significantly increased past 2-year cervical cancer screenings by 1.3 percentage points, with larger effects for Hispanic and non-Hispanic white women. These effects are plausibly concentrated among insured women. CONCLUSIONS: Mandating more generous insurance coverage for even inexpensive, routine services with already high utilization rates such as Pap tests can significantly further increase utilization.

Economic conditions, illicit drug use, and substance use disorders in the United States.

We provide the first analysis of the relationship between economic conditions and the use of illicit drugs other than marijuana. Drawing on US data from 2002 to 2015, we find mixed evidence on the cyclicality of illicit drug use. However, we find robust evidence that economic downturns lead to increases in the intensity of prescription pain reliever use as well as increases in clinically relevant substance use disorders involving opioids. These effects are concentrated among working-age white males with low educational attainment. We conclude that policymakers should consider devoting more, not fewer, resources to treating substance use disorders during economic downturns.

Health Insurance Mandates, Mammography, and Breast Cancer Diagnoses.

We examine the effects of state health insurance mandates requiring coverage of screening mammograms. We find evidence that mammography mandates significantly increased mammography screenings by 4.5-25 percent. Effects are larger for women with less than a high school degree in states that ban deductibles, a policy similar to a provision of federal health reform that eliminates cost-sharing for preventive care. We also find that mandates increased detection of early stage in-situ pre-cancers. Finally, we find a substantial proportion of the increased screenings were attributable to mandates that are not consistent with current recommendations of the American Cancer Society.

The Mechanisms of Alcohol Control.

A substantial economics literature documents that tighter alcohol controls reduce alcohol-related harms, but far less is known about mechanisms. We use the universe of Canadian mortality records to document that Canada's Minimum Legal Drinking Age (MLDA) significantly reduces mortality rates of young men but has much smaller effects on women. Using drinking data that are far more detailed than in prior work, we document that the MLDA substantially reduces 'extreme' drinking among men but not women. Our results suggest that alcohol control efforts targeting young adults should focus on reducing extreme drinking behavior.