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In-Kind Welfare Benefits and Recidivism Risk: Evidence from Medicaid
Nicolás Badaracco, University of Wisconsin-Madison
Marguerite Burns, University of Wisconsin School of Medicine and Public Health
Laura Dague, Texas A&M University and NBER

Of the 600,000 persons returning to the community from state and federal prisons each year in the US, more than 44% are re-arrested within one year. Most adults who serve prison sentences carry substantial debt, have low income and relatively low education, and limited formal employment experience prior to entering prison. Reentry into the community is characterized by a high incidence of adverse outcomes for individuals and their communities - financial hardship, morbidity and mortality, and re-offense. Medicaid coverage, as a means-tested transfer program providing subsidized health insurance, may influence recidivism through both financial and health channels. In this paper, Badaracco, Burns, and Dague provide a comprehensive look at the effects of public health insurance coverage on the post-release behavior of formerly incarcerated adults. The researchers study a natural experiment in which two separate state policy changes resulted in a 60 percentage point increase in Medicaid enrollment at the time of release. Using a series of individual level linked administrative datasets, Badaracco, Burns, and Dague estimate the effects of this huge change in Medicaid enrollment on recidivism. They find declines in recidivism at 6 and 12 months associated with the increase in Medicaid enrollment. Badaracco, Burns, and Dague test for Medicaid enrollment effects on employment and treatment for substance use disorders as potential explanatory mechanisms by which Medicaid coverage may influence recidivism, and show that both employment and health care use increase among the formerly incarcerated as a result of Medicaid enrollment.

The Opioid Safety Initiative and Veteran Suicides
Joshua C. Tibbitts, Washington State University
Benjamin W. Cowan, Washington State University and NBER

Tibbitts and Cowan investigate the relationship between opioid diverting policy and suicides among the veteran population. The opioid epidemic of the past two decades has had devastating health consequences among U.S. veterans and military personnel. In 2013, the Veterans Health Administration (VA) implemented the Opioid Safety Initiative (OSI) with the goal of discouraging prescription opioid dependence among VA patients. Between 2012 and 2017, prescription opioids dispensed by the VA fell 41% (VA, 2018). Because this involved the aggressive curtailing of opioid prescriptions for many VA patients, OSI may have had a detrimental effect on veterans' mental health leading to suicide in extreme cases. In addition, because rural veterans have much higher rates of VA enrollment, more prescription opioid use and abuse, and lower rates of substance abuse and mental health treatment utilization, Tibbitts and Cowan expect any effect of OSI on veteran suicides to be concentrated in rural areas. The researchers find that OSI raised the veteran suicide rate relative to the civilian rate with rural veterans suffering the lion's share of the increase. In particular, OSI raised the rural veteran suicide rate by roughly one-third within the first year of implementation (2013) and by 45 percent as of 2016.


This paper was distributed as Working Paper 29139, where an updated version may be available.

Provider Turf Wars and Medicare Payment Rules
Alice Chen, University of Southern California
Elizabeth L. Munnich, University of Louisville
Stephen Parente, University of Minnesota
Michael R. Richards, Baylor University

Medical care often includes provider teams. However, the scope, efficiency, and necessity of clinical teams is partly determined by prevailing regulations. Chen, Munnich, Parente, and Richards explore such issues in the context of anesthesia care whereby physician-trained anesthesiologists and certified registered nurse anesthetists (CRNAs) commonly engage in joint production. Leveraging states' removal of physician supervision requirements for CRNAs, the researchers find reductions in operating room collaboration but a remaining affinity for teambased care. CRNAs provide 20-25% more hospital services outside of the operating room--suggesting improved productive capacity. Task matching and labor supply adjustments leave Medicare revenues unchanged or higher for each anesthesia provider type.

The Health Impacts of Public Health Funding: Evidence and Lessons from the Fight against HIV/AIDS
Marcus Dillender, University of Illinois at Chicago and NBER

HIV/AIDS has been one of the largest public health crises in recent history, and the U.S. federal government has spent hundreds of billions of dollars fighting the disease. This study examines the impact of federal funding allocated to U.S. cities through the Ryan White CARE Act, which is the largest program for combating HIV/AIDS in the United States. The empirical approach identifies the impact of the funding by studying funding variation that comes from Ryan White policy features that resulted in large funding differences among cities that were originally on parallel HIV/AIDS trajectories and finds that Ryan White's city-level funding has improved HIV/AIDS outcomes in the cities receiving the funds. The estimates indicate that an HIV/AIDS death has been avoided for each $314,000 allocated through the program and that the program has saved approximately 60,000 lives through 2018. The estimates also indicate that funding differences across cities are responsible for the uneven progress in combating HIV/AIDS across the United States.

Importing the Opioid Crisis? Trade, Smuggling, and Fentanyl Overdoses
Timothy J. Moore, Purdue University and NBER
Benjamin Hansen, University of Oregon and NBER
William W. Olney, Williams College

Recent increases in U.S. drug overdose deaths are primarily due to fentanyl, a powerful synthetic opioid that now accounts for two-thirds of opioid overdose deaths. Nearly all fentanyl is smuggled into the U.S., but little is known about how this occurs. In this paper, Moore, Hansen, and Olney show that states with high legal import flows have more fentanyl overdose deaths. This relationship coincides with the rise of fentanyl since 2014 and is not explained by factors potentially affecting demand, including local economic conditions and job losses due to import competition. By 2018, the elasticity of states' fentanyl deaths to import flows is 0.4, while other causes of death do not increase with imports. Moore, Hansen, and Olney assess the role of different types of imports which provides clues about how specifically fentanyl is being smuggled.

Early Childhood Health Inequalities and In-Utero Health Interventions: Evidence from the Treatment of Gestational Diabetes
Gabriella Conti, University College London
Paul Rodriguez-Lesmes, Universidad del Rosario

For years, diagnosis and treatment for gestational diabetes mellitus (GDM) has been an unresolved question. Current guidelines have established diagnosis and treatment standards, but the question remains on the potential impacts on child development via in-utero exposure to diabetes medications. Conti and Rodriguez-Lesmes use uniquely rich data from the Born-in-Bradford cohort study, in which all pregnant women underwent universal screening for GDM based on clear thresholds over oral glucose tolerance tests (OGTT), rather than using pre-existing conditions as a screening criterion (as it is the standard practice in England and elsewhere). To evaluate the effects of GDM treatment, they use the OGTT cutoff within a sharp regression discontinuity design, so the researchers compare children from pregnancies with a positive and negative GDM diagnosis near the cutoff. Conti and Rodriguez-Lesmes find that diagnosis and subsequent treatment of GDM resulted in improved outcomes at birth for both the mother and the child, in particular a significant reduction in the odds of being a macrosomic newborn. However, they find mixed results on child health and development postnatally, which point to an urgent need of studies on the medium- and long-term impacts of GDM treatment.


Jorge Aguero, University of Connecticut
Ege Aksu, City University of New York
Carolina Arteaga, University of Toronto
Alicia Atwood, Vassar College
Sarah Axeen, University of Southern California
Nicolás Badaracco, University of Wisconsin-Madison
Panka Bencsik, University of Chicago
Anne M. Burton, The University of Texas at Dallas
Brandyn F. Churchill, Vanderbilt University
Maoyong Fan, Ball State University
Graham Gardner, Michigan State University
Hanna Glenn, Dana-Farber Cancer Institute
Katherine A. Harris-Lagoudakis, Iowa State University
Thomas A. Hegland, Agency for Healthcare Research and Quality
Laura E. Henkhaus, Vanderbilt University
Lauren Hoehn-Velasco, Georgia State University
Johnny Huynh, University of California at Los Angeles
Kandice A. Kapinos, RAND, UT Southwestern Medical
Matthew Knowles, Vanderbilt University
Conor Lennon, University of Louisville
Shaoying Ma, The Ohio State University
Samuel Mann, Swansea University
Angélica C. Meinhofer, Weill Cornell Medicine
Edward N. Okeke, RAND Corporation
Alfredo R. Paloyo, University of Wollongong
Paul Rodriguez-Lesmes, Universidad del Rosario
Kaylyn R. Sanbower, Emory University
Andrew J.D. Smith, Emory University
Keith F. Teltser, Georgia State University
Hoa Vu, University of Wisconsin-Madison
Lucy Xiaolu Wang, Max Planck Institute for Innovation and Competition, Germany
Katherine Wen, Cornell University
Gal Wettstein, Boston College



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