Effects of the Colorectal Cancer Control Program.

Although colorectal cancer (CRC) screening is highly effective, screening rates lag far below recommended levels, particularly for low-income people. The Colorectal Cancer Control Program (CRCCP) funded $100 million in competitively awarded grants to 25 states from 2009-2015 to increase CRC screening rates among low-income, uninsured populations, in part by directly providing and paying for screening services. Using data from the 2001-2015 Behavioral Risk Factor Surveillance System (BRFSS) and a difference-in-differences strategy, we find no effects of CRCCP on the use of relatively cheap fecal occult blood tests (FOBT). We do, however, find that the CRCCP significantly increased the likelihood that uninsured 50-64-year-olds report ever having a relatively expensive endoscopic CRC screening (sigmoidoscopy or colonoscopy) by 2.9 percentage points, or 10.7%. These effects are larger for women, minorities, and individuals who did not undertake other types of preventive care. We do not find that the CRCCP led to significant changes in CRC cancer detection. Our results indicate that the CRCCP was effective at increasing CRC screening rates among the most vulnerable.

Effects of State Cervical Cancer Insurance Mandates on Pap Test Rates.

OBJECTIVE: To evaluate the effects of state insurance mandates requiring insurance plans to cover Pap tests, the standard screening for cervical cancer that is recommended for nearly all adult women. DATA SOURCES: Individual-level data on 600,000 women age 19-64 from the CDC's Behavioral Risk Factor Surveillance System. STUDY DESIGN: Twenty-four states adopted state mandates requiring private insurers in the state to cover Pap tests from 1988 to 2000. We performed a difference-in-differences analysis comparing within-state changes in Pap test rates before and after adoption of a mandate, controlling for the associated changes in other states that did not adopt a mandate. PRINCIPAL FINDINGS: Difference-in-differences estimates indicated that the Pap test mandates significantly increased past 2-year cervical cancer screenings by 1.3 percentage points, with larger effects for Hispanic and non-Hispanic white women. These effects are plausibly concentrated among insured women. CONCLUSIONS: Mandating more generous insurance coverage for even inexpensive, routine services with already high utilization rates such as Pap tests can significantly further increase utilization.

Health Insurance Mandates, Mammography, and Breast Cancer Diagnoses.

We examine the effects of state health insurance mandates requiring coverage of screening mammograms. We find evidence that mammography mandates significantly increased mammography screenings by 4.5-25 percent. Effects are larger for women with less than a high school degree in states that ban deductibles, a policy similar to a provision of federal health reform that eliminates cost-sharing for preventive care. We also find that mandates increased detection of early stage in-situ pre-cancers. Finally, we find a substantial proportion of the increased screenings were attributable to mandates that are not consistent with current recommendations of the American Cancer Society.

Intended And Unintended Effects Of The War On Poverty: What Research Tells Us And Implications For Policy.

During the mid-1960s, the United States adopted a series of cash and in-kind transfer programs, as well as human capital investment strategies, as part of the War on Poverty. A number of other programs were first proposed as part of this "war" but were not implemented until the mid-1970s. These programs had noble goals: to increase incomes at the bottom of the income distribution, reduce poverty, and improve nutrition, heath, and human capital. However, various features of the programs also had the potential to produce unintended consequences: for example, means-tested programs can discourage work. In this paper, we comprehensively evaluate the main War on Poverty programs that were aimed at the low-income nonelderly population along with several follow-on programs. We focus on both intended and unintended consequences, drawing on the most compelling causal evidence. We conclude with a series of lessons learned and questions that are outstanding.

Utilization of infertility treatments: the effects of insurance mandates.

Over the last several decades, both delay of childbearing and fertility problems have become increasingly common among women in developed countries. At the same time, technological changes have made many more options available to individuals experiencing fertility problems. However, these technologies are expensive, and only 25% of health insurance plans in the United States cover infertility treatment. As a result of these high costs, legislation has been passed in 15 states that mandates insurance coverage of infertility treatment in private insurance plans. In this article, we examine whether mandated insurance coverage for infertility treatment affects utilization. We allow utilization effects to differ by age and education, since previous research suggests that older, more-educated women should be more likely to be directly affected by the mandates than younger women and less-educated women, both because they are at higher risk of fertility problems and because they are more likely to have private health insurance, which is subject to the mandate. We find robust evidence that the mandates do have a significant effect on utilization for older, more-educated women that is larger than the effects found for other groups. These effects are largest for the use of ovulation-inducing drugs and artificial insemination.

Smoking restrictions in bars and bartender smoking in the US, 1992-2007.

OBJECTIVE: The present work is an analysis of whether adoption of state clean indoor air laws (SCIALs) covering bars reduces the proportion of bartenders who smoke primarily by reducing smoking among people already employed as bartenders when restrictions are adopted or by changing the composition of the bartender workforce with respect to smoking behaviours. METHODS: Logistic regressions were estimated for a variety of smoking outcomes, controlling for individual demographic characteristics, state economic characteristics, and state, year, and month fixed effects, using data on 1380 bartenders from the 1992-2007 Tobacco Use Supplement to the Current Population Survey combined with data on SCIALs from ImpacTeen. RESULTS: State restrictions on smoking in bars are negatively associated with whether a bartender smokes, with a 1-point increase in restrictiveness (on a scale of 0-3) associated with a 5.3% reduction in the odds of smoking. Bar SCIALs are positively associated with the likelihood a bartender reports never having smoked cigarettes but not with the likelihood a bartender reports having been a former smoker. CONCLUSION: State clean indoor air laws covering bars appear to reduce smoking among bartenders primarily by changing the composition of the bartender workforce with respect to smoking rather than by reducing smoking among people already employed as bartenders when restrictions are adopted. Such laws may nonetheless be an important public health tool for reducing secondhand smoke.

The effect of Medicaid eligibility expansions on fertility.

In the United States, pregnant women and children's eligibility for Medicaid was expanded dramatically during the 1980s and early 1990s. By lowering pregnancy and child health care costs, the Medicaid expansions may have increased the incentives for women to have children. To investigate this possibility, we examine whether state-level birth and abortion rates are related to the extent of states' Medicaid eligibility expansions and the fraction of women eligible for Medicaid, controlling for economic and demographic factors, during the period 1982 to 1996. We examine birth rates by race, marital status and education as well as overall abortion rates. We find little evidence that the Medicaid expansions led to changes in birth rates or abortion rates. However, some results do suggest that the Medicaid expansions boosted the birth rate among white women who have not completed high school. We find that restrictions on Medicaid funding of abortions decrease abortion rates and increase birth rates. The results thus do not provide definitive evidence that expansions in public health insurance eligibility have sizable effects on women's fertility.

Effects of venue-specific state clean indoor air laws on smoking-related outcomes.

A large literature has documented relationships between state clean indoor air laws (SCIALs) and smoking-related outcomes in the United States. These laws vary within states over time and across venues such as schools, government buildings, and bars. Few studies, however, have evaluated whether the effects of SCIALs are plausibly concentrated among workers who should have been directly affected because they worked at locations covered by the venue-specific restrictions. We fill this gap in the literature using data on private sector workers, government employees, school workers, eating and drinking place workers, and bartenders from the 1992-2007 Tobacco Use Supplements to the Current Population Survey. Our quasi-experimental models indicate robust effects of SCIALs restricting smoking in bars: these laws significantly increased the presence of workplace smoking restrictions as reported by bartenders and reduced the fraction of bartenders who smoke. We do not, however, find that SCIALs in private workplaces, government workplaces, schools, or restaurants increased the presence of workplace smoking restrictions among groups of workers working in venues covered by these laws. This suggests that the smoking reductions associated with SCIALs in previous research are unlikely to have been directly caused by effects of workplace smoking restrictions on workers.

The link between couples' pregnancy intentions and behavior: does it matter who is asked?

CONTEXT: Previous studies have linked pregnancy intentions with some pregnancy-related behaviors and infant health outcomes. However, most have used only women's reports of intentions and examined only maternal behaviors. METHODS: Baseline data from the Fragile Families and Child Wellbeing Study (1998-2000) are used to examine whether parents of newborns considered abortion upon learning of the pregnancy and whether this measure of pregnancy intention is associated with their behaviors during pregnancy or with infant birth weight. Associations between outcomes and each parent's pregnancy intention are explored with multivariate probit regressions or least squares regressions for 737 married and 2,366 unmarried couples. RESULTS: If at least one parent considered abortion, unmarried mothers had a significantly reduced probability of initiating early prenatal care, and unmarried fathers had a significantly reduced probability of providing cash or in-kind support during the pregnancy. The proportion of mothers receiving care in the first trimester was 12 percentage points lower when the mother only or both parents considered abortion than when neither parent did; depending on which parent reported on fathers' support during pregnancy, the proportion of fathers who provided cash or in-kind assistance was 6-10 percentage points lower when the father only considered abortion and 6-14 points lower when both parents considered abortion than when neither did. CONCLUSIONS: Future research on pregnancy intentions should incorporate both men and women. Understanding men's pregnancy intentions and their associations with early support of mothers may inform discussions of how to encourage men's involvement in family planning, prenatal health care and parenting.

Does WIC work? The effects of WIC on pregnancy and birth outcomes.

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.

The impact of welfare reform on marriage and divorce.

The goal of the 1996 Personal Responsibility and Work Opportunity Reconciliation Act was to end needy parents' dependence on governmental benefits, in part by promoting marriage. The prereform welfare system was widely believed to discourage marriage because it provided benefits primarily to single mothers. However, welfare reform may have actually decreased the incentives to be married by giving women greater financial independence via the program's new emphasis on work. This article uses vital statistics data on marriages and divorces during 1989-2000 to examine the role of welfare reform (state waivers and implementation of Temporary Assistance to Needy Families) and other state-level variables on flows into and out of marriage. The results indicate that welfare reform has led to fewer new divorces and fewer new marriages, although the latter result is sensitive to specification and the choice of data.