Journal of Policy Analysis and Management

Published by Wiley
Online ISSN: 1520-6688
Publications
Article
State-legislative support for liberalized abortion policies, the availability of abortion providers, and actual abortion rates vary widely across states. This article uses national data to examine the impact of the following three major, enforceable state abortion restrictions as of 1988 on the access to and use of abortion services: state restrictions on Medicaid financing of abortions for low-income women (36 states), state requirements for parental consent or parental notification for minors to obtain abortions (11 states), and state restrictions on insurance coverage of abortion for public employees (8 states). The impact of state abortion restrictions is becoming an increasingly important policy issue as the number and types of restrictions which can be enforced in the US increase rapidly. The Supreme Court in Webster v. Reproductive Health Services (1989) upheld a Missouri law banning abortions in public hospitals and the involvement of public employees in the performance of abortions; states via this ruling may also enforce mandatory testing for viability after a specified point in the pregnancy. The Supreme Court then in Planned Parenthood of Southeastern Pennsylvania v. Casey (1992) effectively ruled that states can enforce a 24-hour waiting period and a state-prescribed talk on abortion for women seeking abortion. Analysis of the data found that there are significantly fewer hospitals, clinics, and private physicians' offices providing abortions in states with parental consent or notification laws. Moreover the rate of minors' abortions per 1000 teen pregnancies is 16% lower, and the rate of minors' abortions per 1000 women aged 15-19 is 25% lower in states with such laws compared to states without the laws. Data from abortion clinics and referral services in Massachusetts, Minnesota, and Rhode Island suggest that 20-55% of minors are going to court instead of informing their parents. 35% of minors who contacted a clinic in Massachusetts and 49% in Rhode Island went out of state for abortions. As for Medicaid restrictions, there are significantly fewer hospitals, clinics, and private physicians' offices providing abortions in states which restrict funding of abortions as compared to states which do not. State restrictions on insurance coverage of abortion for public employees do not appear to be associated with statistically significant differences in abortion rates or abortion availability.
 
Article
This paper examines the impacts of four abstinence-only education programs on adolescent sexual activity and risks of pregnancy and sexually transmitted diseases (STDs). Based on an experimental design, the impact analysis uses survey data collected in 2005 and early 2006 from more than 2,000 teens who had been randomly assigned to either a program group that was eligible to participate in one of the four programs or a control group that was not. The findings show no significant impact on teen sexual activity, no differences in rates of unprotected sex, and some impacts on knowledge of STDs and perceived effectiveness of condoms and birth control pills
 
Article
Changes in funding, clientele, and treatment practices of public and privately owned substance abuse treatment programs, compelled in part by increased cost containment pressures, have prompted researchers' investigations of the implications of organizational form for treatment programs. These studies primarily probe associations between ownership status, patient characteristics, and services delivered and do not empirically link organizational form or structure to treatment outcomes. Data from the National Treatment Improvement Evaluation Study (NTIES) were used to study the relationship of ownership and other dimensions of publicness identified in the public management literature to patient outcomes, controlling for patient characteristics, treatment experiences, and other program characteristics. A few effects of organizational form and structure on substance abuse treatment outcomes are statistically significant (primarily improved social functioning), although the specific contributions of measures of ownership and publicness to explaining program-level variation are generally small.
 
Article
A fundamental concern with competitive health insurance markets is that they will not supply efficient levels of coverage for treatment of costly, chronic, and predictable illnesses, such as mental illness. Since the inception of employer-based health insurance, coverage for mental health services has been offered on a more limited basis than coverage for general medical services. While mental health advocates view insurance limits as evidence of discrimination, adverse selection and moral hazard can also explain these differences in coverage. The intent of parity regulation is to equalize private insurance coverage for mental and physical illness (an equity concern) and to eliminate wasteful forms of competition due to adverse selection (an efficiency concern). In 2001, a presidential directive requiring comprehensive parity was implemented in the Federal Employees Health Benefits (FEHB) Program. In this study, we examine how health plans responded to the parity directive. Results show that in comparison with a set of unaffected health plans, federal employee plans were significantly more likely to augment managed care through contracts with managed behavioral health "carve-out" firms after parity. This finding helps to explain the absence of an effect of the FEHB Program directive on total spending, and is relevant to the policy debate in Congress over federal parity.
 
Article
Emergency contraception (EC) can prevent pregnancy after sex, but only if taken within 72 hours of intercourse. Over the past 15 years, access to EC has been expanded at both the state and federal level. This paper studies the impact of those policies. We find that expanded access to EC has had no statistically significant effect on birth or abortion rates. Expansions of access, however, have changed the venue in which the drug is obtained, shifting its provision from hospital emergency departments to pharmacies. We find evidence that this shift may have led to a decrease in reports of sexual assault.
 
Article
Are public and private organizations fundamentally different? This question has been among the most enduring inquiries in public administration. Our study explores the impact of organizational ownership on two complementary aspects of performance: service quality and access to services for impoverished clients. Derived from public management research on performance determinants and nursing home care literature, our hypotheses stipulate that public, nonprofit, and for-profit nursing homes use different approaches to balance the strategic tradeoff between two aspects of performance. Panel data on 14,423 facilities were analyzed to compare measures of quality and access across three sectors using different estimation methods. Findings indicate that ownership status is associated with critical differences in both quality and access. Public and nonprofit organizations are similar in terms of quality, and both perform significantly better than their for-profit counterparts. When compared to nonprofit and, in some cases, for-profit facilities, public nursing homes have a significantly higher share of Medicaid recipients. The paper proposes strategies to address the identified long-term care divide.
 
Article
A recent study by the Heritage Foundation (Rector, Johnson, & Noyes, 2003) found evidence of a positive relationship between early sexual intercourse and depressive symptoms. This finding has been used to bolster support for funding abstinence only sex education. However, promoting abstinence will only yield mental health benefits if there is a causal link between sexual intercourse and depression. Using the National Longitudinal Study of Adolescent Health (Add Health), I carefully examine the relationship between early teen sex and several measures of depression. Controlling for a wide set of individual level and family level observable characteristics, cross section estimates consistently show a significant positive relationship between early sexual activity for females and three measures of adverse mental health: self reported depression, a belief that one's life is not worth living, and serious thoughts of suicide. However, difference-in-difference estimates reflect no evidence of a significant relationship between early teen sex and depressive symptoms. These findings suggest that the positive association observed by Rector et al. (2003) can be explained by unmeasured heterogeneity. Thus, promoting abstinence among adolescents is unlikely to alleviate depressive symptoms
 
Article
This study examines whether offering sex education to young teenagers affects several measures of adolescent sexual behavior and health: virginity status, contraceptive use, frequency of intercourse, likelihood of pregnancy, and probability of contracting a sexually transmitted disease. Using data from the National Longitudinal Study of Adolescent Health, I find that while sex education is associated with adverse health outcomes, there is little evidence of a causal link after controlling for unobserved heterogeneity via fixed effects and instrumental variables. These findings suggest that those on each side of the ideological debate over sex education are, in a sense, both correct and mistaken. Opponents are correct in observing that sex education is associated with adverse health outcomes, but are generally incorrect in interpreting this relationship causally. Proponents are generally correct in claiming that sex education does not encourage risky sexual activity, but are incorrect in asserting that investments in typical school-based sex education programs produce measurable health benefits.
 
Article
In the wake of significant budget shortfalls, 37 states and the District of Columbia have recently increased cigarette excise taxes to boost revenues. This study examines the impact of increasing the price of cigarettes, which will occur as a consequence of cigarette excise tax increases, and implementing restrictions on smoking in private worksites, restaurants, government worksites, healthcare facilities, and other public places on young adult smoking progression. This paper employs nationally representative longitudinal data on young adults from the Monitoring the Future Surveys matched with information on site-specific prices and smokefree air laws. The estimates clearly indicate that increasing the price of cigarettes would substantially decrease the number of young adults who progress into higher intensities of smoking. In addition, private worksite restrictions and restrictions on smoking in other public places are found to decrease moderate smoking uptake among young adults.
 
Article
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 replaces AFDC, the largest means-tested cast assistance program for low-income families, with the Temporary Assistance for Needy Families (TANF) block grant. Unlike AFDC, assistance under TANF is limited to five years in a lifetime, and states are required to move families from the assistance rolls into jobs. But not all adult welfare recipients can easily move to work because either they themselves are disabled or they have a child with disabilities requiring special care. This article examines the extent and impact of disability among families on AFDC to gain insight into the potential impact of changes under TANF. Using data from the 1990 Survey of Income and Program Participation (SIPP), we find that in nearly 30 percent of the families on AFDC either the mother or child has a disability. Furthermore, we find that having a disability significantly lowers the probability that a woman leaves AFDC for work but not for other reasons, such as a change in living arrangements. Finally, we find little evidence that having a child with a disability affects the probability of leaving AFDC for any reason.
 
Article
In this paper, we explore whether the specific design of a state's program has contributed to its success in meeting two objectives of the Children's Health Insurance Program (SCHIP): increasing the health insurance coverage of children in lower income families and doing so with a minimum reduction in their private health insurance coverage (crowd-out). In our analysis, we use two years of Current Population Survey data, 2000 and 2001, matched with detailed data on state programs. We focus on two populations: the eligible population of children, broadly defined--those living in families with incomes below 300 percent of the federal poverty line (FPL)--and a narrower group of children, those who we estimate are eligible for Medicaid or SCHIP. Unique state program characteristics in the analysis include whether the state plan covers families; whether the state uses presumptive eligibility; the number of months without private coverage that are required for eligibility; whether there is an asset test; whether a face-to-face interview is required; and specific outreach activities. Our results provide evidence that state program characteristics are significant determinants of program success.
 
Article
State and federal funds are important sources of revenue for medical schools, and a strong case can be made for public support for these institutions. Although the federal role is more widely known, the states in fact provide the bulk of direct support for medical training. The nature of aid from the two sources differs in significant ways. Most federal aid supports research or patient care, but much of state aid goes to support unconditional tuition subsidies. The primary beneficiaries of these subsidies are relatively affluent nonminority students who are beginning lucrative careers in the medical field--careers that would be lucrative even if no subsidies were provided. Nor does it appear that general subsidies are needed to attract poor and minority applicants. While targeted loans and scholarships to individuals may be justified, general tuition subsidies are not.
 
Article
In 1998, 46 states and the four major tobacco companies signed the Master Settlement Agreement (MSA), which stipulated that the tobacco companies pay states $206 billion over 25 years and take steps to reduce youth smoking. The remaining states settled separately. We sought to determine the effect of the settlements on demand for cigarettes. Using a nationwide sample from 1990 to 2002, we estimated a model of the decision to smoke cigarettes. The settlements affected smoking primarily through price increases for cigarettes, although there was evidence that other policy instruments influenced smoking rates for younger smokers. By 2002, the settlements had reduced overall smoking rates by 13 percent for ages 18 to 20 and older than 65 and 5 percent for ages 21 to 64.
 
Article
Estimates of the costs and consequences of many types of public policy proposals play an important role in the development and adoption of particular policy programs. Estimates of the same, or similar, policies that employ different modeling approaches can yield widely divergent results. Such divergence often undermines effective policymaking. These problems are particularly prominent for health insurance expansion programs. Concern focuses on predictions of the numbers of individuals who will be insured and the costs of the proposals. Several different simulation-modeling approaches are used to predict these effects, making the predictions difficult to compare. This paper categorizes and describes the different approaches used; explains the conceptual and theoretical relationships between the methods; demonstrates empirically an example of the (quite restrictive) conditions under which all approaches can yield quantitatively identical predictions; and empirically demonstrates conditions under which the approaches diverge and the quantitative extent of that divergence. All modeling approaches implicitly make assumptions about functional form that impose restrictions on unobservable heterogeneity. Those assumptions can dramatically affect the quantitative predictions made.
 
Article
Policymakers are increasingly concerned that a relatively new class of anti-depressant drugs, selective serotonin re-uptake inhibitors (SSRI), may increase the risk of suicide for at least some patients, particularly children. Prior randomized trials are not informative on this question because of small sample sizes and other limitations. Using variation across countries over time in SSRI sales and suicide, we find that an increase of one pill per capita (a 13 percent increase over 1999 levels) is associated with a 2.5 percent reduction in suicide rates, a relationship that is more pronounced for adults than for children. Our findings suggest that expanding access to SSRIs for adults may be a cost-effective way to save lives, although policymakers are right to remain cautious about pediatric use of SSRIs.
 
Cumulative change in quality-adjusted life-years (in millions) over 50 years depending on the reduction in the hazards of smoking and the change in tobacco use behavior.
Estimated percentage increase in the prevalence of current smokers in 50 years depending on the reduction in the hazards of smoking and the change in tobacco use behavior.
Article
If manufacturing a safer cigarette is technically possible--an open question--then mandating that tobacco manufacturers improve the safety of cigarettes would likely have both positive and negative implications for the nation's health. On the one hand, removing toxins may reduce the incidence of smoking-related diseases and premature mortality in smokers. On the other hand, smokers might be less inclined to quit, those who have quit might resume the habit, and youth who have never smoked will have one less reason to avoid tobacco use. To assess the expected population health impacts of a legislative or regulatory mandate, we created the Tobacco Policy Model, a system dynamics computer simulation model. The model relies on secondary data and simulates the U.S. population over time spans as long as 50 years. Our simulation results reveal that even if requiring cigarettes to be safer makes smoking more attractive and increases tobacco use, a net gain in population health is still possible.
 
Article
Since 1975, vocational rehabilitation has represented a small and declining component of federal disability policy. This trend is perhaps reflective of the relatively crude assessment techniques that have been applied to the program in the past. Using the Virginia Vocational Rehabilitation (VR) program as a prototype, we outline how the data and methods of assessment can be improved for purposes of directing public policy. The key issues include identifying an appropriate comparison group for VR, analysis of longitudinal earnings data, and methods for refining measures of program cost. The analysis provides "fixed-effects" estimates of net earnings impacts for each of three postprogram years stratified by disability classification and gender. These treatment impacts are compared to total and service-specific costs. In general, this analysis suggests that evaluation of VR can be substantially improved and that these improvements can be attained at relatively modest analytic cost.
 
Article
This case examines the expanding role of managed care programs in improving health care for the poor while controlling runaway health care costs. The case asks what the commissioner of health in a large eastern state should do to effectively monitor Medicaid managed care programs in her state. The commissioner faces intense pressures for cost containment and strong, but not universal, support for the managed care solution to health care cost problems. The commissioner is herself concerned that the cost savings attributed to managed care may not be real and that the unintended effects on health care may be adverse. Her immediate challenge is to determine what kinds of data she should require service providers to submit to her agency so that she may effectively monitor managed care programs for health care quality, provide positive feedback to health care providers, and establish politically credible program oversight.
 
Article
We analyze the relationship between prenatal WIC participation and birth outcomes in New York City from 1988-2001. The analysis is unique for several reasons. First, we have over 800,000 births to women on Medicaid, the largest sample ever used to analyze prenatal participation in WIC. Second, we focus on measures of fetal growth distinct from preterm birth, since there is little clinical support for a link between nutritional supplementation and premature delivery. Third, we restrict the primary analysis to women on Medicaid who have no previous live births and who initiate prenatal care within the first four months of pregnancy. Our goal is to lessen heterogeneity between WIC and non-WIC participants by limiting the sample to highly motivated women who have no experience with WIC from a previous pregnancy. Fourth, we analyze a large sub-sample of twin deliveries. Multifetal pregnancies increase the risk of anemia and fetal growth retardation and thus may benefit more than singletons from nutritional supplementation. We find no relationship between prenatal WIC participation and measures of fetal growth among singletons. We find a modest pattern of association between WIC and fetal growth among U.S.-born Black twins. Our findings suggest that prenatal participation in WIC has had a minimal effect on adverse birth outcomes in New York City.
 
Article
U.S. state and local governments have increasingly adopted restrictions on smoking in public places. This paper analyzes nationally representative databases, including the Nationwide Inpatient Sample, to compare short-term changes in mortality and hospitalization rates in smoking-restricted regions with control regions. In contrast with smaller regional studies, we find that smoking bans are not associated with statistically significant short-term declines in mortality or hospital admissions for myocardial infarction or other diseases. An analysis simulating smaller studies using subsamples reveals that large short-term increases in myocardial infarction incidence following a smoking ban are as common as the large decreases reported in the published literature.
 
Article
This study uses data from an experimental employment program and instrumental variables (IV) estimation to examine the effects of maternal job loss on child classroom behavior. Random assignment to the treatment at one of three program sites is an exogenous predictor of employment patterns. Cross-site variation in treatment-control differences is used to identify the effects of employment levels and transitions. Under certain assumptions, this method controls for unobserved correlates of job loss and child well-being, as well as measurement error and simultaneity. IV estimates suggest that maternal job loss sharply increases problem behavior but has neutral effects on positive social behavior. Current employment programs concentrate primarily on job entry, but these findings point to the importance of promoting job stability for workers and their children.
 
Article
This article assumes that nonprofit decisionmakers have an incentive to earn and accumulate surpluses, and it suggests six reasons for this being the case. Based on the assumption that both the program outputs and the equity of a nonprofit yield satisfaction to its decisionmakers, a behavioral model is developed. This is used to derive a demand function for equity, which is then applied to a national sample of 6168 charitable nonprofits drawn by the Internal Revenue Service for the 1985 taxable year. The results substantiate the hypothesis that nonprofit decisionmakers consciously plan to increase their organization's equity. Currently, evidence of continued equity buildup is not sufficient to call into question a nonprofit's exempt status, because federal tax laws assume that surplus accumulations will ultimately be used in support of program mission. However, equity accumulation can become excessive. We present several criteria to define excessive equity accumulation and discuss why large equity accumulations may not be in the best interest of society.
 
Article
This paper explores the relationship between public housing, health outcomes, and health behaviors among low-income housing residents. While public housing can be a dangerous and unhealthy environment in which to live, the subsidized rent may free up resources for nutritious food and health care. In addition, public housing may be of higher quality than the available alternatives, it may provide easier access to health clinics willing to serve the poor, and it may link residents to social support networks, which can improve mental health and the ability to access higher-quality grocery stores. To test whether there is a "back-door" health benefit to the public housing program, we analyze data from the Fragile Families and Child Wellbeing Study. We minimize the effects of selection into public housing with controls and instrumental variables estimation and find that the results are somewhat sensitive to the instrumental variable used, and thus, we conclude that we are unable to detect a robust health benefit from public housing for our measures of health. However, we do find some evidence that public housing residency has mixed effects on domestic violence, increases obesity, and worsens mothers' overall health status.
 
Article
This paper examines the labor market effects of state health insurance mandates that increase the cost of employing a demographically identifiable group. State mandates requiring that health insurance plans cover infertility treatment raise the relative cost of insuring older women of child-bearing age. Empirically, wages in this group are unaffected, but their total labor input decreases. Workers do not value infertility mandates at cost, and so will not take wage cuts in exchange, leading employers to decrease their demand for this affected and identifiable group. Differences in the empirical effects of mandates found in the literature are explained by a model including variations in the elasticity of demand, moral hazard, ability to identify a group, and adverse selection.
 
Article
Over the past two decades states have significantly increased their use of competitive bidding to purchase health and social services from private agencies. Competitive contracting is thought to facilitate program administration, to reduce costs, and to increase the quality of delivered services. We evaluate these claims in light of Massachusetts' experience with competitive contracting for mental health care. We find that few of the expected benefits are achieved. In practice, supposedly competitive bidding systems often degenerate into administratively complicated negotiations between the state and private monopolies. This results in higher costs and lower quality of services. In light of this negative assessment, three strategies for reform are proposed and evaluated.
 
Article
Support for WIC, the Special Supplemental Nutrition Program for Women, Infants, and Children, is based on the belief that "WIC works." This consensus has lately been questioned by researchers who point out that most WIC research fails to properly control for selection into the program. This paper evaluates the selection problem using rich data from the national Pregnancy Risk Assessment Monitoring System. We show that relative to Medicaid mothers, all of whom are eligible for WIC, WIC participants are negatively selected on a wide array of observable dimensions, and yet WIC participation is associated with improved birth outcomes, even after controlling for observables and for a full set of state-year interactions intended to capture unobservables that vary at the state-year level. The positive impacts of WIC are larger among subsets of even more disadvantaged women, such as those who received public assistance last year, single high school dropouts, and teen mothers.
 
Article
This study examines the effects of prenatal WIC participation and the use of prenatal care on Medicaid costs and birth outcomes in five states--Florida, Minnesota, North Carolina, South Carolina, and Texas. The study period is 1987 for Florida, Minnesota, North Carolina, and South Carolina and January-June 1988 for Texas. Prenatal WIC participation was associated with substantial savings in Medicaid costs during the first 60 days after birth, with estimates ranging from $277 in Minnesota to $598 in North Carolina. For every dollar spent on the prenatal WIC program, the associated savings in Medicaid costs during the first 60 days ranged from $1.77 to $3.13 across the five states. Receiving inadequate levels of prenatal care was associated with increases in Medicaid costs ranging from $210 in Florida to $1,184 in Minnesota. Prenatal WIC participation was associated with higher newborn birthweight, while receiving inadequate prenatal care was associated with lower birthweight.
 
Article
In the selective contracting era, consumer choice has generally been absent in most state Medicaid programs, including California's (called Medi-Cal). In a setting where beneficiary exit is not a threat, a large payer may have both the incentives and the ability to exercise undue market power, potentially exposing an already vulnerable population to further harm. The analyses presented here of Medi-Cal contracting data, however, do not yield compelling evidence in favor of the undue market power hypothesis. Instead, hospital competition appears to explain with greater consistency why certain hospitals choose to contract with Medi-Cal while others do not, the trends in inpatient prices paid by Medi-Cal over time, and the effect of price competition on service cutbacks, such as emergency room closures.
 
Article
Although it is well known that vaccines against many infectious diseases confer positive economic externalities via indirect protection, analysts have typically ignored possible herd protection effects in policy analyses of vaccination programs. Despite a growing literature on the economic theory of vaccine externalities and several innovative mathematical modeling approaches, there have been almost no empirical applications. The first objective of the paper is to develop a transparent, accessible economic framework for assessing the private and social economic benefits of vaccination. We also describe how stated preference studies (for example, contingent valuation and choice modeling) can be useful sources of economic data for this analytic framework. We demonstrate socially optimal policies using a graphical approach, starting with a standard textbook depiction of Pigouvian subsidies applied to herd protection from vaccination programs. We also describe nonstandard depictions that highlight some counterintuitive implications of herd protection that we feel are not commonly understood in the applied policy literature. We illustrate the approach using economic and epidemiological data from two neighborhoods in Kolkata, India. We use recently published epidemiological data on the indirect effects of cholera vaccination in Matlab, Bangladesh (Ali et al., 2005) for fitting a simple mathematical model of how protection changes with vaccine coverage. We use new data on costs and private demand for cholera vaccines in Kolkata, India, and approximate the optimal Pigouvian subsidy. We find that if the optimal subsidy is unknown, selling vaccines at full marginal cost may, under some circumstances, be a preferable second-best option to providing them for free. © 2009 by the Association for Public Policy Analysis and Management.
 
Article
This analysis uses March Current Population Survey data from 1999 to 2010 and a differences-in-differences approach to examine how California's first in the nation paid family leave (PFL) program affected leave-taking by mothers following childbirth, as well as subsequent labor market outcomes. We obtain robust evidence that the California program doubled the overall use of maternity leave, increasing it from an average of three to six weeks for new mothers--with some evidence of particularly large growth for less advantaged groups. We also provide evidence that PFL increased the usual weekly work hours of employed mothers of 1- to 3-year-old children by 10 to 17 percent and that their wage incomes may have risen by a similar amount.
 
Article
California legalized the use of marijuana for medicinal purposes nearly 17 years ago, representing a major challenge to the federal government’s scheduling of marijuana as a Schedule I drug in the 1970 Controlled Substance Act. As many predicted, California was simply the first. As of May 2013, 19 states and the District of Columbia now provide legal protection to patients, and in many cases caregivers, for possession and supply of marijuana for medicinal purposes. In November 2012, Colorado and Washington went even further legalizing the sale and possession of marijuana for recreational purposes. Given the tremendous natural experiment that is taking place, one might expect that much would already be known about the benefits and harms of liberalizing marijuana policies. Unfortunately, however, the tremendous uncertainty regarding what protections actually exist, and for whom, in addition to the enormous heterogeneity in the medical marijuana laws that continue to change over time, has meant that we do not yet know as much as we should. The questions of whether marijuana is medicine and whether recreational marijuana use is harmless are necessarily intertwined in all of the debates over policy reform, but these are not the focus of this discussion. There is legitimate evidence that active cannabinoids available in the marijuana plant are useful in the treatment of some medical conditions and symptoms (Leung, 2011; Watson, Benson, & Joy, 2000; Institute of Medicine, 1999) and has been for centuries (Eddy, 2010; Grinspoon, 2005). As such, it is not surprising that the American Medical Association (AMA) adopted a resolution in 2009 urging the federal government to review the case for rescheduling marijuana, noting that doing so would facilitate research and development of cannabinoid-based medicine and avoid the patchwork of inadequate state laws that do not focus on establishing clinical guidelines or standards for medically prescribing marijuana (AMA, 2009). There is also evidence in the biomedical and public health literatures of reasonable pathways through which marijuana can harm health or impact health outcomes (see Hall & Pacula, 2003; Hall & Degenhardt, 2009; Room et al., 2010; or Caulkins et al., 2012 for extensive reviews).However, the causal linkage between recreational marijuana use and many of these health outcomes has yet to be fully established and continues to be a matter of scientific inquiry due to imprecise information on amounts consumed or potency of the substance used. Nonetheless, state liberalization policies move forward, and scientists are trying to use these natural experiments to assist in the identification of benefits and harms from these policies.
 
Article
This article analyzes a comprehensive sample of over 350 chemicals tested for carcinogenicity to assess the determinants of the probability of regulation. Controlling for differences in the risk potency and noncancer risks, synthetic chemicals have a significantly higher probability of regulation overall: this is due to the greater likelihood of U.S. Food and Drug Administration (FDA) regulation. Measures of risk potency increase the probability of regulation by the U.S. Environmental Protection Agency (EPA), have a somewhat weaker positive effect on regulation by the U.S. Occupational Safety and Health Administration (OSHA), and decrease the likelihood of regulation by the FDA. The overall regulatory pattern is one in which the FDA targets synthetic chemicals and chemicals that pose relatively minor cancer risk. The EPA particularly performed more sensibly than many critics have suggested.
 
Article
From 1991 to 2009, the fraction of Medicaid recipients enrolled in HMOs and other forms of Medicaid managed care (MMC) increased from 11 percent to 71 percent. This increase was largely driven by state and local mandates that required most Medicaid recipients to enroll in an MMC plan. Theoretically, it is ambiguous whether the shift from fee-for-service into managed care would lead to an increase or a reduction in Medicaid spending. This paper investigates this effect using a data set on state- and local-level MMC mandates and detailed data from the Centers for Medicare and Medicaid Services (CMS) on state Medicaid expenditures. The findings suggest that shifting Medicaid recipients from fee-for-service into MMC did not on average reduce Medicaid spending. If anything, our results suggest that the shift to MMC increased Medicaid spending and that this effect was especially present for risk-based HMOs. However, the effects of the shift to MMC on Medicaid spending varied significantly across states as a function of the generosity of the state's baseline Medicaid provider reimbursement rates.
 
Article
All industrialized countries are grappling with a common problem—how to provide assistance of various kinds to their rapidly aging populations. The problem for countries searching for models of efficient and high-quality long-term care (LTC) policies is that fewer than a dozen countries have government-organized, formal LTC policies. Relatively new surveys focused on the elderly populations of about 25 countries could become the basis for research on which LTC policy design choices have desired outcomes for individuals and society and might be replicable in other countries. As in earlier decades when U.S. researchers created the Current Population Survey (CPS) modules and the Survey of Income and Program Participation to answer policy questions, researchers and policy analysts are now at a point where a concerted effort is needed to generate questions that international comparative research on LTC could answer as well as the data needed to address the questions.
 
Article
Declines in the welfare caseload in the late 1990s brought significant change to the lives of many low-educated, single mothers. Many single mothers left welfare and entered the labor market and others found different ways to avoid going on public assistance. These changes may have affected the health and health behaviors of these women. To date, there has been little study of this issue. In this paper, we obtained estimates of the association between changes in the welfare caseload caused by welfare policy, and four health behaviors--smoking, drinking, diet, and exercise--and four self-reported measures of health--weight, days in poor mental health, days in poor physical health, and general health status. The results of our study reveal that recent declines in the welfare caseload were associated with less binge drinking, but otherwise welfare reform had little effect on health and health behaviors.
 
Article
The hypothesis that marriage increases men's earnings has contributed to legislative support for the Healthy Marriage Initiative (HMI). However, previous studies of this phenomenon have not controlled for many relevant characteristics that select men into marriage, nor have they focused on low-income, unmarried fathers-the population targeted by HMI. We use the Fragile Families and Child Wellbeing Study, which measures many previously unobserved confounders, to test for a relationship between marriage and earnings. We use a variety of analytic strategies to control for selection (including differencing and propensity scores) and find no evidence of an effect of transitions to marriage on the earnings of unmarried fathers that differs from zero, either for the full sample or subsamples defined by race-ethnic category and baseline cohabitation status.
 
Article
Sixteen percent of children 6-11 years of age were classified as overweight in 1999-2002, four times the percentage in 1965. Although poverty has traditionally been associated with underweight as a result of poor diet, researchers have recently pointed to a paradox in the U.S., which is that low income and obesity can coexist in the same population. This paper first examines whether income is linked to overweight in school-age children. Second, it explores whether food programs such as the Food Stamp Program, the National School Lunch Program, and the School Breakfast Program are associated with overweight among children in different income groups. The data come from the nationally representative 1997 Panel Study of Income Dynamics Child Development Supplement. No evidence either that poor children are more likely to be overweight or that food programs contribute to overweight among poor children was found.
 
Top-cited authors
Eric A. Hanushek
  • Stanford University
Robert MacCoun
  • Stanford University
Susanna Loeb
  • Brown University
Helen F. Ladd
  • Duke University
Donald Boyd
  • University at Albany, The State University of New York