This paper examines the relationship between early exposure to the opioid epidemic and voting behavior in US presidential elections. After its 1996 national release, OxyContin quickly penetrated local markets, contributing to addiction, economic disruption, and community distress that may have increased demand for political change. I exploit cross-state variation in triplicate prescription laws, which required physicians to produce an additional copy of each opioid prescription for state monitoring and shaped differential exposure to the emergence of OxyContin. In subsequent elections, states without triplicate prescription laws experienced a 2.60 percentage point higher Republican vote share relative to states with these policies. The voting response was nearly twice as large in areas with lower baseline GOP support, approximately three times larger in Southern compared with non-Southern states, and more pronounced in counties with lower employment rates. The results indicate that state policy environments associated with greater opioid exposure were followed by persistent shifts in presidential voting patterns toward the Republican Party.
"Middle school blues"-a situation in which parental mental health declines to its lowest point during their children's middle school years-is widespread yet often overlooked. Deteriorating parental mental health disrupts effective parenting and negatively impacts children's outcomes. However, there is limited research on how to improve parental mental health. We fill this gap using data from a unique cluster randomized controlled trial conducted in Chinese middle schools. In this trial, parents in the treatment classes were offered a four-month parental involvement program on empathy and positive parenting. We find that the program led to a 0.17 standard deviation increase in parental mental health for treated parents, as measured by the GHQ-12 score. The effect size indicates that the program is significantly effective in helping parents combat middle school blues. We attribute the program's impact on parental mental health to improvements in parenting skills, increased time investments, better children's mental health, and the development of positive personality traits. Notably, at a cost of only $30 per class, our results indicate that this program is highly cost-effective.
We study the mental health of graduate students and faculty at 14 economics departments in Europe. Using clinically validated surveys sent out in the fall of 2021, we find that 34.7 percent of graduate students experience moderate to severe symptoms of depression or anxiety and 17.3 percent report suicidal or self-harm ideation in a two-week period. We find that 19.2 percent of students with significant symptoms are in treatment. Among faculty members, 15.8 percent experience moderate to severe depression or anxiety symptoms, with prevalence higher among nontenure track (42.9 percent) and tenure track (31.4 percent) faculty than tenured (9.6 percent) faculty. We estimate that the COVID-19 pandemic accounts for about 74 percent of the higher prevalence of depression symptoms and 30 percent of the higher prevalence of anxiety symptoms in our European sample relative to a 2017 US sample of economics graduate students. We also document issues in the work environment, including a high incidence of sexual harassment, and make recommendations for improvement.
More than 385 US localities and 7 states have implemented restrictions on sales of flavored electronic nicotine delivery systems (ENDS), yet these policies' effects remain unclear. Utilizing comprehensive data on tobacco product flavor policies linked to retail sales data from January 2018 through March 2023, we estimate the effects of these restrictions. Our findings reveal that ENDS flavor restrictions yield substantial decreases in total ENDS sales, primarily owing to significant declines in flavored ENDS sales alongside nonsignificant increases in unflavored ENDS sales. Further analyses find that ENDS flavor restrictions increase sales of combustible cigarettes, a more harmful product: 11 to 15 additional cigarettes are purchased for every 1 less 0.7 mL ENDS pod sold because of these policies. This uptick in cigarette sales stems primarily from non-menthol cigarettes and includes brands disproportionately used by underage youth. These findings suggest that the public health benefits from reducing ENDS sales via flavor restrictions may be offset by the public health costs of consequent increases in cigarette consumption.
Public schools provide a range of health care through screening programs aimed at identifying health issues early. Even when health needs are identified, limited engagement with parents can be a barrier to supportive treatment. We estimate the effectiveness of targeted intensive family-follow-up in the vision screening program in the largest school district in the country. The follow-up is successful at improving glasses wearing and vision outcomes. There is no effect on downstream academic and health outcomes, though that may be because measurable outcomes are too distal or coarse to identify important relationships between them and vision acuity.
This study examines the impact of water purification on long-run old-age mortality. We examine the effects of early-life and childhood exposure to improvements in water quality due to citywide water filtration programs in 25 major American cities on later-life old-age longevity of male individuals. We employ data from Social Security Administration death records linked with the 1940 census. The difference-in-difference regressions suggest an improvement in male longevity of about 3.2 months. A series of balancing tests do not reveal evidence that changes in sociodemographic and socioeconomic characteristics of individuals confound the estimates. We also implement a full battery of sensitivity analyses and show that the effect is robust across specifications, subsamples, and functional form checks. Analyses using 1950-70 censuses suggest that a portion of the long-term links can be explained by improvements in individuals' education and income as a result of early-life exposure to water filtration. We also show that treated cohorts reveal improvements in height and cognitive scores during early adulthood.
Expanding public health insurance to parents may not only benefit parents, but also have spillover effects on their children. In this paper, we exploit the natural experiment arising from the Affordable Care Act to estimate the causal effects of expanding public health insurance to low-income parents on the well-being of parents and their children. Using a difference-in-differences model with data from the 2010-17 National Health Interview Surveys, we find significant improvements in health-care access, increases in health-care utilization, reductions in financial burden, and a slight improvement in health status for low-income parents. For low-income children in the Medicaid expansion states, we find decreases in both emergency care utilization and hospitalizations. These findings suggest short-term positive spillover effects of parental insurance coverage on low-income children's well-being via improved health-care utilization.
Clinicians in low- and middle-income countries often deviate from care guidelines and underdeliver high-value preventive care. Focusing on hypertension screening, we investigate several explanations for underdelivery using a randomized experiment with standardized patients (SPs). Across 600 clinics in two major Indian cities, we found that nearly half of clinicians failed to screen SPs-even though screening is highly cost-effective and universally recommended by Indian guidelines. We did not find evidence that underscreening was driven by an absence of equipment and staff or a lack of clinicians' knowledge on how to screen for hypertension. Our results also suggest that screening is not driven by time pressure nor by clinicians' personal judgment on which patients should be screened. However, we find notable differences between public and private facilities, with clinicians in private facilities screening significantly more often. Overall, we find that conventional explanations for underdelivery-such as screening knowledge, resources, or time pressure-may not be the prime drivers of inadequate preventive care provision in the Indian setting. Rather, our results suggest that clinician effort in India is highly influenced by provider care environments and incentive structures.
The introduction of highly active antiretroviral therapy (HAART) in 1995 transformed the prognosis of an HIV infection from a death sentence to a manageable chronic health condition. Using a difference-in-differences strategy, this paper exploits spatial variation in HIV/AIDS incidence at the time HAART treatment was introduced and finds that, in addition to reducing HIV/AIDS deaths, the introduction of HAART led to a disproportionate decrease in suicide rates for groups most affected by the virus. Estimates suggest that HAART saved approximately 756 men aged 25 to 44 from suicide each year following its introduction.
We exploit a quasi-natural experiment based on a series of reforms in Spain that improved fathers' bargaining power by shifting the custody decision from being unilaterally determined by the mother to a joint decision. Employing a triple-difference specification that compares women with and without children in treated and control regions before and after the reforms, we find that the policy led to a large and significant decrease in intimate partner violence (-43.3 percent), with the largest effects among women over 30 and in regions with low take-up rates. Our results are in line with previous studies that find that women empowerment may lead to an increase of intimate partner violence in societies with strong gender norms as male partners see their status being threatened (Angelucci and Heath 2020; Heath 2014; Garc & iacute;a-Ramos 2021; Hoehn-Velasco and Silverio-Murillo 2020).
The seemingly inexorable worldwide rise in health care's share of GDP from 1970 to 2009 markedly slowed from 2009 to 2019, both in the US and across a broad cross section of 19 OECD countries. To assess whether this slowdown represents a reduced steady-state growth rate or a temporary pause, we estimate a decomposition of health-care spending growth with the residual defining the role of medical technology. Income and medical technology are the main drivers of health-care cost growth over the 1970-2019 period, accounting for 43 percent and 35 percent of the growth in the US, respectively, and 57 percent and 21 percent of the growth in the other 19 OECD countries. The time series for the 20-country residual shows a structural break in 2004 that reduces annual growth in health-care spending by an average of 1.1 percentage points, a key driver of the post-2009 slowdown in health-care spending. The slowdown was further deepened by the effects of the Great Recession and, in the US, reduced medical price inflation, partially offset by faster population aging in the US and in most other countries. Looking to 2028-38 to exclude pandemic aftereffects, our results imply some acceleration in growth but nonetheless a substantial bending of the curve.
We use data on siblings near the minimum drinking age to provide causal estimates of peer effects in alcohol consumption, exploiting the increase in consumption of the older sibling in a regression discontinuity design. We find no evidence for positive spillover effects of an older sibling's legal access to alcohol on the younger sibling's alcohol consumption. Although imprecise, preferred point estimates imply that younger sibling binge drinking decreases at the cutoff. These negative reduced-form spillover effects are larger for siblings who are likely to spend more time together, for measures of excessive alcohol consumption, and in subgroups where the first-stage discontinuity is largest. We argue that these patterns of heterogeneity are consistent with younger siblings learning from the costs of their older siblings' drinking behavior.
We studied the long-term effect of a randomized informational nudge on influenza vaccination rates through a field experiment. The study was conducted in collaboration with a major health insurer in Switzerland. A letter informing consumers about the possibility of vaccination in selected pharmacies was used as the impetus. One year later, the same nudge was repeated for half of the initial recipients, while it was discontinued for the other half. We found that the nudge was effective in the short run but failed to have persistent or additive effects in the second year. Our findings highlight the importance of annual reminders to sustain and enhance the impact of informational nudges on influenza vaccination rates. Furthermore, by linking the experiment to administrative health insurance data, we observed the impact of the nudge on not only targeted behavior (i.e., pharmacy vaccinations) but also untargeted behavior (physician vaccinations). We observed some crowding out of physician-provided vaccinations among individuals in the treatment group who had been vaccinated in the previous influenza season.
Government-subsidized reinsurance can reduce insurers' exposure to large health claims and can therefore make health insurance more affordable and attract more consumers. By mechanically transferring money from governments to insurers, public reinsurance can reduce premiums, but may also reduce premiums more than dollar-for-dollar if healthier consumers enroll or the insurance market becomes more competitive. We study 12 states that implemented, between 2017 and 2021, reinsurance programs for individual insurance purchased through the Marketplaces created by the Affordable Care Act. Using synthetic event study methods, we examine their impact on the distribution of premiums, the number of insurers, and enrollment. On average, these reinsurance programs decreased premiums by 9 to 19 percent in the first two years of their implementation but had no impact on insurer participation and minimal impact on enrollment in the Marketplaces. Our evidence suggests reinsurance mostly reduced premiums by reducing exposure to claims without more fundamental improvements in the Marketplaces.
Understanding the effect of place on health and health-care spending is a long-standing question with important implications for improving health and the efficiency of health-care spending. To answer this question, recent studies have exploited variation in place from elderly persons moving. The key assumption of these studies is that moving is exogenous conditional on observed characteristics (e.g., age and sex) and place-of-origin fixed effects (or person fixed effects). In this article, we document the extent of selection among elderly movers on a set of observable characteristics and estimate differences in spending and hospitalizations associated with such selection. Specifically, we measured the amount of selection between movers and non-movers, and among movers by the type of move made, as characterized by differences in Medicare spending and hospitalization between origin and destination locations. Our analysis shows that there is a substantial amount of selection among movers on observable characteristics not used in previous studies and that such selection is associated with large and economically important differences in Medicare spending and hospitalizations. We also show that the inclusion of person fixed effects does not eliminate the problem from unmeasured confounding due to time-varying effects of the observed characteristics on individual outcomes.
We study how retirement affects mental health using a partial identification framework for panel data. With this framework, we estimate identification regions that are transformed into quantitative policy recommendations by adopting a minimax-regret decision rule. Under relatively weak assumptions, we find that retirement can have a moderate, positive effect on individuals whose preretirement mental health is below average of the corresponding age cohort. Our minimax-regret analysis further suggests that while retirement can be delayed without affecting the mental health of most of the population, it is advisable to facilitate the retirement of people with poor mental health.
