Working Papers
Government Recommendations and Health Behaviors: Evidence from Breast Cancer Screening Guidelines
Conditionally Accepted · Economic Journal
Conditionally Accepted · Economic Journal
We provide novel evidence on how healthcare decision-making responds to changes in government recommendations by studying the United States Preventive Services Task Force’s 2009 decision to stop recommending mammogram screenings for women aged 40–49. Using a difference-in-differences identification strategy, we find that the guideline revision reduced mammography among 40–49-year-old women by 6–10 percent (from a baseline rate of 48.8 percent) relative to their older counterparts. We also identify large spillovers onto women aged 30–39 who were subsequently 25 percent less likely to receive a mammogram recommendation and up to 60 percent less likely to receive a mammogram. Additional analyses suggest the revision reduced overdiagnosis of early-stage tumors. Finally, we find that the 2009 update increased confusion about recommendations for preventing cancer.
Health Care Reform and Firm Dynamics: Evidence from Medicare Part D and the Retail Pharmacy Industry
Health care reforms are often enacted before implementation, creating uncertainty that can shape firms’ decisions. We examine how Medicare Part D affected the retail pharmacy industry using 2000–2009 establishment-level data, leveraging the fact that Part D disproportionately affected counties with larger elderly populations. Consistent with predictions from a conceptual model in which pre-implementation uncertainty discourages entry and lower post-implementation margins prevent full recovery, we find that Part D was associated with a 5-percent reduction in pharmacies, driven by fewer openings rather than more closures. We also find suggestive evidence that reduced pharmacy access dampened Part D’s mortality benefits.
Does Food Assistance Drive Spending on Sugary Foods? Evidence from the Pandemic Electronic Benefit Transfer Program
Although it is unclear whether food assistance contributes to lower diet quality among recipients, policymakers are actively working to restrict SNAP-eligible purchases of items high in added sugars. We provide timely evidence on the extent to which food assistance increases spending on sugary items by studying the Pandemic Electronic Benefit Transfer (P-EBT) program, which provided food assistance benefits to families of children who lost access to free and reduced-price school meals due to COVID-19 pandemic school closures. Leveraging state-level variation in the timing of P-EBT disbursements and using a stacked difference-in-differences identification strategy with NielsenIQ Consumer Panel data, we find that P-EBT disbursement was associated with a 16-percent increase in weekly spending on sugary items among SNAP-eligible households with school-aged children. Notably, this increase exceeded the percentage increase in overall food spending for this group, suggesting that SNAP-eligible households with school-aged children allocated a disproportionately large share of their P-EBT-driven purchases toward sugary items relative to their pre-period baseline. We do not detect changes among households unlikely to have received P-EBT benefits or in placebo disbursement years.
Do Physical Characteristics Influence How People Evaluate Non-Physical Traits? Evidence from the Excess Bodyweight Penalty in the Online Dating Market
I use two online survey experiments to test whether physical characteristics affect how people evaluate non-physical traits. I find that participants scored dating profiles displaying overweight/obese photos 17% lower than profiles displaying healthy-weight photos. This penalty was driven by a reduction in the scores assigned to both the photos and the same profile text; participants who viewed heavier photos perceived the text as less indicative of work ethic and intelligence. There is no evidence that participants imposed smaller penalties on profiles reporting higher-earning occupations, suggesting that individuals are limited in their ability to compensate for excess body weight with higher socioeconomic status.
Broadband Internet Access and Adolescent Mental Health in the U.S.
Revisions Requested · Southern Economic Journal
Revisions Requested · Southern Economic Journal
Coverage: The 74
Broadband internet has become a critical component of U.S. infrastructure, but policymakers are increasingly concerned that the widespread adoption of this technology has adversely affected adolescent mental health. To test this hypothesis, we use 2009–2019 National and State Youth Risk Behavior Survey data and leverage the nationwide rollout of broadband internet. First, we show that adolescents in states with greater broadband internet access reported spending more time online. Next, we find that a one-standard-deviation increase in broadband internet access was associated with a 9.3–16.5-percent increase in adolescent suicide ideation. While we document increases in suicide ideation for both girls and boys, the results are most pronounced for adolescent girls.
Work in Progress
The Vaccines for Children Program and the Health of Low-Income Children
The Vaccines for Children Program and the Health of Low-Income Children
Work in Progress
The Role of Federal Funding in Reducing the Prevalence of Obesity
The Role of Federal Funding in Reducing the Prevalence of Obesity
Publications
Partisan Differences in Healthcare Decision-Making: Evidence from a Vaccine Experiment
Policymakers use information campaigns to alter health behaviors, but their effectiveness depends on how the information compares to viewers’ initial beliefs and their perceptions of its value. In August 2024, we experimentally tested whether political identity influenced how individuals responded to information about the COVID-19 vaccine. Our sample included 288 self-identified Democrats and 291 self-identified Republicans. We found that Democrats and Republicans similarly overestimated the frequency and severity of COVID-19 infections, as well as the vaccination rate. Participants were not better at predicting the COVID-19 experiences of their concordant party. However, participants who learned they underestimated the discordant party vaccination rate were more likely to report an intent to receive a COVID-19 vaccine.
“There She Is, Your Ideal”: Negative Social Comparisons and Health Behaviors
Coverage: USA Today, New England Public Media, The List
We provide novel evidence on the role of negative social comparisons in population health behaviors by exploiting variation in Miss America and Miss USA beauty pageant winners. We show that there was more front-page newspaper coverage and more pageant-related internet search behavior following a home-state win. Teen girls and pageant-aged women with home-state winners were more likely to report that they were trying to lose weight, and pregnant women gained less gestational weight. We do not detect meaningful changes for teen boys, young adult men, or older women for whom social comparisons were plausibly less salient.
Supply-Side Opioid Restrictions and the Retail Pharmacy Market
While policymakers routinely limit the sale of goods thought to be of risk to public health, relatively less is known about whether and how these policies affect firm performance. Using 2000–2018 National Establishment Time-Series data and a difference-in-differences strategy, we show that state “pill mill” laws intended to reduce the overprescribing of opioids reduced retail pharmacy sales and employment. These reductions were most pronounced in highly competitive areas and for standalone pharmacies. Meanwhile, pharmacies located across the border in states without a pill mill law experienced increases in sales and employment. Our results are consistent with these laws adversely affecting pharmacies filling inappropriate opioid prescriptions without meaningfully altering patient access to retail pharmacies.
Anti-Bullying Laws and Weight-Related Disparities in Suicidality
Coverage: WBUR
Appearance-based bullying is common among teenagers and may inflict substantial psychological harm on its victims. Overweight and obese students are both more likely to be bullied at school and more likely to engage in suicidal behaviors than their healthy-weight counterparts. Using data from the National and State Youth Risk Behavior Surveys and a difference-in-differences approach, we find that ABL adoption is associated with a 6–19 percent reduction in suicidal behaviors among overweight or obese teens; estimates for healthy-weight teens are considerably smaller in magnitude and statistically insignificant. Weight-based disparities in suicidal behaviors are reduced most by ABLs among obese teenage girls.
Social Comparisons and Adolescent Body Misperception: Evidence from School Entry Cutoffs
We provide novel evidence on the role of social comparisons in shaping adolescent body misperception. Using an instrumental variables approach leveraging variation in relative age generated by school entry cutoff months, we show that relatively younger students are more likely to describe their bodies as lighter than the clinically relevant BMI category implied by their reported heights and weights. This result is driven by relatively younger students who are classified as normal weight for their age describing themselves as “too thin.” We then show that relatively younger students are more likely to desire to gain weight, consume more calorie-dense foods, and report lower levels of physical activity.
Effects of Environmental Exposures on Weight-Related Behaviors and Outcomes
The US obesity rate has increased alongside an increase in extreme weather events, such as heatwaves, which may influence an individual’s desired bodyweight, dietary habits, and level of physical activity. Using data from the Behavioral Risk Factor Surveillance System and an identification strategy leveraging temperature deviations from local seasonal norms, we show that adults were less likely to report trying to lose weight, dieting to lose weight, and exercising to lose weight when temperatures fell below 20–25°C (68–77°F). Despite these behavioral changes, we find no evidence of a relationship between temperature and BMI.
Effect of Vaccine Recommendations on Consumer and Firm Behavior
Coverage: Pharmaceutical Executive
We provide novel evidence on how firms and patients respond to vaccine recommendations. In 2014, the Advisory Committee on Immunization Practices recommended that elderly adults receive the pneumococcal vaccine Prevnar 13. Using a difference-in-differences strategy, we first show that, following the recommendation, the manufacturer (Pfizer) increased direct-to-consumer advertising. We then document increased Prevnar 13–related information-seeking behavior, and we show that targeted adults were more likely to have received a pneumococcal vaccine and were more connected to the health care system. Overall, the recommendation increased both Medicare Part B drug expenditures and Pfizer sales by approximately $1 billion annually, with little to no observable health benefits.
State-Mandated School-Based BMI Assessments and Self-Reported Adolescent Health Behaviors
Between 2003 and 2017, 24 states began requiring schools to perform Body Mass Index assessments on students. Using the 1991–2017 National and State Youth Risk Behavior Surveys and a stacked difference-in-differences identification strategy, I show that these state-mandated school-based BMI assessments were associated with an increase in the likelihood that teens described themselves as overweight and reported that they were trying to lose weight. The relationship was most pronounced for overweight teens, suggesting that the assessments improved awareness about BMI status among this group, though I also find that non-overweight teen girls were subsequently more likely to incorrectly describe themselves as overweight.
State SUNucate Laws, Google Searches for Sun Protection Terms, and Youth Sunscreen Use
State SUNucate laws — which have been adopted by 27 states and require schools to permit youths to carry and apply sunscreen on school grounds — were examined for their association with changes in Google Search behavior for sun protection terms and self-reported sunscreen use by youths. Using Google Trends data for 2004–2022 and Youth Risk Behavior Survey data for 2009–2019, we find that state SUNucate laws were associated with a 27.2% increase in Google search popularity for “sunscreen” and an 8.3% increase in sunscreen use among high school youths.
Bad Lighting: Effects of Youth Indoor Tanning Prohibitions
Indoor tanning beds emit UV light at concentrations higher than natural sunlight and have been classified as carcinogenic to humans by the World Health Organization. We are the first to study the role of state laws prohibiting youths from indoor tanning using a difference-in-differences research design. We find that youth indoor tanning prohibitions reduced population search intensity for tanning-related information. Among white teen girls, the prohibitions reduced self-reported indoor tanning and increased sun-protective behaviors. We also find that the prohibitions significantly reduced the size of the indoor tanning market.
The Roles of Cost and Recommendations in Driving Vaccine Take-Up: Evidence from the Herpes Zoster Vaccine
Analyzing shingles vaccination, we show that 60-year-olds — who were recommended by the Advisory Committee on Immunization Practices to receive the vaccine — were no more likely to be vaccinated than their 59-year-old counterparts prior to the Affordable Care Act. After the ACA’s preventive services provision required private insurance plans to cover recommended vaccines without patient cost-sharing, adults aged 60 or older were more likely to receive the vaccine, and we document a similar increase for 50- to 59-year-olds after the recommendation age was lowered to 50.
The Effect of E-Verify Laws on Crime
E-Verify laws, which have been adopted by 23 states, require employers to verify whether new employees are eligible to legally work prior to employment. Using data from the 2004–2015 National Incident Based Reporting System, we find that the enactment of E-Verify is associated with a 7% reduction in property crime incidents involving Hispanic arrestees. This finding was strongest for universal E-Verify mandates that extend to private employers. The magnitudes of the estimates suggest that E-Verify laws averted $491 million in property crime costs to the United States.
Immigration Enforcement and Infant Health
Coverage: Tradeoffs
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 2003–2016 and a difference-in-differences design, we find that intensified enforcement, especially during the third trimester, increases the likelihood of low birth weight. The findings underscore the importance of current immigration policies in shaping the birth outcomes of many American children.
How Important is the Structure of School Vaccine Requirement Opt-Out Provisions?
Coverage: Marketplace, Tradeoffs
Recent increases in vaccine-preventable diseases have led policymakers to reconsider the scope of vaccine requirement exemptions. Yet eliminating these provisions is politically difficult. Beginning in 2009, sixth grade girls in Washington, DC were required to receive the HPV vaccine or submit a one-time opt-out form. In 2014, the requirement was expanded to all students grades 6–12, and those not vaccinating were required to opt-out annually. I show that the movement from a one-time opt-out provision to an annual requirement increased the probability that teen girls in Washington, DC initiated HPV vaccination by 11 percentage points. Teen boys were 20 percentage points more likely to be vaccinated.
Insurance Coverage, Provider Contact, and Take-Up of the HPV Vaccine
Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and the single biggest cause of cervical cancer. Despite the existence of a highly effective vaccine, HPV vaccination rates remain low. Using the National Immunization Survey–Teen, 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, driven in part by increases in Medicaid coverage, the probability of having a recent checkup, and knowledge about the HPV vaccine.
Unauthorized Immigrants’ Access to Driver’s Licenses and Auto Insurance Coverage
Fourteen states and the District of Columbia allow unauthorized immigrants to obtain driver’s licenses. Using variation in the timing and location of these policy changes, we show these Unauthorized Immigrant License Policies (UILPs) are associated with a 1% increase in both the number of licensed drivers and liability insurance coverage, although we do not document a statistically significant relationship with auto insurance claims. Our results are consistent with UILPs licensing unauthorized immigrants who were already driving.
E-Verify Mandates and Unauthorized Immigrants’ Health Insurance Coverage
Over the last two decades, state and local governments have adopted policies requiring employers to electronically verify the work eligibility of their new hires to disrupt unauthorized immigrants’ access to the formal labor market. I show that state E-Verify mandates are associated with a 5-percentage point reduction in the probability that likely unauthorized immigrants are employed and a 2-percentage point reduction in the probability that they have employer-sponsored insurance. This pattern can be explained by selective outmigration of otherwise unemployed and uninsured likely unauthorized immigrants.
The Effects of Minimum Wages on Low-Skilled Immigrants’ Wages, Employment, and Poverty
Raising the minimum wage has been advanced as a complementary policy to comprehensive immigration reform to improve low-skilled immigrants’ economic well-being. Using data from the 1994 to 2016 Current Population Survey, we conclude that minimum wage increases reduced employment of less-educated Hispanic immigrants, with estimated elasticities of around –0.1. However, we also find that the wage and employment effects of minimum wages on low-skilled immigrants diminished over the last decade. Finally, our results show that raising the minimum wage is an ineffective policy tool for reducing poverty among immigrants.
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