Many NBER-affiliated researchers publish some of their findings in medical and other journals that preclude pre-publication distribution. This makes it impossible to include these papers in the NBER Working Paper Series. This is a partial listing of recent papers in this category by NBER affiliates.
The ACA's Impact on Racial and Ethnic Disparities in Health Insurance Coverage and Access to Care
Health Affairs 39(3), March 2020, pp. 395–402.
This paper examines how the insurance coverage expansions of the Affordable Care Act (ACA) affected racial and ethnic disparities in health care coverage and access for nonelderly adults. It uses the Census Bureau’s American Community Survey to track insurance coverage and the Behavioral Risk Factor Surveillance System to measure access to care between 2008 and 2017. In the years since the law went into effect, insurance coverage increased significantly for all racial and ethnic groups. Disparities in coverage decreased because coverage increased more for non-Hispanic blacks and Hispanics than for non-Hispanic whites. In states that expanded Medicaid as part of the ACA, the uninsurance rate fell more, and the black-white gap disappeared. Hispanics however remained significantly less insured than non-Hispanic whites in all states. For access to care, there was less evidence of a break in trend in 2014 than there was for insurance coverage, but disparities nevertheless decreased over time. Before the ACA, blacks and Hispanics were substantially more likely to go without care for financial reasons and lack of a usual source of care, but their access to care improved after the ACA. Despite these improvements, a large number of adults remain uninsured, and the uninsurance rate among blacks and Hispanics is still substantially higher than the rate among whites.
Effects of a Natural Disaster on Mortality Risks over the Longer Term
Nature Sustainability, May 2020.
This study examines how mortality and individual-specific traumatic exposures at the time of a natural disaster affect mortality risks of survivors over the subsequent 10 years, using data from Aceh, Indonesia, collected before and after the 2004 Indian Ocean tsunami. While 5 percent of the province’s population perished, there was substantial variation across geographic areas, with some communities losing most of their residents while, in nearby communities, everyone survived. In rich, longitudinal interview data collected before and at multiple points after the tsunami, the researchers followed participants who were ages 35 and older at the time of the tsunami. Though post-disaster stress and post-traumatic stress symptoms can affect disease and mortality, this can be obscured by an opposing selective survival effect: those who do not die in a disaster may be selected for characteristics that confer survival. This was evident in this study: survivors who, at the time of the tsunami, were living in communities where higher fractions of the population perished were, on average, less likely to die in the ensuing 10 years, indicating positive selection in terms of characteristics associated with longevity. Only among older adults (age 50 or older at the time of the tsunami) did individual-specific tsunami exposure increase post-disaster mortality: for females whose spouse died in the tsunami and for males with poor post-tsunami psychosocial health (PTSD symptoms). This underlines the importance of long-term follow-up, indicating that, after 10 years, the effects of scarring from individual-specific exposures to the tsunami had emerged among older adults, counteracting reductions in risk from positive mortality selection.
Effects of a Workplace Wellness Program on Employee Health, Health Beliefs, and Medical Use: A Randomized Clinical Trial
JAMA Internal Medicine, May 2020.
This randomized clinical trial evaluated the effect of a comprehensive workplace wellness program at the University of Illinois at Urbana-Champaign on employee health, health beliefs, and medical use over a two-year period. Members of the treatment group were offered incentives to participate in the program. Those who completed a yearly biometric screening and health risk assessment received randomly assigned cash awards ($0 to $200) and were eligible to register for a wellness activity class each semester. On completion of a wellness activity, participants earned a cash or gift card award ($0 to $75). Those offered the program were compared to a control group that was invited to complete biometric screenings 12 and 24 months after randomization, but was not eligible to participate in the other components of the wellness program. The intervention significantly improved employee beliefs about their own health status (body-mass index, high cholesterol, high blood pressure, fasting glucose level). Also, a significantly higher proportion of employees in the treatment group reported having a primary care physician after 24 months. However, there were no significant effects of the program on measured physical health outcomes, rates of diagnoses of diabetes, hypertension, or hyperlipidemia, or the use of health care services after 12 or 24 months. This study concludes that workplace wellness programs are unlikely to significantly improve employee health or reduce medical use in the short term.