We examine the effect of Medicaid expansion under the Affordable Care Act (ACA) on substance use disorder (SUD) treatment utilization and financing. We combine data on admissions to specialty facilities and Medicaid-reimbursed prescriptions for medications commonly used to treat SUDs in nonspecialty outpatient settings with an event-study design. Several findings emerge from our study. First, among patients receiving specialty care, Medicaid coverage and payments increased. Second, the share of patients who were uninsured and who had treatment paid for by state and local government payments declined. Third, private insurance coverage and payments increased. Fourth, expansion also increased prescriptions for SUD medications reimbursed by Medicaid. Fifth, we find suggestive evidence that admissions to specialty treatment may have increased one or more years post-expansion. However, this finding is sensitive to specification and we observe differential pretrends between the treatment and comparison groups. Thus, our finding for admissions should be interpreted with caution.

Low participation rates in government assistance programs are a major policy concern in the United States. This paper studies take-up of Section 8 housing vouchers, a program in which take-up rates are quite low among interested and eligible households. We link 18,109 households in Chicago that were offered vouchers through a lottery to administrative data and study how baseline employment, earnings, public assistance, arrests, residential location, and children's academic performance predict take-up. Our analysis finds mixed evidence of whether the most disadvantaged or distressed households face the largest barriers to program participation. We also study the causal impact of peer behavior on take-up by exploiting idiosyncratic variation in the timing of voucher offers. We find that the probability of lease-up increases with the number of neighbors who recently received voucher offers. Finally, we explore the policy implications of increasing housing voucher take-up by applying reweighting methods to existing causal impact estimates of voucher receipt. This analysis suggests that greater utilization of vouchers may lead to larger reductions in labor market activity. Differences in take-up rates across settings may be important to consider when assessing the external validity of studies identifying the effects of public assistance programs.

We use experimental survey methods in a nationally representative survey to test alternative ways of identifying (1) individuals in the population who would be better able to work if they received workplace accommodation for a health condition; (2) the rate at which these individuals receive workplace accommodation; and (3) the rate at which accommodated workers are still working four years later, compared to similar workers who were not accommodated. We find that question order in disability surveys matters. We present suggestive evidence of priming effects that lead people to understate accommodation when first asked about work-limiting health problems. We also find a sizeable fraction of workers who report they receive a workplace accommodation for a health problem but do not report work limitations . Our preferred estimate of the size of the accommodation-sensitive population is 22.8 percent of all working age adults. We find that 47-58 percent of accommodation-sensitive individuals lack accommodation and would benefit from some kind of employer accommodation to either sustain or commence work. Finally, among accommodation-sensitive individuals, workers who were accommodated for a health problem in 2014 were 13.2 percentage points (18.5 percent) more likely to work in 2018 than those who were not accommodated in 2014.

Older adults are at elevated risk of reducing labor supply due to poor health, partly because of high rates of symptoms that may be alleviated by medical marijuana. Yet, surprisingly little is known about how this group responds to medical marijuana laws (MMLs). We quantify the effects of state medical marijuana laws on the health and labor supply of adults age 51 and older, focusing on the 55 percent with one or more medical conditions with symptoms that may respond to medical marijuana. We use longitudinal data from the Health and Retirement Study to estimate event study and differences-in-differences regression models. Three principle findings emerge from our analysis. First, active state medical marijuana laws lead to lower pain and better self-assessed health among older adults. Second, state medical marijuana laws lead to increases in older adult labor supply, with effects concentrated on the intensive margin. Third, the effects of MMLs are largest among older adults with a health condition that would qualify for legal medical marijuana use under current state laws. Findings highlight the role of health policy in supporting work among older adults and the importance of including older adults in assessments of state medical marijuana laws.

Transaction costs pose significant barriers to participation in public programs. We analyze how Social Security Disability Insurance (SSDI) application behavior was affected by iClaim, a 2009 innovation that streamlined the online application process. We use a difference-in-differences design to compare application rates before and after 2009 across counties with varying degrees of access to high-speed internet. We estimate that counties with internet connectivity one standard-deviation above the mean experienced a 1.6 percent increase in SSDI applications, and a 2.8 percent increase in appeals after the reform. We estimate that the increase in applications due to iClaim can explain 15 percent of the overall increase in applications between 2008 and 2011. Higher exposure to the online application led to a slightly larger increase in SSDI awards, meaning there was a small but significant increase in the overall award rate. Application rates increased the most in rural areas, while appeals and awards had more significant increases in urban areas. These results suggest that the online application reduced transaction costs to applicants, and the lower costs improved the overall targeting efficiency of the application process.

Previous research in the US has found negative health effects of contamination when it triggers regulatory violations. An important question is whether levels of contamination that do not trigger a health-based violation impact health. We study the impact of drinking water contamination in community water systems on birth outcomes using drinking water sampling results data in Pennsylvania. We focus on the effects of water contamination for births not exposed to regulatory violations. Our most rigorous specification employs mother fixed effects and finds changing from the 10th to the 90th percentile of water contamination (among births not exposed to regulatory violations) increases low birth weight by 12% and preterm birth by 17%.

For many low-income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out-of-pocket costs and additional benefits. We examine whether Medicaid participation by low-income adults age 65 and up increased as a result of Medicaid expansions to working-age adults under the Affordable Care Act (ACA). Previous literature documents so-called "welcome mat" effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working-age adults increased Medicaid participation among low-income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an "on-ramp" effect; that is, low-income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non-expansion states. This on-ramp effect is an important mechanism behind welcome mat effects among some older adults.

The effects of paid parental leave policies on infant health have yet to be established. In this paper we investigate these effects by exploiting the introduction of California Paid Family Leave (PFL), the first program in the U.S. that specifically provides working parents with paid time off for bonding with a newborn. We measure health using the full census of infant hospitalizations in California and a set of control states, and implement a differences-in-differences approach. Our results suggest a decline in infant admissions, which is concentrated among those causes that are potentially affected by closer childcare (and to a lesser extent breastfeeding). Other admissions that are unlikely to be affected by parental leave do not exhibit the same pattern.

Many public school diversity efforts rely on reassigning students from one school to another. While opponents of such efforts articulate concerns about the consequences of reassignments for students' educational experiences, little evidence exists regarding these effects, particularly in contemporary policy contexts. Using an event study design, we leverage data from an innovative socioeconomic school desegregation plan to estimate the effects of reassignment on reassigned students' achievement, attendance, and exposure to exclusionary discipline. Between 2000 and 2010, North Carolina's Wake County Public School System (WCPSS) reassigned approximately 25 percent of students with the goal of creating socioeconomically diverse schools. Although WCPSS's controlled school choice policy provided opportunities for reassigned students to opt out of their newly reassigned schools, our analysis indicates that reassigned students typically attended their newly reassigned schools. We find that reassignment modestly boosts reassigned students' math achievement, reduces reassigned students' rate of suspension, and has no offsetting negative consequences on other outcomes. Exploratory analyses suggest that the effects of reassignment do not meaningfully vary by student characteristics or school choice decisions. The results suggest that carefully designed school assignment policies can improve school diversity without imposing academic or disciplinary costs on reassigned students.

COVID symptom screening, a new workplace practice, is already affecting many millions of American workers. As of this writing, 34 states already require, and federal guidance recommends, frequent screening of at least some employees for fever or other symptoms. This paper provides the first empirical work identifying major features of symptom screening in a broad population and exploring the trade-offs employers face in using daily symptom screening. First, we find that common symptom checkers could screen out up to 7 percent of workers each day, depending on the measure used. Second, we find that the measures used will matter for three reasons: Many respondents report any given symptom, survey design affects responses, and demographic groups report symptoms at different rates, even absent fluctuations in likely COVID exposure. This last pattern can potentially lead to disparate impacts and is important from an equity standpoint.

Value-based payment programs, also known as pay-for-performance, use financial incentives to motivate providers to invest in quality and are a critical part of Medicare health care reform. This study examines the first year of the Home Health Value-Based Purchasing program, a nationally representative cluster randomized experiment implemented by the Centers for Medicare & Medicaid Services in 2016. The goal of the program is to achieve better home health care quality. Home health agencies in treatment states were rewarded or penalized based on their performance on agency-reported and non-agency-reported quality measures. The program improved agency-reported measures by approximately one percentage point, and performance gains suggest a dose-response relationship with respect to incentive size. However, the performance gains in agency-reported measures did not reflect true quality improvement. I find evidence that agencies manipulated their coding of patients and inflated their performance. Coding manipulation explains the entirety of the program's impact on agency-reported measures.

Stable housing is critical for health, employment, education, and other social outcomes. Evictions reflect a form of housing instability that is experienced by millions of Americans each year. Inadequately treated psychiatric disorders have the potential to influence evictions in several ways. For example, these disorders may impede labor market performance and thus the ability to pay rent, or increase the likelihood of risky and/or nuisance behaviors that can lead to a lease violation. We estimate the effect of local access to psychiatric treatment on eviction rates. We combine data on the number of psychiatric treatment centers that offer outpatient and residential care within a county with eviction rates in a two-way fixed-effects framework. Our findings imply that 10 additional psychiatric treatment centers in a county lead to a reduction of 2.1% in the eviction rate.

E-cigarette taxes are an active area of legislation and have important regulatory implications by proxying e-cigarette accessibility. We examine the effect of e-cigarette taxes on prepregnancy and prenatal smoking using the near-universe of births to mothers conceiving between 2013 and 2019 in the United States. Using fixed effect regressions, we show that e-cigarette taxes increase prepregnancy and prenatal smoking. We also find evidence that e-cigarette taxes reduce prepregnancy and 3rd trimester e-cigarette use. Finally, we show that e-cigarette taxes increase news coverage of e-cigarettes and raise perceptions of risk of e-cigarettes.

We consider the distributional implications of Social Security policy changes in the context of increases in life expectancy and differential mortality. Using a robust microsimulation model, we examine how several options for raising the retirement age, including a scenario that applies a mortality adjustment in combination with such policies, affect different types of individuals and households. Policy changes are simulated for Social Security beneficiaries in 2030 using the Modeling Income in the Near Term (MINT) microsimulation model. The analysis shows that increasing either the age at which individuals receive their full retirement benefit alone or the early eligibility and full retirement ages together result in across-the-board reductions in benefit levels. The policies are projected to result in slightly higher poverty, but the expected rise is sharper among groups known to experience higher rates of mortality, as well as many disadvantaged groups. Analysis of a hypothetical adjustment to offset the historical impacts of differential mortality by lifetime earnings on lifetime benefit receipt, when combined with these retirement age increases, shows varied results. While some groups of individuals experience sharper reductions in median monthly benefits, the adjustment has an offsetting and protective effect for the benefits of disadvantaged groups when combined with options that would raise the retirement age. This combined package of policies, as well as simulations that incorporate a behavioral adjustment in benefit claiming ages, result in an increase of less than one percentage point in the average poverty rate.

How should schools assign students to more rigorous math courses so as best to help their academic outcomes? We identify several hundred California middle schools that used 7th-grade test scores to place students into 8th-grade algebra courses and use a regression discontinuity design to estimate average impacts and heterogeneity across schools. Enrolling in 8th-grade algebra boosts students' enrollment in advanced math in ninth grade by 30 percentage points and eleventh grade by 16 percentage points. Math scores in tenth grade rise by 0.05 standard deviations. Women, students of color, and English-language learners benefit disproportionately from placement into early algebra. Importantly, the benefits of 8th-grade algebra are substantially larger in schools that set their eligibility threshold higher in the baseline achievement distribution. This suggests a potential tradeoff between increased access and rates of subsequent math success.

Despite the significant cost of prescription (Rx) drug abuse and calls from policymakers for effective interventions, there is limited research on the effects of policies intended to limit such abuse. This study estimates the effects of prescription drug monitoring (PDMP) programs, which constitute a key policy targeting access to non-medical use of Rx drugs. Based on objective indicators of abuse as measured by substance abuse treatment admissions and mortality related to Rx drugs, estimates do not suggest any substantial effects of instituting an operational PDMP. We find, however, that mandatory-access provisions, which raised PDMP utilization rates by actually requiring providers to query the PDMP prior to prescribing a controlled drug, are significantly associated with a reduction in Rx drug abuse. The effects are driven primarily by a reduction in opioid abuse, generally strongest among young adults (ages 18 to 24), and underscore important dynamics in the policy response. Robustness checks are consistent with a causal interpretation of these effects. We also assess potential spillovers of mandatory PDMPs on the use of other illicit drugs and find a complementary reduction in admissions related to cocaine and marijuana abuse.

A lack of affordable housing is a pressing issue for many low-income American families and can lead to eviction from their homes. Housing assistance programs to address this problem include public housing and other assistance, including vouchers, through which a government agency offsets the cost of private market housing. This paper assesses whether the receipt of either category of assistance reduces the probability that a family will be evicted from their home in the subsequent six years. Because no randomized trial has assessed these effects, we use observational data and formalize the conditions under which a causal interpretation is warranted. Families living in public housing experience less eviction conditional on pre-treatment variables. We argue that this evidence points toward a causal conclusion that assistance, particularly public housing, protects families from eviction.

Household food insecurity status in the United States is ascertained by a battery of close-ended questions. We posit that the monthly nature of benefit receipt from the Supplemental Nutrition Assistance Program (SNAP) creates experiences of food hardship, which become salient in the context of SNAP receipt, and in turn exert influence on the response to food security questions. We test this hypothesis by examining answers to a 30-day food security module in relation to when SNAP benefits are received. We find that for SNAP households near the end of or at the beginning of the benefit month, the probability of being classified as food insecure increases by 11 percentage points, over a baseline of 42 percent. We also find that the probability of responding affirmatively to any of the first five items in the module increases during this time. We discuss the importance of these findings for the estimation of food security and its implication on program evaluation.

Medicare is a large government health insurance program in the United States that covers about 60 million people. This paper analyzes the effects of Medicare insurance on health for a group of people in urgent need of medical care: people with cancer. We used a regression discontinuity design to assess impacts of near-universal Medicare insurance at age 65 on cancer detection and outcomes, using population-based cancer registries and vital statistics data. Our analysis focused on the three tumor sites for which screening is recommended both before and after age 65: breast, colorectal, and lung cancer. At age 65, cancer detection increased by 72 per 100,000 population among women and 33 per 100,000 population among men; cancer mortality also decreased by nine per 100,000 population for women but did not significantly change for men. In a placebo check, we found no comparable changes at age 65 in Canada. This study provides the first evidence to our knowledge that near-universal access to Medicare at age 65 is associated with improvements in population-level cancer mortality.

Tougher immigration enforcement was responsible for 1.8 million deportations between 2009 and 2013 alone--many of them were fathers of American children. We exploit the geographic and temporal variation in the escalation of interior immigration enforcement to assess its impact on the structure of families to which many of the deported fathers of U.S.-born children belonged. We find that the average increase in immigration enforcement during the 2005 to 2015 period has raised by 19 percent the likelihood that Hispanic U.S.-born children might live without their parents in households headed by naturalized relatives or friends unthreatened by deportation. Likewise, the same increase in immigration enforcement has raised by 20 percent these children's propensity to live with likely undocumented mothers who report their spouses as being absent--a reasonable finding given that most children with a likely undocumented father have undocumented mothers. Given the negative consequences of being raised by a single parent or without parents, plus the parallel increase in interior immigration enforcement, gaining a better understanding of the collateral damage of heightened enforcement on the families to which these children belong is well warranted.

Recently, U.S. advocates and funders have supported direct cash transfers for individuals and families as an efficient, immediate, and non-paternalistic path to poverty alleviation. Open questions remain, however, about their implementation. We address these using data from debit card transactions, customer service call-line logs, and in-depth interviews from a randomized control study of a monthly unconditional cash gift delivered via debit card to mothers of young children living near the federal poverty line. Because much of the impact of the intervention occurs through mothers' decisions about how to allocate the Baby's First Years (BFY) money, we argue that implementation science must recognize the role of policy targets in implementing policy, not just in terms of policy outcomes but also policy implementation processes. Further, our analysis shows that mothers experience key aspects of the cash intervention's design as intended: they viewed the cash gift as unconditional and knew the money was reliable and would continue monthly, receiving the correct amount with few incidents. Delivering funds via debit card worked well, offering mothers flexibility in purchasing. We also illuminate how design features shaped mothers' experiences. First, although they knew it was unconditional, the social meaning of the BFY money to mothers-seen as "the baby's money"-shaped their engagement with and allocation of it. Second, low public visibility of mothers' receipt of this money limited the financial demands or requests from others, potentially facilitating more agency over and a greater ability to use the money as they chose, without claims from kin.