Effects of Contextual Economic Factors on Childhood Obesity.

OBJECTIVES: To examine the association between changes in contextual economic factors on childhood obesity in the US. METHODS: We combined data from 2003, 2007, and 2011/2012 National Surveys of Children's Health for 129,781 children aged 10-17 with 27 state-level variables capturing general economic conditions, labor supply, and the monetary or time costs of calorie intake, physical activity, and cigarette smoking. We employed regression models controlling for demographic factors and state and year fixed effects. We also examined heterogeneity in economic effects by household income. RESULTS: Obesity risk increased with workforce proportion in blue-collar occupations, urban sprawl, female labor force participation, and number of convenience stores but declined with median household income, smoking ban in restaurants, and full service restaurants per capita. Most effects were specific to low income households, except for density of supercenters/warehouse clubs which was significantly associated with higher overweight/obesity risk only in higher income households. CONCLUSIONS FOR PRACTICE: Changes in state-level economic factors related to labor supply and monetary or time cost of calorie intake may affect childhood obesity especially for children in low-income households. Policymakers should consider these effects when designing programs aimed at reducing childhood obesity.

Effects of the Affordable Care Act on Health Care Access and Self-Assessed Health After 3 Years.

Using data from the Behavioral Risk Factor Surveillance System, we examine the causal impact of the Affordable Care Act on health-related outcomes after 3 years. We estimate difference-in-difference-in-differences models that exploit variation in treatment intensity from 2 sources: (1) local area prereform uninsured rates from 2013 and (2) state participation in the Medicaid expansion. Including the third postreform year leads to 2 important insights. First, gains in health insurance coverage and access to care from the policy continued to increase in the third year. Second, an improvement in the probability of reporting excellent health emerged in the third year, with the effect being largely driven by the non-Medicaid expansions components of the policy.

Who Gained Insurance Coverage in 2014, the First Year of Full ACA Implementation?

The most significant pieces of the Affordable Care Act (exchanges, subsidies, Medicaid expansion, and individual mandate), implemented in 2014, were associated with sizable gains in coverage nationally that were divided equally between gains in Medicaid and private coverage. These national trends mask heterogeneity in gains by state Medicaid expansion status, age, income level, and source of coverage. Copyright © 2016 John Wiley & Sons, Ltd.

Toward innovative, cost-effective, and systemic solutions to improve outcomes and well-being of military families affected by autism spectrum disorder.

The burdens faced by military families who have a child with autism are unique. The usual challenges of securing diagnostic, treatment, and educational services are compounded by life circumstances that include the anxieties of war, frequent relocation and separation, and a demand structure that emphasizes mission readiness and service. Recently established military autism-specific health care benefits set the stage for community-viable and cost-effective solutions that can achieve better outcomes for children and greater well-being for families. Here we argue for implementation of evidence-based solutions focused on reducing age of diagnosis and improving access to early intervention, as well as establishment of a tiered menu of services, individualized to the child and family, that fit with the military ethos and system of health care. Absence of this new model of care could compromise the utility and sustainability of the autism-specific benefit.

Do e-cigarette retail licensure laws reduce youth tobacco use?

E-cigarette licensure laws (ELLs) require retailers to obtain a state license to sell e-cigarettes over the counter. This study is the first to comprehensively explore the effect of ELL adoption on youth tobacco product use. Using data from the State Youth Risk Behavior Survey (YRBS) and a difference-in-differences approach, we find no evidence that ELL adoption reduces youth ENDS use. The precision of our estimates allows us to rule out, with 95 % confidence, ELL-induced declines in prior-month, frequent, and everyday youth ENDS use of more than 0.7, 0.3, and 0.4 percentage points, respectively. The pattern of null findings persists when we examine ELLs that impose higher penalties for retailer non-compliance, higher renewable licensure fees, and criminal in addition to civil penalties. We conclude that ELLs have only limited success in curbing access to ENDS among youths.

Intended and unintended effects of e-cigarette taxes on youth tobacco use.

Over the past decade, rising youth use of e-cigarettes and other electronic nicotine delivery systems (ENDS) has contributed to aggressive regulation by state and local governments. Between 2010 and mid-2019, ten states and two large counties adopted ENDS taxes. We use two large national surveys (Monitoring the Future and the Youth Risk Behavior Surveillance System) to estimate the impact of ENDS taxes on youth tobacco use. We find that ENDS taxes reduce youth ENDS consumption, with estimated ENDS tax elasticities of -0.06 to -0.21. However, we estimate sizable positive cigarette cross-tax effects, suggesting economic substitution between cigarettes and ENDS for youth. These substitution effects are particularly large for frequent cigarette smoking. We conclude that the unintended effects of ENDS taxation may considerably undercut or even outweigh any public health gains.

The effects of e-cigarette taxes on e-cigarette prices and tobacco product sales: Evidence from retail panel data.

We estimate the effect of e-cigarette tax rates on e-cigarette prices, e-cigarette sales, and sales of other tobacco products using NielsenIQ Retail Scanner data from 2013 to 2019. We find that 90% of e-cigarette taxes are passed on to consumer retail prices. We then estimate reduced form and instrumental variables regressions to examine the effects of e-cigarette and cigarette taxes and prices on sales. We calculate an e-cigarette own-price elasticity of -2.2 and particularly large elasticity of demand for flavored e-cigarettes. Further, we document a cigarette own-price elasticity of -0.4 and positive cross-price elasticities of demand between e-cigarettes and cigarettes, suggesting economic substitution.

Does procedure profitability impact whether an outpatient surgery is performed at an ambulatory surgery center or hospital?

Ambulatory surgery centers (ASCs) are small (typically physician owned) healthcare facilities that specialize in performing outpatient surgeries and therefore compete against hospitals for patients. Physicians who own ASCs could treat their most profitable patients at their ASCs and less profitable patients at hospitals. This paper asks if the profitability of an outpatient surgery impacts where a physician performs the surgery. Using a sample of Medicare patients from the National Survey of Ambulatory Surgery, we find that higher profit surgeries do have a higher probability of being performed at an ASC compared to a hospital. After controlling for surgery type, a 10% increase in a surgery's profitability is associated with a 1.2 to 1.4 percentage point increase in the probability the surgery is performed at an ASC.

Time spent exercising and obesity: An application of Lewbel's instrumental variables method.

This paper examines the role physical activity plays in determining body mass using data from the American Time Use Survey. Our work is the first to address the measurement error that arises when time use during a single day-rather than average daily time use over an extended period-is used as an explanatory variable. We show that failing to account for day-to-day variation in activities results in the effects of time use on a typical day being understated. Furthermore, we account for the possibility that physical activity and body mass are jointly determined by implementing Lewbel's instrumental variables estimator that exploits first-stage heteroskedasticity rather than traditional exclusion restrictions. While averaging 30 min of transportation-related biking or walking per day lowers the BMI of men by 1.5, we find no effect of physically active leisure on the BMI of men in our sample. In contrast, 30 min of per day of either type of physical activity lowers the BMI of women by 1.

Did COVID-19 change life insurance offerings?

The profitability of life insurance offerings is contingent on accurate projections and pricing of mortality risk. The COVID-19 pandemic created significant uncertainty, with dire mortality predictions from early forecasts resulting in widespread government intervention and greater individual precaution that reduced the projected death toll. We analyze how life insurance companies changed pricing and offerings in response to COVID-19 using monthly data on term life insurance policies from Compulife. We estimate event-study models that exploit well-established variation in the COVID-19 mortality rate based on age and underlying health status. Despite the increase in mortality risk and significant uncertainty, the results generally indicate that life insurance companies did not increase premiums or decrease policy offerings due to COVID-19. Nonetheless, we find some evidence that premiums differentially increased for individuals with very high risk and that some policies were removed for the oldest of the old.

Chance elections, social distancing restrictions, and KENTUCKY's early COVID-19 experience.

Early in the pandemic, slowing the spread of novel coronavirus disease 2019 (COVID-19) relied on non-pharmaceutical interventions. All U.S. states adopted social-distancing restrictions in March and April of 2020, though policies varied both in timing and scope. Compared to states with Democratic governors, those with Republican governors often adopted measures for shorter durations and with greater resistance from their residents. In Kentucky, an extremely close gubernatorial election immediately prior to the discovery of SARS-CoV-2 replaced a Republican incumbent with a Democrat, despite Republicans easily winning all other statewide races. This chance election result offers a unique opportunity to examine the impact of early social distancing policies in a relatively conservative, rural, white-working-class state. Our study begins by estimating an event-study model to link adoption of several common social distancing measures-public school closures, bans on large gatherings, closures of entertainment-related businesses such as restaurants, and shelter-in-place orders (SIPOs)-to the growth rate of cases across counties in the Midwest and South in the early stages of the pandemic. These policies combined to slow the daily growth rate of COVID-19 cases by 9 percentage points after 16 days, with SIPOs and entertainment establishment closures accounting for the entire effect. In order to obtain results with more direct applicability to Kentucky, we then estimate a model that interacts the policy variables with a "white working class" index characterized by political conservatism, rurality, and high percentages of white, evangelical Christian residents without college degrees. We find that the effectiveness of early social distancing measures decreased with higher values of this index. The results imply that the restrictions combined to slow the spread of COVID-19 by 12 percentage points per day in Kentucky's two largest urban counties but had no statistically detectable effect across the rest of the state.

The Affordable Care Act's Coverage Impacts in the Trump Era.

The 2016 US presidential election created uncertainty about the future of the Affordable Care Act (ACA) and led to postponed implementation of certain provisions, reduced funding for outreach, and the removal of the individual mandate tax penalty. In this article, we estimate how the causal impact of the ACA on insurance coverage changed during 2017 through 2019, the first 3 years of the Trump administration, compared to 2016. Data come from the 2011-2019 waves of the American Community Survey (ACS), with the sample restricted to non-elderly adults. Our model leverages variation in treatment intensity from state Medicaid expansion decisions and pre-ACA uninsured rates. We find that the coverage gains from the components of the law that took effect nationally-such as the individual mandate and regulations and subsidies in the private non-group market-fell from 5 percentage points in 2016 to 3.6 percentage points in 2019. In contrast, the coverage gains from the Medicaid expansion increased in 2017 (7.0 percentage points) before returning to the 2016 level of coverage gains in 2019 (5.9 percentage points). The net effect of the ACA in expansion states is a combination of these trends, with coverage gains falling from 10.8 percentage points in 2016 to 9.6 percentage points in 2019.

Racial and Ethnic Disparities in COVID-19: Evidence from Six Large Cities.

As of June 2020, the coronavirus pandemic has led to more than 2.3 million confirmed infections and 121 thousand fatalities in the USA, with starkly different incidence by race and ethnicity. Our study examines racial and ethnic disparities in confirmed COVID-19 cases across six diverse cities-Atlanta, Baltimore, Chicago, New York City, San Diego, and St. Louis-at the ZIP code level (covering 436 "neighborhoods" with a population of 17.7 million). Our analysis links these outcomes to six separate data sources to control for demographics; housing; socioeconomic status; occupation; transportation modes; health care access; long-run opportunity, as measured by income mobility and incarceration rates; human mobility; and underlying population health. We find that the proportions of Black and Hispanic residents in a ZIP code are both positively and statistically significantly associated with COVID-19 cases per capita. The magnitudes are sizeable for both Black and Hispanic, but even larger for Hispanic. Although some of these disparities can be explained by differences in long-run opportunity, human mobility, and demographics, most of the disparities remain unexplained even after including an extensive list of covariates related to possible mechanisms. For two cities-Chicago and New York-we also examine COVID-19 fatalities, finding that differences in confirmed COVID-19 cases explain the majority of the observed disparities in fatalities. In other words, the higher death toll of COVID-19 in predominantly Black and Hispanic communities mostly reflects higher case rates, rather than higher fatality rates for confirmed cases.

The effects of traditional cigarette and e-cigarette tax rates on adult tobacco product use.

We study the effects of traditional cigarette and e-cigarette taxes on use of these products among adults in the United States. Data are drawn from the Behavioral Risk Factor Surveillance System and National Health Interview Survey over the period 2011 to 2018. Using two-way fixed effects models, we find evidence that higher traditional cigarette tax rates reduce adult traditional cigarette use and increase adult e-cigarette use. Similarly, we find that higher e-cigarette tax rates increase traditional cigarette use and reduce e-cigarette use. Cross-tax effects imply that the products are economic substitutes. Our results suggest that a proposed national e-cigarette tax of $1.65 per milliliter of vaping liquid would raise the proportion of adults who smoke cigarettes daily by approximately one percentage point, translating to 2.5 million extra adult daily smokers compared to the counterfactual of not having the tax.

The impact of the Affordable Care Act on health care access and self-assessed health in the Trump Era (2017-2018).

OBJECTIVE: To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on health care access and self-assessed health during the first 2 years of the Trump administration (2017 and 2018). DATA SOURCE: The 2011-2018 waves of the Behavioral Risk Factor Surveillance System (BRFSS), with the sample restricted to nonelderly adults. The BRFSS is a commonly used data source in the ACA literature due to its large number of questions related to access and self-assessed health. In addition, it is large enough to precisely estimate the effects of state policy interventions, with over 300 000 observations per year. DESIGN: We estimate difference-in-difference-in-differences (DDD) models to separately identify the effects of the private and Medicaid expansion portions of the ACA using an identification strategy initially developed in Courtemanche et al (2017). The differences come from: (a) time, (b) state Medicaid expansion status, and (c) local area pre-2014 uninsured rates. We examine ten outcome variables, including four measures of access and six measures of self-assessed health. We also examine differences by income and race/ethnicity. PRINCIPAL FINDINGS: Despite changes in ACA administration and the political debate surrounding the ACA during 2017 and 2018, including these fourth and fifth years of postreform data suggests continued gains in coverage. In addition, the improvements in reported excellent health that emerged with a lag after ACA implementation continued during 2017 and 2018. CONCLUSIONS: While gains in access and self-assessed health continued in the first 2 years of the Trump administration, the ongoing debate at both the federal and state level surrounding the future of the ACA suggests the need to continue monitoring how the law impacts these and many other important outcomes over time.

Strong Social Distancing Measures In The United States Reduced The COVID-19 Growth Rate.

State and local governments imposed social distancing measures in March and April 2020 to contain the spread of the novel coronavirus disease (COVID-19). These measures included bans on large social gatherings; school closures; closures of entertainment venues, gyms, bars, and restaurant dining areas; and shelter-in-place orders. We evaluated the impact of these measures on the growth rate of confirmed COVID-19 cases across US counties between March 1, 2020, and April 27, 2020. An event study design allowed each policy's impact on COVID-19 case growth to evolve over time. Adoption of government-imposed social distancing measures reduced the daily growth rate of confirmed COVID-19 cases by 5.4 percentage points after one to five days, 6.8 percentage points after six to ten days, 8.2 percentage points after eleven to fifteen days, and 9.1 percentage points after sixteen to twenty days. Holding the amount of voluntary social distancing constant, these results imply that there would have been ten times greater spread of COVID-19 by April 27 without shelter-in-place orders (ten million cases) and more than thirty-five times greater spread without any of the four measures (thirty-five million cases). Our article illustrates the potential danger of exponential spread in the absence of interventions, providing information relevant to strategies for restarting economic activity.

Rising cigarette prices and rising obesity: coincidence or unintended consequence?

Economists have begun to debate if the rise in cigarette prices in the U.S. in recent decades has contributed to the nation's rise in obesity, reaching conclusions that are surprisingly sensitive to specification. I show that allowing for the effect to occur gradually over several years leads to the conclusion that a rise in cigarette prices is actually associated with a long-run reduction in body mass index and obesity. This result is robust to the different methodologies used in the literature. I also provide evidence that indirect effects on exercise and food consumption may explain the counterintuitive result.

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.

The three-year impact of the Affordable Care Act on disparities in insurance coverage.

OBJECTIVE: To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on disparities in insurance coverage after three years. DATA SOURCE: The 2011-2016 waves of the American Community Survey (ACS), with the sample restricted to nonelderly adults. DESIGN: We estimate a difference-in-difference-in-differences model to separately identify the effects of the nationwide and Medicaid expansion portions of the ACA using the methodology developed in the recent ACA literature. The differences come from time, state Medicaid expansion status, and local area pre-ACA uninsured rates. In order to focus on access disparities, we stratify our sample separately by income, race/ethnicity, marital status, age, gender, and geography. PRINCIPAL FINDINGS: After three years, the fully implemented ACA eliminated 43% of the coverage gap across income groups, with the Medicaid expansion accounting for this entire reduction. The ACA also reduced coverage disparities across racial groups by 23%, across marital status by 46%, and across age-groups by 36%, with these changes being partly attributable to both the Medicaid expansion and nationwide components of the law. CONCLUSIONS: The fully implemented ACA has been successful in reducing coverage disparities across multiple groups.