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"Empirical work shows that health insurance coverage improves children's health and that healthier children have better educational and labor market outcomes. This suggests that the benefits of higher insurance rates among children go beyond improvements in health. However, there are no investigations in the United States that track the long-term socioeconomic benefits of health insurance coverage during childhood. Using data from the Children of the National Longitudinal Survey of Youth to estimate family fixed effects models, I find evidence that health insurance coverage at ages 0-4 has a positive effect on test scores in mathematics, reading recognition, reading comprehension, and vocabulary at ages 5-14. The second essay in this dissertation, co-authored with Charles Courtemanche, investigates the effect of the Massachusetts health care reform on self-reported health. The main objective of this reform was to achieve universal health insurance coverage through a combination of insurance market reforms, mandates, and subsidies. This reform was later used as a model for the Patient Protection and Affordable Care Act (ACA). Using individual-level data from the Behavioral Risk Factor Surveillance System and a difference in differences estimation strategy, this essay provides evidence that this reform led to better overall self-assessed health. Several determinants of overall health, including physical health, mental health, functional limitations, joint disorders, body mass index, and moderate physical activity also improved. Public food assistance programs share the fundamental goal of helping needy and vulnerable people in the U.S. obtain access to nutritious foods that they might not otherwise be able to afford. These programs also have other objectives, such as improving recipients' health, furthering children's development and school performance. To investigate these broader impacts, the third chapter of this dissertation, co-authored with David Ribar, examines the relationship between participation in food assistance programs, family routines and time use. Results from fixed effects models estimated using longitudinal data from the Three-City Study indicate that SNAP participation is negatively associated with homework routines. WIC participation on the other hand, is positively associated with family routines in general and with dinner routines, homework routines, and family-time routines in particular."--Abstract from author supplied metadata.
Immigrants are more likely to be low income than their US-born peers, but they face more barriers to enrolling in government safety net programs. Children of immigrants, the majority of whom are US citizens, are less likely to enroll in some programs designed to protect their health and welfare. This dissertation explores issues of immigrant families’ engagement with public health insurance and nutritional assistance programs in three chapters. The first chapter describes levels and time trends of immigrant families’ participation in key safety net programs. The study covers the years 1996 to 2013 using data from the Survey of Income and Program Participation (SIPP) and the New Immigrant Survey (NIS). For children, the study presents data and regression-adjusted estimates of the associations between being from an immigrant family, and having likely undocumented family members, and participation in each of five safety net programs: the Food Stamps Program; National School Lunch Program; School Breakfast Program; Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and public health insurance. The second chapter evaluates the effects of six state policies that implemented early Affordable Care Act (ACA) adult Medicaid expansions. The analysis focuses on citizen adults of immigrant and native families. It uses the American Community Survey (ACS) from 2008 to 2013 and a difference-in-differences method with synthetic control states to estimate the effects of the expansions on insurance coverage outcomes for citizen adults of immigrant and native family backgrounds. The policies produced a range of responses, from a 2 percentage point public insurance coverage increase in California to an 8 percentage point increase in Connecticut. There was some evidence of private insurance crowd-out in Connecticut, the District of Columbia, and Minnesota, but there were also net reductions in uninsurance for most states. Responses to the new policies were slightly lower among young adults than for the full adult population. In general, insurance coverage changes did not measurably differ among individuals from immigrant families as compared with those from native families. The third chapter analyzes public health insurance expansions for children. Medicaid expansions have the potential to greatly increase coverage for children in immigrant families, who have low levels of private insurance and high uninsurance rates. However, take-up may be lower in immigrant families than native families due to poor information and “chilling” anti-immigrant sentiment. I estimate take-up from 1996 to 2013 using instrumental variables regression and data from the Survey of Income and Program Participation (SIPP). This study finds that new eligibility for public insurance produces a 9-to-13 percentage point increase in public coverage among children of immigrants, which is indistinguishable from the 11-to-12 percentage point increase among children of natives. These findings reject a strong chilling effect, although the question will be important to revisit in the changing policy environment.
This dissertation contains three essays that look at the impact of food assistance programs on individuals behavior. The United States government offers a variety of welfare programs meant to provide assistance to families and individuals. This dissertation focuses on two specific food assistance programs: the Supplemental Nutrition Assistance Program (SNAP) and National School Lunch Program (NSLP). While the NSLP is not traditionally thought of as a welfare program, it provides subsidized meals for all school children, regardless of income, and further subsidizes meals for children from low-income households. The first essay uses primary data to determine if pre-ordering and nudging affect childrens selection behavior in the lunchroom. Research on food assistance programs and nutrition is particularly important given recent legislation changes and increases in adolescent obesity. The second essay analyzes the impact of students a la carte choices in the lunchroom on their selection of fruit, vegetables, and low fat dairy. The third essay studies the impact that state policies have on an individuals decision to migrate to another state.
This dissertation focuses on examining the impact of public spending in health insurance and health care markets. Health care subsidies account for a fast-growing share of public expenditures in many developed and developing countries, making them an ever more important component of fiscal policy discussions. Two principle projects constitute my dissertation research. In the first project, I examine the heterogeneity in the impact of subsidized health insurance coverage on individual welfare, in the context of a Chinese public health insurance program. In the course of this research, I have also developed new econometric methods to address the empirical challenges of studying the effects of health insurance. These methods have broad applications beyond topics in health economics. In the second project, I look at the role of tax subsidies in the supply of health care. In particular, I exploit variations in state and federal level tax policies in the U.S to estimate the impact of government subsidies on ownership choice, provision of public services and the quality of hospitals. The first chapter of the dissertation mainly assesses the effect of public health insurance on program beneficiaries' welfare, by evaluating a new national public medical insurance program in China, Urban Resident Basic Insurance (URBMI). This program, introduced in 2007 and having an annual fiscal expenditure of 30 billion RMB, aims to provide coverage to more than 200 million urban residents including elderly, children, college students and unemployed adults. I exploit the city-variation in policy generosity as an exogenous determinant of URBMI enrollment. Using data from the Chinese Health and Nutrition Survey (CHNS), I find that URBMI increases welfare on several margins. Having insurance coverage increases health care spending while decreasing the out-of-pocket payments, providing protection from the financial risk. It also increases efficiency in medical spending by inducing the use of preventative care and reducing the probability of hospitalization. In terms of health outcomes, insurance coverage has a significant impact on subjective self-ratings in health and happiness. I also extend my examination to consider the labor market effects of URBMI. Since this program provides insurance coverage outside of employment status, it will potentially increase an individual's mobility between jobs and impact the retirement decision. In Chapter 2, building on the results of the first chapter, I explore the heterogeneity in the impact of health insurance through a semiparametric model. Since URBMI is a national program covering a wide range of subpopulations, observed and unobserved individual characteristics may play an important role in determining the response of an individual to insurance coverage. This chapter builds a panel data model with endogenous treatment, which incorporates unobserved individual heterogeneity non-additively into the outcome. The model is estimated in the context of a semiparametric setting. I first propose a two-stage semiparametric least square (SLS) method to consistently estimate the model parameters and then conduct a localized 2SLS procedure to recover the quantile treatment effect. Identification, consistency, and root-N asymptotic normality of estimators for parameters and marginal effects are proved. The estimation results reveal substantial variation in the impact of URBMI by age, income and gender. Children, the elderly above the age of 70, and females ages 25-40 benefit the most from the program. Adult males and individuals with incomes below the median level do not respond significantly to insurance coverage. The findings of heterogeneous insurance effects have important policy implications for the cost-effectiveness of URBMI across population groups, suggesting the need for differentiated insurance programs. In the third chapter, another form of subsidy in health care markets is studied. This chapter focuses on assessing the effect of government subsidies on the supply side of the health care market in the U.S. An important form of government subsidies to health care providers is the tax exemption for non-profit organizations. The validity and efficiency of such practice has long been under debate. Recently, many state and federal laws have been enacted that mandate the reporting of benefits provided to the community by non-profit providers. This chapter studies the hospital sector. Given the preferential tax treatment for nonprofit hospitals, the tax rate, in conjunction with community benefit reporting requirement (CRR), determine the net subsidy provided to a nonprofit hospital compared to its for-profit counterpart. I exploit the variation in tax policy across states and over time to identify the effect of tax subsidy on the ownership choice of hospitals. I further differentiate behavior between nonprofit versus for-profit hospitals, including cost, provision of undercompensated care as well as quality. Using Center for Medicare and Medicaid Services(CMS) hospital cost report data from 1996 to 2015, I estimate a 4-6 percent increase in the probability of non-profit conversion into for-profit hospitals due to the enactment of CRR. Moreover, the effect of CRR diminishes with the tax rate. My results further show that hospitals divert community benefit spending to teaching to meet the requirement of CRR, rather than increasing provision of uncompensated care.
In these essays, I study the effects of prenatal or early life access to public programs on subsequent health outcomes, employing quasi-experimental research settings derived from several exogenous changes in public policies: (1) the Unborn Child Option of the Children's Health Insurance Program (CHIP), (2) the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, and (3) the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program. In the first chapter, I examine the causal effects of in utero public health insurance on child health beyond birth outcomes. The implementation of the Unborn Child Option (UCO) as part of the Children's Health Insurance Program (CHIP) provides a unique opportunity to isolate the causal effects of in utero public health insurance on child health beyond birth outcomes. The UCO allowed previously ineligible pregnant noncitizens to obtain public health insurance for prenatal care. Regardless of the reform, U.S.-born children of these women receive birthright citizenship and become eligible for public health insurance if their household income is low enough. Thus, the only thing changed by the reform is access to in utero public health insurance, holding post-birth coverage constant. Using state-level variation in whether and when the UCO was adopted, I find that the reform caused improvement in children's health and development. Interestingly, it only appears from preschooler ages while no improvement is shown at earlier periods. I accordingly provide suggestive evidence on one possible mechanism: the improved maternal mental health during pregnancy. In the second chapter, I study the effects of public health insurance in the prenatal period on health outcomes in early childhood. The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) new option eliminated the five-year waiting period for Medicaid and CHIP eligibility that had been imposed on pregnant noncitizens since the 1996 welfare reform. The results show that CHIPRA new option caused an improvement in children's health. Children who were eligible in utero have a 13% better parent-reported health status compared to those who were not. Additional analysis shows that this improvement was due to the take-up of CHIPRA new option. In the third chapter, we study how an early life nutrition program affects health and economic outcomes in adulthood. The Supplemental Nutrition Program for Women, Infants, and Children (WIC) is intended to improve the nutritional well-being of low-income pregnant and post-partum women, infants, and children, by giving food vouchers for specific items with key nutrients. We utilize variation across counties in the date of implementation of the WIC program to identify the impact of the program on later life health and economic outcomes. Using geocoded data from the Panel Study of Income Dynamics, we find that early life exposure to the WIC program caused a lower incidence of high blood pressure and asthma in adulthood, while no clear improvement is shown in economic outcomes.
In recent years the `farm to table' trend, the idea of understanding linkages between agricultural supply, food systems, and the food that is consumed, has been growing in popularity. This dissertation takes this idea a step further and examines topics on the progression from `farm to health outcomes.' It is important to recognize not only that food systems impact the way consumers eat, but that those food choices impact health outcomes and the way that medical care is consumed. The three essays of this dissertation examine three separate points along this continuum to improve the understanding of how food systems, food choice, health outcomes, and healthcare consumption interact. The first essay evaluates factors associated with school districts' decisions to participate in farm to school (FTS) programs. I leverage the USDA's Farm to School Census to analyze factors associated with FTS participation, the types of FTS activities implemented, and the challenges faced by participating school districts. I use spatially articulate data to estimate the spatial spillover effects of FTS participation. The results demonstrate that both school characteristics and local farm production factors are associated with FTS participation. The estimated spatial spillover effect is positive, suggesting that areas with a high penetration of FTS activities have lower barriers associated with implementing FTS programs. In my second essay, I shift to evaluating how parent-child pairs make the daily school lunch decision. Meals served in the National School Lunch Program (NSLP) are on average more healthful than alternatives, implying that increasing participation in the NSLP can improve nutrition for a large number of children. However, there is little understanding of the household decision process that determines participation in the NSLP. This study uses a parent-child choice experiment to assess the impact of both parent and child on NSLP participation. The results show that both have a significant impact on the chosen meal, where parents are concerned with meal palatability and nutrition, while the child only cares about palatability. The decision is also influenced by the household structure and demographics, and the inclusion of local foods in the school lunch option. My final essay evaluates how access to medical care can impact lifestyle choices. I evaluate if there is an ex ante moral hazard effect in health insurance markets. Ex ante moral hazard occurs when an individual takes on more risk knowing they will not bear the full cost of the consequences. In the case of health insurance, this could mean taking on unhealthful eating habits knowing that if these habits lead to illness the cost of care will be covered by insurance. Using panel data from the National Longitudinal Youth Survey 1997, I find evidence of an ex ante moral hazard effect in BMI, binge drinking, and smoking, suggesting that people take on less healthful behaviors, holding all else constant, when they have health insurance. The existence of ex ante moral hazard suggests that insurance companies can seek efficiency gains by finding ways to structure policies that diminish this moral hazard effect.
This important collection of essays, originating in a 1989 conference on the disadvantaged in American health care, provides incisive commentary on U.S. health care policy and politics. Examining public responses to health crises and analyzing the political logic of the American community, this volume charts the immobility of U.S. health policy in recent years and points to its disastrous consequences for the 1990s. Focusing on the particular needs of disadvantaged groups--the elderly, children, people with AIDS, the mentally ill, the chemically dependent, the homeless, the hungry, the medically uninsured--these essays develop strong policy statements. The authors describe the growth in U.S. health care programs, from Kerr-Mills to Medicare, Medicaid, and subsequent revisions, and stress the serious omissions resulting from incremental policy expansion, both in identifying disadvantaged groups and in implementing programs. They report the weakness of the U.S. health care system compared to systems of other technologically developed countries. Contributors. Deborah A. Stone and Theodore R. Marmor, Judith Feder, Alice Sardell, Bruce C. Vladeck, Michael Lipsky and Marc A. Thibodeau, Daniel M. Fox, William E. McAuliffe, M. Gregg Bloche and Francine Cournos, Lawrence D. Brown, James A. Morrone
Originally published in 1995. This study collects and analyses the results of hunger studies carried out in the United States during the 1980s, whether national, state or local. It also reviews the history and development of food assistance programs and policy. This is an unusual and fascinating study of public health policy which employs meta-analysis to investigate the sociodemographic factors affecting those seeking food assistance and draws recommendations for future studies and to feed into policy decisions.
The study of addiction is dominated by a narrow disease ideology that leads to biological reductionism. In this short volume, editors Granfield and Reinarman make clear the importance of a more balanced contextual approach to addiction by bringing to light critical perspectives that expose the historical and cultural interstices in which the disease concept of addiction is constructed and deployed. The readings selected for this anthology include both classic foundational pieces and cutting-edge contemporary works that constitute critical addiction studies. This book is a welcome addition to drugs or addiction courses in sociology, criminal justice, mental health, clinical psychology, social work, and counseling.