Pub Date : 2021-01-01Epub Date: 2020-12-22DOI: 10.1086/711723
David Powell, Rosalie Liccardo Pacula
Recent evidence suggests that the short-term transition of the opioid crisis from prescription opioids to heroin can be attributed to the reformulation of OxyContin, which substantially reduced access to abusable prescription opioids. In this paper, we find that over a longer time horizon, reformulation stimulated illicit drug markets to grow and evolve. We compare overdose trajectories in areas more exposed to reformulation, defined as states with higher rates of nonmedical OxyContin use before reformulation, to less exposed areas. More exposed areas experienced disproportionate increases in fatal overdoses involving synthetic opioids (fentanyl) and nonopioid substances like cocaine, suggesting that these new epidemics are related to the same factors driving the rise in heroin deaths. Instead of just short-term substitution from prescription opioid to heroin overdoses, the transition to illicit markets spurred by reformulation led to growth in the overall overdose rate to unprecedented levels.
{"title":"THE EVOLVING CONSEQUENCES OF OXYCONTIN REFORMULATION ON DRUG OVERDOSES.","authors":"David Powell, Rosalie Liccardo Pacula","doi":"10.1086/711723","DOIUrl":"10.1086/711723","url":null,"abstract":"<p><p>Recent evidence suggests that the short-term transition of the opioid crisis from prescription opioids to heroin can be attributed to the reformulation of OxyContin, which substantially reduced access to abusable prescription opioids. In this paper, we find that over a longer time horizon, reformulation stimulated illicit drug markets to grow and evolve. We compare overdose trajectories in areas more exposed to reformulation, defined as states with higher rates of nonmedical OxyContin use before reformulation, to less exposed areas. More exposed areas experienced disproportionate increases in fatal overdoses involving synthetic opioids (fentanyl) and nonopioid substances like cocaine, suggesting that these new epidemics are related to the same factors driving the rise in heroin deaths. Instead of just short-term substitution from prescription opioid to heroin overdoses, the transition to illicit markets spurred by reformulation led to growth in the overall overdose rate to unprecedented levels.</p>","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8460090/pdf/nihms-1666645.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39453109","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-01-01Epub Date: 2021-10-04DOI: 10.1086/716199
Thomas G McGuire, Anna L Zink, Sherri Rose
Modifications of risk-adjustment systems used to pay health plans in individual health insurance markets typically seek to reduce selection incentives at the individual and group levels by adding variables to the payment formula. Adding variables can be costly and lead to unintended incentives for upcoding or service utilization. While these drawbacks are recognized, they are hard to quantify and difficult to balance against the concrete, measurable improvements in fit that may be achieved by adding variables to the formula. This paper takes a different approach to improving the performance of health plan payment systems. Using the HHS-HHC V0519 model from the Marketplaces as a starting point, we constrain fit at the individual and group level to be as good or better than the current payment model while reducing the number of variables in the model. We introduce three elements in the design of plan payment: reinsurance, constrained regressions, and machine learning methods for variable selection. The fit performance of our alternative formulas with many fewer variables is as good or better than the current HHS-HHC V0519 formula.
{"title":"Improving the Performance of Risk Adjustment Systems: Constrained Regressions, Reinsurance, and Variable Selection.","authors":"Thomas G McGuire, Anna L Zink, Sherri Rose","doi":"10.1086/716199","DOIUrl":"10.1086/716199","url":null,"abstract":"<p><p>Modifications of risk-adjustment systems used to pay health plans in individual health insurance markets typically seek to reduce selection incentives at the individual and group levels by adding variables to the payment formula. Adding variables can be costly and lead to unintended incentives for upcoding or service utilization. While these drawbacks are recognized, they are hard to quantify and difficult to balance against the concrete, measurable improvements in fit that may be achieved by adding variables to the formula. This paper takes a different approach to improving the performance of health plan payment systems. Using the HHS-HHC V0519 model from the Marketplaces as a starting point, we constrain fit at the individual and group level to be as good or better than the current payment model while <i>reducing</i> the number of variables in the model. We introduce three elements in the design of plan payment: reinsurance, constrained regressions, and machine learning methods for variable selection. The fit performance of our alternative formulas with many fewer variables is as good or better than the current HHS-HHC V0519 formula.</p>","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8635414/pdf/nihms-1733043.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39949457","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Substance use disorders (SUDs) are a major social concern. There is an extensive economic literature estimating the social costs associated with SUDs in terms of health care, labor market outcomes, and crime. However, beyond anecdotal claims that SUD treatment centers (SUDTCs), settings in which patients receive care, reduce residential property values, there is little empirical work on this question. We apply a spatial difference-in-differences model and administrative data to test this relationship. We find that SUDTCs sort into lower-value areas, but once SUDTC selection is addressed, we find no evidence that SUDTCs influence residential property values.
{"title":"Substance Use Disorder Treatment Centers and Residential Property Values","authors":"Brady P. Horn, Aakrit Joshi, J. Maclean","doi":"10.1086/713033","DOIUrl":"https://doi.org/10.1086/713033","url":null,"abstract":"Substance use disorders (SUDs) are a major social concern. There is an extensive economic literature estimating the social costs associated with SUDs in terms of health care, labor market outcomes, and crime. However, beyond anecdotal claims that SUD treatment centers (SUDTCs), settings in which patients receive care, reduce residential property values, there is little empirical work on this question. We apply a spatial difference-in-differences model and administrative data to test this relationship. We find that SUDTCs sort into lower-value areas, but once SUDTC selection is addressed, we find no evidence that SUDTCs influence residential property values.","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2020-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1086/713033","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41486477","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and the single biggest cause of cervical cancer, as well as certain cancers of the head and throat, anus, vulva, vagina, and penis. Between 2008 and 2012 nearly 40,000 people annually were diagnosed with an HPV-related cancer. Despite these staggering numbers and the existence of a highly effective vaccine, HPV vaccination rates remain low. In this paper, I show that state Medicaid expansions as part of the Affordable Care Act were associated with a 3–4 percentage point increase in the probability that a teenager initiated the HPV vaccine. This relationship appears to have been driven in part by increases in Medicaid coverage, the probability of having a recent checkup, and knowledge about the HPV vaccine. Supporting this pathway, I show that Medicaid expansion states saw increased searches for “pediatrician,” “Gardasil” (a trade name of the HPV vaccine), and “HPV cancer.”
{"title":"Insurance Coverage, Provider Contact, and Take-Up of the HPV Vaccine","authors":"Brandyn F. Churchill","doi":"10.1086/713037","DOIUrl":"https://doi.org/10.1086/713037","url":null,"abstract":"Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and the single biggest cause of cervical cancer, as well as certain cancers of the head and throat, anus, vulva, vagina, and penis. Between 2008 and 2012 nearly 40,000 people annually were diagnosed with an HPV-related cancer. Despite these staggering numbers and the existence of a highly effective vaccine, HPV vaccination rates remain low. In this paper, I show that state Medicaid expansions as part of the Affordable Care Act were associated with a 3–4 percentage point increase in the probability that a teenager initiated the HPV vaccine. This relationship appears to have been driven in part by increases in Medicaid coverage, the probability of having a recent checkup, and knowledge about the HPV vaccine. Supporting this pathway, I show that Medicaid expansion states saw increased searches for “pediatrician,” “Gardasil” (a trade name of the HPV vaccine), and “HPV cancer.”","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2020-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1086/713037","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48397296","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Catalina Amuedo‐Dorantes, Brandyn F. Churchill, Yang Song
The past two decades were characterized by an unprecedented increase in interior immigration enforcement and heightened stress due to fears of family separation and loss of income among undocumented immigrants. Using vital statistics on infant births from the National Center for Health Statistics for the 2003 through 2016 period and a difference-in-differences design, we compare the health outcomes of infants with likely undocumented mothers before and after the intensification of immigration enforcement within US counties. We find that intensified enforcement, especially during the third trimester, increases the likelihood of low birth weight (<2,500 grams). We also present suggestive evidence that the effect could be driven by heightened stress and fears associated with police-based enforcement during pregnancy. The findings underscore the importance of current immigration policies in shaping the birth outcomes of many American children.
{"title":"Immigration Enforcement and Infant Health","authors":"Catalina Amuedo‐Dorantes, Brandyn F. Churchill, Yang Song","doi":"10.1086/718510","DOIUrl":"https://doi.org/10.1086/718510","url":null,"abstract":"The past two decades were characterized by an unprecedented increase in interior immigration enforcement and heightened stress due to fears of family separation and loss of income among undocumented immigrants. Using vital statistics on infant births from the National Center for Health Statistics for the 2003 through 2016 period and a difference-in-differences design, we compare the health outcomes of infants with likely undocumented mothers before and after the intensification of immigration enforcement within US counties. We find that intensified enforcement, especially during the third trimester, increases the likelihood of low birth weight (<2,500 grams). We also present suggestive evidence that the effect could be driven by heightened stress and fears associated with police-based enforcement during pregnancy. The findings underscore the importance of current immigration policies in shaping the birth outcomes of many American children.","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2020-12-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45272765","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
W. Evans, Sarah Kroeger, Elizabeth L Munnich, Grace Ortuzar, Kathryn L. Wagner
Hospital readmissions generate enormous costs and are the subject of increased scrutiny among US lawmakers. The Affordable Care Act created the Community-Based Care Transitions Program (CCTP) to test models for improving care transitions after hospital discharge with the goal of reducing 30-day Medicare hospital readmission rates by 20 percent. Few of these demonstrations showed sustained reductions in readmission rates. In contrast to more traditional medically focused programs, the Chicago Southland Coalition for Transition Care (CSCTC) utilized social workers solely to manage care transitions in an effort to address nonmedical obstacles to recovery. Using a difference-in-differences model and the census of Medicare discharges over the 2010–15 period, we evaluate the impact of this program. We select as a comparison group hospitals in the Chicago area with similar pretreatment trends in readmission rates and total discharges. Treatment-on-treated estimates indicate that the CSCTC program reduced 30-, 60-, and 90-day readmission rates by a statistically significant 14 percent or more of the sample mean, and reduced readmission costs an amount equal to CSCTC program cost. Effects are driven by black and Hispanic patients as well as those with dual eligibility for both Medicare and Medicaid.
{"title":"Reducing Readmissions by Addressing the Social Determinants of Health","authors":"W. Evans, Sarah Kroeger, Elizabeth L Munnich, Grace Ortuzar, Kathryn L. Wagner","doi":"10.1086/711725","DOIUrl":"https://doi.org/10.1086/711725","url":null,"abstract":"Hospital readmissions generate enormous costs and are the subject of increased scrutiny among US lawmakers. The Affordable Care Act created the Community-Based Care Transitions Program (CCTP) to test models for improving care transitions after hospital discharge with the goal of reducing 30-day Medicare hospital readmission rates by 20 percent. Few of these demonstrations showed sustained reductions in readmission rates. In contrast to more traditional medically focused programs, the Chicago Southland Coalition for Transition Care (CSCTC) utilized social workers solely to manage care transitions in an effort to address nonmedical obstacles to recovery. Using a difference-in-differences model and the census of Medicare discharges over the 2010–15 period, we evaluate the impact of this program. We select as a comparison group hospitals in the Chicago area with similar pretreatment trends in readmission rates and total discharges. Treatment-on-treated estimates indicate that the CSCTC program reduced 30-, 60-, and 90-day readmission rates by a statistically significant 14 percent or more of the sample mean, and reduced readmission costs an amount equal to CSCTC program cost. Effects are driven by black and Hispanic patients as well as those with dual eligibility for both Medicare and Medicaid.","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2020-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1086/711725","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42460875","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In this paper we estimate the effect of adult children’s education on parental health using data from the 2011 China Health and Retirement Longitudinal Study (CHARLS). We find that parents of better-educated children have better health, measured by self-rated health status. Using geographic proximity to school as the instrumental variable, we find that an extra year of children’s education could increase the probability of parental good health status by about 7.7 percentage points. This result is corroborated by the estimates based on an alternative identification strategy. We also find suggestive evidence that smoking behavior, use of preventive care, and especially management of chronic conditions are potential channels through which children’s education can improve parental health.
{"title":"Children’s Education and Parental Health","authors":"Zhiqiang Liu","doi":"10.1086/711704","DOIUrl":"https://doi.org/10.1086/711704","url":null,"abstract":"In this paper we estimate the effect of adult children’s education on parental health using data from the 2011 China Health and Retirement Longitudinal Study (CHARLS). We find that parents of better-educated children have better health, measured by self-rated health status. Using geographic proximity to school as the instrumental variable, we find that an extra year of children’s education could increase the probability of parental good health status by about 7.7 percentage points. This result is corroborated by the estimates based on an alternative identification strategy. We also find suggestive evidence that smoking behavior, use of preventive care, and especially management of chronic conditions are potential channels through which children’s education can improve parental health.","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2020-09-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1086/711704","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41412370","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
US states have implemented many policies to lessen the severity of the opioid crisis. This study investigates prescription drug monitoring programs, the reformulation of OxyContin, and Pill Mill laws on illicit drug possession and sellers. I perform difference-in-differences analyses to study policy-induced substitution to heroin and illicit opioids as measured through rates of heroin and diverted opioid possession and dealers. I find evidence that state policies cause increases in heroin possession and dealers, and that these effects are similar in magnitude to effects spurred by the reformulation of OxyContin.
{"title":"Policy-Induced Substitution to Illicit Drugs and Implications for Law Enforcement Activity","authors":"Justine Mallatt","doi":"10.1086/716462","DOIUrl":"https://doi.org/10.1086/716462","url":null,"abstract":"US states have implemented many policies to lessen the severity of the opioid crisis. This study investigates prescription drug monitoring programs, the reformulation of OxyContin, and Pill Mill laws on illicit drug possession and sellers. I perform difference-in-differences analyses to study policy-induced substitution to heroin and illicit opioids as measured through rates of heroin and diverted opioid possession and dealers. I find evidence that state policies cause increases in heroin possession and dealers, and that these effects are similar in magnitude to effects spurred by the reformulation of OxyContin.","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2020-09-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44163835","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Lucie Schmidt, Lara D. Shore-Sheppard, Tara Watson
The Affordable Care Act (ACA) expanded the availability of public health insurance, decreasing the relative benefit of participating in disability programs but also lowering the cost of exiting the labor market to apply for disability benefits. In this paper, we explore the impact of expanded access to Medicaid through the ACA on applications to the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs. Using the fact that the Supreme Court decision of June 2012 made the Medicaid expansion optional for the states, we compare changes in county-level SSI and SSDI caseloads in contiguous county pairs across a state border. We find no significant effects of the Medicaid expansion on applications or awards to either SSI or SSDI, and can reject economically meaningful impacts of Medicaid expansions on applications to disability programs.
{"title":"The Impact of the ACA Medicaid Expansion on Disability Program Applications","authors":"Lucie Schmidt, Lara D. Shore-Sheppard, Tara Watson","doi":"10.1086/710525","DOIUrl":"https://doi.org/10.1086/710525","url":null,"abstract":"The Affordable Care Act (ACA) expanded the availability of public health insurance, decreasing the relative benefit of participating in disability programs but also lowering the cost of exiting the labor market to apply for disability benefits. In this paper, we explore the impact of expanded access to Medicaid through the ACA on applications to the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs. Using the fact that the Supreme Court decision of June 2012 made the Medicaid expansion optional for the states, we compare changes in county-level SSI and SSDI caseloads in contiguous county pairs across a state border. We find no significant effects of the Medicaid expansion on applications or awards to either SSI or SSDI, and can reject economically meaningful impacts of Medicaid expansions on applications to disability programs.","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2020-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138540229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
An annual flu vaccination is one of the least controversial and most widely recommended preventive health measures. However, only a fraction of those who are suggested to get a flu vaccination actually receive it. We focus on past personal outcomes to understand how individual learning influences patterns over time using medical claims for a 5 percent panel sample of Medicare beneficiaries. We find that individuals learn from personal suffering from the flu and such learning is conditional on whether they had taken a flu vaccination in the same flu season. If they did not get vaccinated for the flu, having the flu later on encourages them to get the flu vaccine the following year. But if they had been vaccinated and still got the flu, their likelihood of getting a flu shot next year is significantly reduced. The outbreak of the H1N1 flu did not break the qualitative pattern of “learning by suffering” but it does change the magnitude of response.
{"title":"Learning By Suffering?","authors":"G. Jin, Thomas G. Koch","doi":"10.1086/711564","DOIUrl":"https://doi.org/10.1086/711564","url":null,"abstract":"An annual flu vaccination is one of the least controversial and most widely recommended preventive health measures. However, only a fraction of those who are suggested to get a flu vaccination actually receive it. We focus on past personal outcomes to understand how individual learning influences patterns over time using medical claims for a 5 percent panel sample of Medicare beneficiaries. We find that individuals learn from personal suffering from the flu and such learning is conditional on whether they had taken a flu vaccination in the same flu season. If they did not get vaccinated for the flu, having the flu later on encourages them to get the flu vaccine the following year. But if they had been vaccinated and still got the flu, their likelihood of getting a flu shot next year is significantly reduced. The outbreak of the H1N1 flu did not break the qualitative pattern of “learning by suffering” but it does change the magnitude of response.","PeriodicalId":45056,"journal":{"name":"American Journal of Health Economics","volume":null,"pages":null},"PeriodicalIF":3.7,"publicationDate":"2020-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1086/711564","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42349206","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"经济学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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