Chad D. Meyerhoefer

This is the first study to estimate the impact of sports gambling legalization on food sufficiency using the staggered implementation of state laws between 2021-2023. By analyzing Google searches for online sportsbooks and legal wagers, we show that interest in sports gambling increases sharply following legalization. Applying an imputation-based difference-in-differences design to biweekly Household Pulse Survey (HPS) data, we find that legalized sports gambling reduces household food sufficiency by 2.1 percent among working-age adults without a college degree, which translates to a 10.5 percent decline among active bettors. This effect is cyclical, persisting for three-to-five months during NFL seasons. Additionally, the declines in food sufficiency are larger among households with adults aged 25-44 and racial/ethnic minorities. Using additional data from the HPS, Behavioral Risk Factor Surveillance System and Current Population Survey, our exploration of mechanisms suggests that the negative effects on food sufficiency operate through financial distress rather than changes in mental health or labor supply. A back-of-the-envelope calculation indicates that legalization of sports gambling in nine states resulted in an additional 284,000 food-insufficient households and $130.2 million in excess healthcare expenditures annually.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

We use national physician-pair panel data to examine how switching electronic health record (EHR) developers affects out-of-network referrals from primary care physicians (PCPs) to specialists. We estimate a difference-in-differences model, exploiting changes in EHR developer adoption by physicians’ affiliated hospitals. After a change in the PCP’s EHR developer, referrals to same-developer specialists increase by 5.8%, and referrals to specialists using the PCP’s prior EHR decrease by 4.2%. Referrals to the PCP’s most commonly referred-to specialists are not affected by changes in EHR developer, but shifts in referral patterns are particularly pronounced when the PCP is male and the specialist is female, when the PCP has more experience than the specialist and when the new EHR developer has a majority market share. These results are robust to estimation approaches that account for heterogenous treatment effects and physician selection into hospital systems. Our theoretical model indicates that PCP preferences for convenience may reduce referrals to the highest-quality specialists and lead to EHR market agglomeration, presenting a possible economic rationale for antitrust regulation of information blocking.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Estimates of the impact of body mass index and obesity on health and labor market outcomes often use instrumental variables estimation (IV) to mitigate bias due to endogeneity. When these studies rely on survey data that include self‐ or proxy‐reported height and weight, there is non‐classical measurement error due to the tendency of individuals to under‐report their own weight. Mean reverting errors in weight do not cause IV to be asymptotically biased per se, but may result in bias if instruments are correlated with additive error in weight. We demonstrate the conditions under which IV is biased when there is non‐classical measurement error and derive bounds for this bias conditional on instrument strength and the severity of mean‐reverting error. We show that improvements in instrument relevance alone cannot eliminate IV bias, but reducing the correlation between weight and reporting error mitigates the bias. A solution we consider is regression calibration (RC) of endogenous variables with external validation data. In simulations, we find IV estimation paired with RC can produce consistent estimates when correctly specified. Even when RC fails to match the covariance structure of reporting error, there is still a reduction in asymptotic bias.

We investigate the effects of regulations governing the practice autonomy of dental hygienists on dental care use with the 2001–2014 Medical Expenditure Panel Survey. We measure the strength of autonomy regulations by extending the Dental Hygiene Professional Practice Index to the years 2001–2014, allowing us to capture changes in regulations within states over time. Using a difference‐in‐differences framework applied to selected states, we find that relaxing supervision requirements to provide dental hygienists moderate autonomy results in an increase in total dental visits due to greater use of preventive dental care. However, the use of dental treatment decreases when states adopt the highest level of autonomy. Both sets of estimates increase in magnitude when we subset the sample to dental care provider shortage areas. In support of these findings, we show that dental visits shift to dental hygienists in shortage areas when states expand the scope of practice of hygienists, and that there is an increase in tasks performed by hygienists, such as cleanings and dental exams.

This chapter summarizes the research on the economic costs of obesity. Specifically, it reports estimates of the causal effect of obesity on two major categories of costs: 1) direct medical care costs; and 2) indirect job absenteeism costs. Recent estimates indicate that obesity raises medical care costs by US$2,781 per individual with obesity, doubling medical care costs relative to those of normal weight. The aggregate medical care costs of obesity in adults in the United States in 2016 were US$289 billion. Obesity also raises a worker's number of missed workdays by an average of three per year, more than doubling the number of workdays missed due to illness. Estimates of the aggregate productivity loss due to obesity-related job absenteeism in the United States range from a lower bound of US$14.9 billion to an upper bound of US$29.8 billion. These costs are useful for estimating the negative externalities associated with obesity, for calculating the cost-effectiveness of policies to prevent and reduce obesity, and for making the business case for a private firm to take steps such as adopting a wellness program or including weight loss drugs on their health insurance formulary.

Elections permit the continuance of democracy and enable economic development, but may have unintended effects on health. By applying a two-part model with regression discontinuity design to administrative health care claims, we determine that elections increased health care use during legally specified campaign periods by as much as 19% for first-time voters. Contrary to earlier studies focusing on mental health, we find higher spending on the treatment of physical health conditions, such as acute respiratory infections, gastrointestinal conditions and injuries. Levels of medical spending during campaign periods were highest in rural areas and among low-to-middle-income men. Using data on campaign spending from local elections, we identify campaign rallies as one important mechanism for the transmission of disease. Our findings provide additional rationale for policies that limit campaign spending on the grounds that it is socially wasteful.

We determine how enrollment in the Children's Health Insurance Program (CHIP) over an extended period of time affects medical and dental care use, health status and academic achievement. In contrast to prior research, which focuses on the program's effects during infancy and early childhood, we examine CHIP enrollment among elementary and middle school students. Using the 1999-2007 panels of the Early Childhood Longitudinal Study, Kindergarten Class and an instrumental variables model to address selection bias, we find that an additional year of CHIP enrollment increases the regular use of routine medical care by 16 percent, but has no detectible effects on overall parent-reported health status, obesity or test scores in reading and math.

Using a sample of New York City restaurants, we examine the relationship between a wine's bottle margin and whether the restaurant offers that same wine by the glass. We find that restaurants offer less expensive wines by the glass but set higher margins on these bottles than for similar wines offered only in bottles. Overall, offering wine by the glass is associated with a 5.0% increase in the bottle price and a 12.2% increase in the bottle margin. We find similar results for retail and wholesale markups of wine bottles. Our results offer evidence that settles a theoretical ambiguity in the menu-pricing literature (Anderson and Dana, 2009) about whether to raise or lower the price of a high-quantity package when introducing a low-quantity package of a good, as it applies to restaurant wine pricing. (JEL Classifications: L11, L83)

Past research suggests there are systematic associations between oral health and chronic illness among older adults. Although causality has not yet been credibly established, periodontitis has been found to be associated with higher risk of both heart disease and stroke. We advance this literature by estimating the direct association between dental care use and systemic health using multiple waves of the 1992 to 2016 Health and Retirement Study. Through the inclusion of individual fixed effects in our regression models, we account for unobservable time-invariant characteristics of individuals that might otherwise bias estimates of the association between dental care use and health. We find statistically significant negative associations between dental care use and the number of health conditions, self-reported overall health, the incidence of heart disease, and the incidence of stroke. In particular, the use of dental care within the past 2 y is associated with a 2.7% reduction in the likelihood of being diagnosed with a heart condition and a reduction in the likelihood of a stroke diagnosis of between 5.3% and 11.6%. We also find large positive correlations between edentulism and the measures of chronic illness. Associations from models estimated separately for men and women are qualitatively similar to one another. These findings provide additional motivation for the consideration of a Medicare dental benefit.