In this article, we exploit the recent, rapid diffusion of the use of GLP-1 drugs among individuals with diabetes to measure the effect of the use of these drugs on mental health, self-rated health, employment, and marriage. The documented large weight loss from GLP-1 use may plausibly affect these outcomes and evidence of these broader impacts of GLP-1 use is necessary to evaluate their full value. Estimates are obtained using a longitudinal (within-person) regression approach. Results indicate that GLP-1 use is not meaningfully associated with mental health, self-rated health, employment, and marriage. Overall, our analysis adds new evidence about how GLP-1 use is affecting the lives of individuals with diabetes. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

One way to measure the efficiency of the Affordable Care Act (ACA) is the extent to which gains in publicly supported health insurance reduced uninsured rates. Using data from the 2008–2024 American Community Survey, we examine time trends in rates of uninsured, public insurance coverage, and employer-sponsored insurance (ESI) by groups defined by the ratio of income to the Federal Poverty Line (FPL). We obtain estimates of associations between changes in public coverage and changes in uninsured and ESI exploiting state-by-year variation in ACA implementation. Importantly, we estimate the total effect of the ACA—including both the Medicaid expansion and Marketplace coverage—on uninsured and ESI rates. For adults in households below 150% of the federal poverty level (FPL), increases in public insurance coverage were associated with one-for-one decrease in uninsured and no change in ESI. For adults with incomes between 151%–400% FPL, each percentage point increase in public coverage was associated with about a 0.6 percentage point decrease in uninsured and a 0.4 decrease, or crowd out, in ESI. Crowd-out was larger among groups with higher pre-ACA ESI rates such as parents and married adults. Using variation from the Medicaid expansion alone to evaluate the ACA’s effect on ESI leads to overstating crowd-out among low-income adults (below 150% FPL) and understating crowd-out among higher-income adults (above 250% FPL). Our findings suggest that policies intended to subsidize health insurance of higher income groups, for example, the enhanced premium subsidies, are far less efficient than policies intended to further expand public insurance to low-income groups, for example, in non-expansion states. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

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.

Importance Undocumented and many noncitizen immigrants are largely excluded from federally funded health insurance programs, creating substantial gaps in health coverage and financial strain on safety-net hospitals that disproportionately serve these populations through uncompensated care. Several states have implemented state-funded health coverage expansions for immigrants, but the financial implications of these policies remain poorly understood. Objective To examine whether Health Benefits for Immigrant Seniors (HBIS) and Health Benefits for Immigrant Adults (HBIA) programs in Illinois were associated with changes in hospitals’ charity care and bad debt. Design, Setting, and Participants This cohort study of nonfederal general medical and surgical hospitals from January 1, 2017, to December 31, 2023, used Healthcare Cost Report Information System data. Difference-in-differences regression compared hospital financial outcomes in Illinois with hospitals in comparison states. Difference-in-differences-in-differences models examined variation by county share of immigrant populations. Analysis was performed from October 1, 2024, to June 12, 2026. Exposure Illinois HBIA and HBIS programs. Main Outcomes and Measures Hospital-reported bad debt and charity care. Results The study included 161 hospitals in Illinois and 1902 hospitals in comparison states. Illinois hospitals were located in counties with a higher share of Hispanic population (mean [SD], 11.4% [10.1%] vs 9.1% [10.6%]; standardized mean difference [SMD], 0.23) and higher median income ($58 121 [range, $34 982-$100 325] vs $56 102 [range, $23 968-$134 050]; SMD, 0.17), but a lower share of uninsured population (mean [SD], 7.8% [2.0%] vs 9.1% [3.5%]; SMD, −0.68). Illinois (treatment) and control hospitals were largely comparable on hospital-level attributes. In adjusted difference-in-differences models, the HBIA and HBIS programs were associated with declines in bad debt (−0.08 [95% CI, −0.11 to −0.04), adjusted bad debt (−0.13 [95% CI, −0.17 to −0.09), charity care (−0.19 [95% CI, −0.26 to −0.13), and adjusted charity care (−0.19 [95% CI, −0.27 to −0.12). Results were robust in entropy-balanced models, which showed reductions for adjusted bad debt (−0.14 [95% CI, −0.20 to −0.09]) and adjusted charity care (−0.15 [95% CI, −0.23 to −0.07). Estimated reductions in charity care were more sensitive to potential violations of the parallel trends assumption than reductions in bad debt. Conclusions and Relevance In this cohort study of hospitals in Illinois and comparison states, the HBIA and HBIS programs were associated with significant reductions in hospital bad debt and suggestive reductions in charity care. State-funded health insurance expansions for undocumented and noncitizen immigrants were associated with improved hospital financial stability and may help address persistent gaps in insurance coverage among immigrants.

We examine the effect of family earnings on child math and reading test scores using the minimum wage as an instrument for family earnings. We show that a higher minimum wage raises earnings significantly and that the effect of the minimum wage on family earnings varies by maternal skill. Notably, a higher minimum wage is not associated with meaningful reductions in maternal work hours and weeks worked. Overall, we find that family earnings have little effect on child achievement test scores. OLS estimates are positive, but very small. IV estimates are small and mostly statistically insignificant, but precisely enough estimated to rule out benefits exceeding 0.03 standard deviations per additional $1000 earnings.

During the COVID-19 pandemic, the federal government issued stimulus checks and expanded the child tax credit. These payments varied by marital status and the number of children in the household. We exploit this plausibly exogenous variation in income during pregnancy to obtain estimates of the effect of income on infant health. Data are from birth certificates and the sample focuses on mothers with high school or less education. The main estimates indicate that pandemic cash payments had virtually no statistically significant, or clinically or economically meaningful effects on infant health (birth weight, gestational age, and fetal growth outcomes), at least for the range of payments received by most mothers.

Racial differences in mortality are large, persistent and likely caused, at least in part, by racism. While the causal pathways linking racism to mortality are conceptually well defined, empirical evidence to support causal claims related to its effect on health is incomplete. In this study, we provide a unique set of facts about racial disparities in mortality that all theories of racism and health need to confront to be convincing. We measure racial disparities in mortality between ages 40 and 80 for both males and females and for several causes of death and, measure how those disparities change with age. Estimates indicate that racial disparities in mortality grow with age but at a decreasing rate. Estimates also indicate that the source of racial disparities in mortality changes with age, sex and cause of death. For men in their fifties, racial disparities in mortality are primarily caused by disparities in deaths due to external causes. For both sexes, it is racial disparities in death from healthcare amenable causes that are the main cause of racial disparities in mortality between ages 55 and 75. Notably, racial disparities in cancer and other causes of death are relatively small even though these causes of death account for over half of all deaths. Adjusting for economic resources and health largely eliminate racial disparities in mortality at all ages and the mediating effect of these factors grows with age. The pattern of results suggests that, to the extent that racism influences health, it is primarily through racism’s effect on investments to treat healthcare amenable diseases that cause racial disparities in mortality. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

In this article, we examine the association between family wealth and academic achievement and socioemotional behaviors of children ages 5 to 12. We examine whether wealth prior to birth and at ages 4 or 5 affects academic test scores and behavioral problems during two periods of childhood, ages 5 to 8 and ages 9 to 12, for a large and relatively recent cohort of children. We also examine associations between different forms of wealth (e.g., home equity) and child achievement and behaviors. Finally, we assess whether wealth prior to birth mediates racial/ethnic disparities in child achievement and disparities in achievement by maternal education/ability (AFQT). Results of our analysis indicate that wealth, particularly financial wealth that is the most liquid, has a modest positive association with achievement test scores. We also find that wealth is associated with fewer behavioral problems, but these results are less robust.

In this article, we use data from the Head Start Impact Study to assess the effect of attending preschool at ages three and four on cognitive and behavioral skills and whether these effects depreciate and fadeout or result in dynamic complementarities that affect skills. Evidence from our analyses suggests that effects of preschool depreciated significantly within a year and that there were no positive dynamic complementarities that offset depreciation. Furthermore, our findings suggest that only a small fraction of the accumulation of cognitive and behavioral skills from ages three to four and four to five can be explained by preschool attendance limiting its ability to address racial and socioeconomic disadvantages in child development.

Prescription opioid use among women of reproductive age and pregnant women is relatively common, and increased prescription opioid use is associated with a commensurate increase in opioid use disorder (OUD) among pregnant women and neonatal abstinence syndrome (NAS) among infants. In this article, we examine whether state opioid control policies affected prescription opioid use and, in turn, infant health and maternal behaviors. Results from our analysis suggest that reductions in prescription opioid use because of state prescription opioid control policies have improved infant health marginally at the population level with larger implied effects at the individual level.

This article describes a conceptual and empirical approach for estimating a human capital production function of child development that incorporates mother- or child-fixed effects. The use of mother- or child-fixed effects is common in this applied economics literature, but its application is often inconsistent with human capital theory. We outline the problem and demonstrate its empirical importance with an analysis of the effect of Head Start and preschool on child and adult outcomes. The empirical specification we develop has broad implications for a variety of applied microeconomic analyses beyond our specific application. Results of our analysis indicate that attending Head Start or preschool had no economically or statistically significant effect on child or adult outcomes.

We examine whether fees paid by Medicaid for primary care affects the use of health care services among adults with Medicaid coverage who have a high school or less than high school degree. The analysis spans the large changes in Medicaid fees that occurred before and after the ACA-mandated fee increase for primary care services in 2013–2014. We use data from the Behavioral Risk Factors Surveillance System and a difference-in-differences approach to estimate the association between Medicaid fees and whether a person has a personal doctor; a routine check-up or flu shot in the past year; whether a woman had a pap test or a mammogram in the past year; whether a person has ever been diagnosed with asthma, diabetes, cardiovascular diseases, cancer, COPD, arthritis, depression, or kidney diseases; and, whether a person reports good-to-excellent health. Estimates indicate that Medicaid fee increases were associated with small increases in the likelihood of having a personal doctor, or receiving a flu shot, although only having a personal doctor remained significant when accounting for multiple hypothesis testing. We conclude that Medicaid fees did not have a major impact on the use of primary care or on the consequences of that care.

To examine whether higher cost-sharing deterred prescription opioid use. Medicare Part D claims from 2007 to 2016 for a 20% random sample of Medicare enrollees. We obtain estimates of the effect of cost-sharing on prescription opioid use using ordinary least squares and instrumental variables methods. In both, we exploit the variation (change) in cost-sharing within plans over time for a sample of beneficiaries who remain in the same plan. Focusing on changes in cost-sharing within a plan for a constant sample of beneficiaries mitigates potential bias from plan selection and using a constant set of weights derived from use in year (t) eliminates changes in the cost-sharing indexes due to (endogenous) consumer choice in year (t+1). Part D plans adopted benefit changes designed to reduce opioid use, including moving opioids to higher cost-sharing tiers. Increasing plan copayments for hydrocodone or oxycodone was associated with reductions in plan-paid claims and offsetting increases in cash claims. Widespread availability of low-cost generics combined with the anti-clawback provision in Part D mediated the effect of higher cost sharing to curb opioid use. As plans moved generic opioids to higher cost-sharing tiers, beneficiaries simply paid cash prices and aggregate use remained largely unchanged. The anti-clawback provision in Part D, intended to protect beneficiaries from price gouging, limited plans' ability to constrain opioid use through typical demand-side measures such as increased cost-sharing.

Ban-the-box (BTB) laws are a widely used public policy rooted in employment law related to unnecessarily exclusionary hiring practices. BTB laws are intended to improve the employment opportunities of those with criminal backgrounds by giving them a fair chance during the hiring process. Prior research on the effectiveness of these laws in meeting their objective is limited and inconclusive. An important study is Doleac and Hanson (2020) who reported that BTB laws adversely affected the employment of young, low-educated Black men. In this article, we extend the Doleac and Hanson (2020) study in two ways: we include additional years of data that span a period of rapid expansion of BTB laws and we examine different types of BTB laws depending on the employers affected (e.g., public sector). Results indicate that BTB laws, any type of BTB law or BTB laws covering different types of employers, have no systematic or statistically significant association with employment of low-educated men, both young and old and across racial and ethnic groups. We speculate that the lack of effectiveness of BTB laws stems from the difficulty in enforcing such laws and already high rates of employer willingness to hire those with criminal histories.

We examine how export expansion induced by the U.S-Vietnam Bilateral Trade Agreement (BTA) affected migration, school enrollment, work and healthcare use of young children and adolescents in Vietnam. To do so, we exploit variation in tariff reductions across industries associated with the BTA and differences in industry employment shares across Vietnamese provinces prior to the policy change. We find that the BTA led to migration to the most affected provinces, particularly by adolescents (15 to 18) and young adults (19 to 29). The BTA also increased household expenditures, slightly decreased employment among nonmigrant adults and increased employment among migrant adults. Among adolescents, enrolment increased among non-migrants, but fell among migrants, with the opposite pattern for working. For children (7 to 14), enrolment did not change among non-migrants, but fell for migrants, who typically moved with their family. Conditional on being enrolled, education expenditures increased for both children and adolescents. We find evidence that healthcare utilization decreased for both children and adolescents.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

The contribution of cigarette smoking to national health expenditures is thought to be large, but our current understanding of the effect of smoking on annual medical expenditures is limited to studies that use cross-sectional data to make comparisons of medical care expenditures between smokers and never smokers at a particular age. We develop a dynamic economic model of smoking and medical care use that highlights two forms of selection: selective mortality and non-random cessation. To test predictions from our model, we construct novel longitudinal profiles of medical expenditures of smokers and never smokers from merged National Health Interview Survey and Medicare claims information. Consistent with our theory, we find that, from a given age, smokers generate higher expenditures prospectively, because of a higher incidence in inpatient usage, and lower expenditures retrospectively, because of lower outpatient usage. Between ages 65 and 84, we find that the expected value of the discounted sum of total expenditures is lower for smokers, mainly because of excess mortality. We find no evidence that cigarette smoking is a burden on Medicare.

More than a quarter of physicians in the United States are international medical graduates (IMGs). This statistic, although large, does not fully capture the importance of IMGs in certain specialties and locations. We provide a comprehensive profile of IMGs documenting where and in what specialties they work and how these distributions have changed over time. Estimates show that IMGs disproportionately work in densely populated, low-income communities with sicker residents and low physician density. IMGs are overrepresented in primary care and the lowest paying specialties, and their concentration in these specialties is growing. Calculations show that U.S. medical graduates exit the workforce at 2.5 times the exit rate of IMGs suggesting that in the near future IMGs will likely provide care for an increasingly larger share of Americans.

Effects of the minimum wage on labor market outcomes have been extensively debated and analyzed. Less studied, however, are other consequences of the minimum wage that stem from changes in a household's income and labor supply. We examine effects of the minimum wage on child health. To obtain estimates, we use data from the National Survey of Children's Health and a difference-in-differences design. We find that an increase in the minimum wage throughout childhood is associated with improvement in child health. Much of the benefit of a higher minimum wage is associated with the period between birth and age 5.