Impact of Social Policies on Health

Abstract

For my dissertation, I apply experimental and quasi-experimental methods to investigate how three social policy interventions influenced the demand for medical care and health. These policies are designed to help individuals and families at the lower end of the income distribution.

Chapter one examines the effect of a guaranteed income program on health care utilization. During the first two years of the COVID-19 pandemic, the City of Chelsea, a city just north of Boston, Massachusetts, allocated monthly cash benefits of up to $400 per month via lottery, providing a unique opportunity to evaluate the causal effects of income using a randomized controlled study design. I obtained and linked participants’ electronic health record data across multiple health systems. Leveraging the random assignment of the lottery, I found that adults who received the cash benefit had significantly fewer emergency department visits by 87.0 visits per 1000 participants for a 27% relative reduction, which included decreased use of the emergency department for reasons related to behavioral health and substance use, and fewer admissions to the hospital from the emergency department. Adults who received the cash benefit also had increased use of outpatient subspecialty care. These results suggest that policies to alleviate poverty by providing income support may improve health and access to care.

Chapter two examines the effect of increases in state minimum wages on mental health. While the federal minimum wage has remained unchanged since 2009, many U.S. states have raised their minimum wage. I used a stacked difference-in-differences model to compare states that raised their minimum wage to those that did not before and after the minimum wage began rising. I found a large and statistically significant reduction in the number of poor mental health days by 0.40 days per month among states with the largest increases in their minimum wage, representing a 7% relative improvement in mental health. These findings provide a public health rationale for increasing the minimum wage and support the institution of policies that boost income for low-wage workers.

Chapter three examines the effect of supplemental benefits from a Medicare Advantage health insurer in which beneficiaries with chronic obstructive lung disease could enroll in a program that provided reduced cost sharing for inhalers and medication management services. Using a study design that leverages the variation in program enrollment driven by randomized invitation, I found that the program improved inhaler adherence substantially by 15.5 percentage points, or a 55% relative improvement, and led to a meaningful but statistically nonsignificant narrowing of the racial disparity in inhaler use. To better align insurance coverage with clinical benefit while also improving racial equity, insurers might consider lowering cost sharing and providing medication management services for clinically effective, high-value services.