HOW LABOR MARKETS AND WELFARE POLICIES SHAPE HEALTH ACROSS THE LIFE COURSE:
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1 HOW LABOR MARKETS AND WELFARE POLICIES SHAPE HEALTH ACROSS THE LIFE COURSE: THE POTENTIALS AND LIMITATIONS OF NATURAL POLICY EXPERIMENTS Kate Strully University at Albany, SUNY * Prepared for session on How measurement and modeling of social determinants of health can inform actions to reduce disparities, 2012 National Conference on Health Statistics
2 LABOR MARKETS, WELFARE POLICIES, AND POPULATION HEALTH The Social Determinants of Health: Where we live, learn, work and play can have a greater impact on how long and how well we live than medical care. -- RWJF Commission to Build a Healthier America The Health Effects of Non-Health Policy: There are likely to be unintended health costs and benefits to labor market and welfare policies. Our old nemesis unmeasured confounding: Assignment to labor market and welfare treatment and control groups is typically non-random.
3 NATURAL EXPERIMENTAL APPROACH We try to recognize naturally occurring unique circumstances in which treatment assignment is uncorrelated with unmeasured characteristics related to the outcome.
4 LOGIC & ASSUMPTIONS OF NATURAL EXPERIMENTAL APPROACHES Natural experiment affecting treatment assignment (Z) Labor market/welfare Treatment (T) Health outcome (Y) Unmeasured characteristics (u)
5 POLICY NATURAL EXPERIMENTS Typically relying on policy change that affected some subpopulations or geographic regions (treatment group), while not affecting others (control group). Often state variation over time.
6 EFFECTS OF PRENATAL POVERTY ON BIRTH WEIGHT: STATE EARNED INCOME TAX CREDITS (EITC) AS A NATURAL EXPERIMENT Strully, K., D. Rehkopf, and Z. Xuan (2010). The effects of prenatal poverty on infant health: State earned income tax credits and birth weight. American Sociological Review.75(4):
7 POVERTY, EITC, AND BIRTH WEIGHT Enactment State EITC (Z t-1 ) Maternal poverty (employment/income) (T) Infant birth weight (Y t ) Unmeasured characteristics (u)
8 TWO QUESTIONS 1. Treating EITC primarily as a natural experiment for low-income mothers income/employment, is there a causal effect of prenatal poverty on birth weight? 2. How have recent expansions of work-based welfare programs (e.g., the EITC) impacted child health?
9 THE EARNED INCOME TAX CREDIT (EITC) The EITC is a typically refundable tax credit designed to reduce the tax burden on, and supplement the incomes of, low-wage workers in the United States. Federal EITC administered by IRS since 1970s. But, since early 1980s, several states have enacted their own state EITCs as well , 16 states enacted credits: Colorado, District of Columbia, Kansas, Maine, Maryland, Minnesota, New Jersey, New York, Oklahoma, Vermont, Wisconsin, Illinois, Iowa, Massachusetts, Oregon, Rhode Island e.g., CO credit %; MN 10%-33%; WI 5%(1 kid)-75% (3 kids)
10 VARIATION IN STATE EITCS AND BIRTH WEIGHT Data U.S. Natality Detail File Birth certificate data Samples limited to unmarried mothers with high school degree or less
11 DIFFERENCE-IN-DIFFERENCE MODEL OF STATE EITCS AND BIRTH WEIGHT (WITH STATE AND YEAR FE) Y ist = β 0 + β 1 EITC s(t-1) + β 2 Individual Controls ist + β 3 State Econ/Policy Controls s(t-1) + β 4 State t + β 5 Year s + u EITC: whether a woman gave birth in a state with an EITC in a given year; Individual Controls: Maternal age, high school, race, and smoking (both predictor and outcome); baby sex State Econ/Policy Controls: WIC participation, minimum wage, Medicaid spending, unemployment rate, number poor, TANF work requirements, AFDC/TANF benefit size (quartiles) State: dummy variables for each of the U.S. states and DC state fixed-effects Year: dummy variables for years ( ) year fixed-effects
12 EFFECTS OF STATE EITC AND AFDC/TANF ON BIRTH WEIGHT Birth Weight (OLS Regression) State EITC *** (1.211) N 8,762,028
13 EFFECTS OF STATE EITC AND AFDC/TANF ON BIRTH WEIGHT Birth Weight (OLS Regression) State EITC *** (1.211) 2 nd AFDC/TANF Quartile 3 nd AFDC/TANF Quartile 4 nd AFDC/TANF Quartile (1.205) (1.766) 8.415*** (2.641) N 8,762,028
14 CONCLUSIONS, CAVEATS, NEXT STEPS Poverty relief through both EITC and AFDC/TANF appear to improve birth weight. Next steps/teaser: Project (with Rehkopf and Dow) looking at EITCs and child obesity. Children of the National Longitudinal Survey of Youth (NLSY79) Main predictors: difference in a family s estimated EITC in given year (T) and one year later (T+1), using earnings /family structure in year T to estimate EITC. Reduces confounding from behavioral responses to EITC.
15 OTHER EXAMPLES OF LABOR MARKET/WELFARE POLICY NATURAL EXPERIMENTS
16 OTHER SELECTED EXAMPLES OF NATURAL EXPERIMENTS Temporal and/or geographic variation in policy: Compulsory schools laws Lleras-Muney (2002): evidence that education reduces mortality Social security notch Snyder and Evans (2005): increases in social security benefits positively associated with mortality Non-linear effects of education or income? Can these results be generalized to other populations? Other examples: Lottery winnings (e.g., Lindhal 2005) Dutch famine (e.g., Susser 1994; Lumey and Stein 1997; and others) Casinos on tribal land (e.g., Wolfe et al. 2012) Can these relatively rare income-generating events be generalized to more common ways that people get income (e.g., labor market)?
17 CONCLUSIONS/LOOKING AHEAD Natural experiments are important for identifying the health effects of non-health policy. But, they are also limited. Difficult assumptions (internal validity); Some times limited generalizability (external validity). How can we strengthen them and/or reduce our reliance on them? Add repeated questions about people s policy exposures and treatments to main national health datasets (e.g., NHIS, NHANES, BRFSS, etc). Although need to be cognizant of potential reporting error. Possibilities for adding some degree of intentional randomization when we implement new policies?
18 EXTRA SLIDES
19 SELECTION INTO TREATMENT GROUPS Natural experimental approach: we try to recognize naturally occurring unique circumstances in which treatment assignment (Z) is uncorrelated with u. Winship and Morgan (1999) Estimation of Causal Effects from Observational Data. American Sociological Review. 25:
20 The EITC: Two-Part Exposure 1. Refundable tax credit for a given level of earnings 2. Employment incentives Evidence that federal EITC expansions increase labor market entry for less educated single mothers. We ve replicated this for state EITCs.
21 STRUCTURE OF THE EITC
22 Natality Data: Means for Key Variables Single mothers with high school or less Birth weight State has EITC.083 Smoked.287 Mother Black.417 Mother HS degree.490 N 8,762,028
23 Effect of State EITCs & AFDC/TANF on Smoking Smoking Logistic Regression (Odds Ratios) State EITC 0.949*** 2 nd AFDC/TANF Quartile 3 nd AFDC/TANF Quartile 4 nd AFDC/TANF Quartile (0.006) (0.011) (0.013) 1.096*** (0.016) N 5,260,202
24 Effect of State EITCs & AFDC/TANF on Birth Weight (adj for smoking) Birth Weight OLS Regression (States with smoking data) Birth Weight OLS Regression (States with smoking data) State EITC *** (1.500) 2 nd AFDC/TANF Quartile 3 nd AFDC/TANF Quartile 4 nd AFDC/TANF Quartile * (2.857) (2.234) (3.879) Smoked N 5,254,642
25 Effect of State EITCs & AFDC/TANF on Birth Weight (adj for smoking) Birth Weight OLS Regression (States with smoking data) State EITC *** (1.500) Birth Weight OLS Regression (States with smoking data) *** (1.471) 2 nd AFDC/TANF Quartile 3 nd AFDC/TANF Quartile 4 nd AFDC/TANF Quartile * (2.857) (2.234) (3.879) *** (2.815) (3.188) (3.823) Smoked *** (0.589) N 5,254,642 5,254,642
26 CAVEATS Internal and external validity of natural experiment No evidence of dose response Needs further tests with alternative EITC measures Estimates reflect average treatment effect; may not apply to particular cases/states
27 EFFECT OF STATE EITC ON BIRTH WEIGHT FOR ALTERNATIVE SAMPLES (NATALITY DATA) High Education Married Sample First Births State EITC (5.939) 7.727*** (0.826) 5.267*** (1.178) N 283,889 17,204,823 8,529,601
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