Aggregation and the estimated effects of economic conditions on health

Business cycles and healthcare employment

Is healthcare employment recession-proof? We examine the long-standing hypothesis that healthcare employment is stable across the business cycle. We explicitly distinguish between negative aggregate demand and supply shocks in studying how healthcare employment responds to recessions, and show that this response depends largely on the type of the exogenous shock triggering the recession. First, aggregate healthcare employment responds procyclically during demand-induced recessions but remains stable during supply-induced recessions. Second, healthcare utilization drops significantly during demand-induced recessions, explaining the decline in healthcare employment during these periods. Finally, there is significant heterogeneity in the employment responses of the healthcare sub-sectors. While healthcare employment in most sub-sectors responds procyclically during recessions caused by both negative demand and supply shocks, it responds countercyclically in nursing-dominant sectors. Importantly, by isolating the recessionary impact of negative aggregate demand shocks from supply shocks on healthcare employment, we provide new empirical evidence that healthcare employment, in general, is not recession-proof.

Joint effects of Medicaid eligibility and fees on recession-linked declines in healthcare access and health status

Whether Medicaid can function as a safety net to offset health risks created by health insurance coverage losses due to job loss is conditional on (1) the eligibility guidelines shaping the pathway for households to access the program for temporary relief, and (2) Medicaid reimbursement policies affecting the value of the program for both the newly and previously enrolled. We find states with more expansive eligibility guidelines lowered the healthcare access and health risk of coverage loss associated with rising unemployment during the 2007-2009 Great Recession. Rises in cost-related barriers to care associated with unemployment were smallest in states with expansive eligibility guidelines and higher Medicaid-to-Medicare fee ratios. Similarly, states whose Medicaid programs had expansive eligibility guidelines and higher fees saw the smallest recession-linked declines in self-reported good health. Medicaid can work to stabilize access to health care during periods of joblessness. Our findings yield important insights into the alignment of at least two Medicaid policies (i.e., eligibility and payment) shaping Medicaid's viability as a safety net.

Relationship Between Sex-Specific Labor Market Performance and Breastfeeding Prevalence

BACKGROUND

Prior research has explored the association between women's employment status and breastfeeding at the individual level, however; a notable gap in scholarly inquiry exists regarding the relationship between labor market performance and breastfeeding at the population level.

RESEARCH AIM

The aim of this paper is to investigate the association between labor market performance and breastfeeding prevalence in the United States.

METHODS

This study is a cross-sectional analysis of the association between labor market performance and the prevalence of breastfeeding. Our analysis is conducted at the state level using data published up to late 2021 from the Current Population Survey and the National Immunization Survey. The first dataset was used to construct aggregate and sex-specific state level indicators of labor market performance for both males and females. The second dataset supplied the proportion of mothers breastfeeding for the corresponding birth cohort from each state.

RESULTS

Higher average weekly hours worked by females in the year before giving birth was associated with a lower prevalence of breastfeeding, but employment rates among females did not significantly affect breastfeeding prevalence. Among males, current employment rates were positively associated with breastfeeding prevalence; however, no significant relationship was observed between breastfeeding prevalence and average weekly work hours worked.

CONCLUSION

Sex-specific labor market performance may play a role in breastfeeding decisions and the timing of labor market performance relative to childbirth is important. Furthermore, these results highlight that employment rates and hours worked might be associated with child health through breastfeeding prevalence.

Economic instability, income, and unemployment effects on mortality: using SUR panel data in Iran

This study aims to investigate the effects of socioeconomic factors on mortality in Iran. To this end, this research examines how economic instability, income, and unemployment affect mortality using a seemingly unrelated regression (SUR) with panel data for 30 provinces in Iran from 2004 to 2019. The results indicate that unemployment and mortality have a countercyclical relationship among the working age-groups 20-59 but a procyclical pattern among old-age (60+), except for rural mortality. This result is harmonious between employment and age-group mortality. This finding implies that unemployment increases mortality in working age-groups due to psychological stress and poverty risk. In addition, the income level decreases mortality in all ages over 40 years due to the provision of higher access to health and medical services and social welfare. However, it increases mortality in rural areas and age-group 20-39 because of their hazardous, unsafe, and stressful work conditions. Therefore, policymakers should plan for an inclusive economic growth to reduce poverty and out-of-pocket payments and increase the quality and accessibility of public health services, especially for beneficiaries of lower social groups. Moreover, they should adopt strategies to alleviate the burden of premature, preventable, and treatable deaths.

"Deaths of despair" over the business cycle: New estimates from a shift-share instrumental variables approach

This study presents new evidence of the effects of short-term economic fluctuations on suicide, fatal drug overdose, and alcohol-related mortality among working-age adults in the United States from 2003-2017. Using a shift-share instrumental variables approach, I find that a one percentage point increase in the aggregate employment rate decreases current-year non-drug suicides by 1.7 percent. These protective effects are concentrated among working-age men and likely reflect a combination of individual labor market experiences as well as the indirect effects of local economic growth. I find no consistent evidence that short-term business cycle changes affect drug or alcohol-related mortality. While the estimated protective effects are small relative to secular increases in suicide in recent decades, these findings are suggestive of important, short-term economic factors affecting specific causes of death and should be considered alongside the longer-term and multifaceted social, economic, and cultural determinants of America's "despair" epidemic.

Understanding the association between county-level unemployment and health stratified by education and income in the southwestern United States

Past research on the relationship between unemployment rates and population health has produced mixed findings. The relationship can be influenced by the kinds of health outcomes observed, time frame, level of geographic aggregation, and other factors. Given these mixed findings, there is a need to add to our knowledge about how unemployment rates and population health are related. There is limited research that examines the association of unemployment rates with both physical and mental health, while simultaneously stratifying populations by income and education levels. Using survey-based self-reported data, this first population-based study examined the association between unemployment rates and physically and mentally unhealthy days in the southwestern United States, by county-level stratification of income (high and low) as well as education (high and low), from 2015 to 2019. After controlling for covariates, associations were modelled using negative binomial regression, with autocorrelative residuals, and were reported as rate ratios (RR). Overall, we found that a 1% rise in unemployment rates was significantly associated with an increase in physically unhealthy days [adjusted RR 1.007; 95% CI, 1.004-1.011, P < 0.001] and mentally unhealthy days [RR 1.006; 95% CI, 1.003-1.009, P  < 0.001]. Upon stratification, a significant risk was found among the high education and high income category [RR 1.035; 95% CI, 1.021-1.049, P  < 0.001], as well as for the high education and low income category [RR 1.026; 95% CI, 1.013-1.040, P  < 0.001]. A better understanding of how unemployment is associated with the health of communities with different education and income levels could help reduce the burden on society through tailored interventions and social policies not only in the United States, but also in other developed nations.

Newborns during the crisis: Evidence from the 1980s' farm crisis

The sudden and jumping interest rate in the early 1980s triggered a severe economic crisis in the US agriculture sector. To identify the effects of wealth losses on the health condition of cohorts born in the midst of the crisis, this paper constructs an instrumental variable for wealth by exploiting the geographic variation in crop production and the timing of the shock. This study finds that wealth losses generates long-lasting health impacts for these newborns. A one percent wealth loss leads to an approximately 0.008 and 0.003 percentage point increase in the low and very low birth weight rates, respectively. In addition, cohorts growing up in areas of greater impacts have worse self-reported health condition before age 17 than others. They also have more metabolic-syndrome issues and smoke more regularly than other cohorts in adulthood. Lower expenditures on food and prenatal care might explain the negative health effects on cohorts born during the crisis. The study shows that households in areas with greater wealth losses have more declining expenditures on food at home and prenatal-care doctor visits.

Mortality inequalities in France since the 1920s: Evidence of a reversal of the income gradient in mortality

Many recent studies show that Europe has had a lower mortality inequality for most ages than the United States over the last thirty years. However, the evolution of the income gradient in mortality all along the twentieth century remains poorly understood. This article uses a unique dataset that gives the annual lifetables and fiscal income for the 90 administrative regions of mainland France from 1922 to 2020. The income gradients in mortality are computed across regions using a traditional method with calendar ages and, alternatively, with mortality milestones to control for the increase in life expectancy over time. The study reveals a systematic reversal of the gradient that occurred around the 1970s for both sexes and all ages or mortality groups when calculated at an aggregated level. Inequality in mortality amongst the oldest age groups has however returned to a level observed at least ten years earlier because of Covid-19, even after controlling for mortality improvements over the period.

The "Quiet Revolution" and the cesarean section in the United States

This paper estimates how changes in family structure and women's labor market attachment during the last fifty years have affected the incidence of cesarean delivery in the United States. Both sets of factors are strongly related to cesarean utilization, and have generally changed so as to increase the rate of cesarean delivery over time. Altogether, changes in these factors, complemented by demographic changes, raised the U.S. cesarean section rate by eleven percentage points since the late 1970s, nearly two-thirds of the increase over that period. Today's elevated cesarean section rate is in part a social phenomenon.

Mortality during Resource Booms and Busts

Using national data on county-level mortality, coal mining, and shale development, we examine the effects of resource booms and busts on mortality in the United States. We find evidence that decreases in operating coal mines increased total all-cause mortality, non-drug mortality, and opioid overdose mortality, especially for counties with greater than 10 operating coal mines in 2000. Our model results for drug overdose mortality and opioid overdose mortality are sensitive to the panel's start year. For shale development, the shale boom is associated with increases in non-drug suicides but otherwise had little impact on mortality. Our findings suggest a potential role for job-training programs and the cultivation of local healthcare resources in regions suffering coal busts and suicide prevention in areas with shale development.

Does unemployment worsen babies' health? A tale of siblings, maternal behaviour, and selection

We study in-utero exposure to economic fluctuations on birth outcomes by exploiting geographical variation in the unemployment rate across local areas in England, and by comparing siblings born to the same mother. Using rich individual data from hospital administrative records for 2003-2012, babies' health is found to be strongly pro-cyclical. This overall result masks marked differences between babies born in the most affluent areas whose health at birth improves in a recession, and babies born in the average-to-lowest income deprived areas whose health deteriorates. Maternal alcohol consumption, smoking, and delay in the first antenatal care assessment - combined with parental income loss, are found to drive the results. While differences in maternal risky behaviours can explain the heterogenous effects.

Urban scaling of opioid overdose deaths in the USA: a cross-sectional study in three periods between 2005 and 2017

OBJECTIVES

To describe the association between population size, population growth and opioid overdose deaths-overall and by type of opioid-in US commuting zones (CZs) in three periods between 2005 and 2017.

SETTINGS

741 CZs covering the entirety of the US CZs are aggregations of counties based on commuting patterns that reflect local economies.

PARTICIPANTS

We used mortality data at the county level from 2005 to 2017 from the National Center for Health Statistics.

OUTCOME

Opioid overdose deaths were defined using underlying and contributory causes of death codes from the International Classification of Diseases, 10th revision (ICD-10). We used the underlying cause of death to identify all drug poisoning deaths. Contributory cause of death was used to classify opioid overdose deaths according to the three major types of opioid, that is, prescription opioids, heroin and synthetic opioids other than methadone.

RESULTS

Opioid overdose deaths were disproportionally higher in largely populated CZs. A CZ with 1.0% larger population had 1.10%, 1.10%, and 1.16% higher opioid death count in 2005-2009, 2010-2014, and 2015-2017, respectively. This pattern was largely driven by a high number of deaths involving heroin and synthetic opioids, particularly in 2015-2017. Population growth over time was associated with lower age-adjusted opioid overdose mortality rate: a 1.0% increase in population over time was associated with 1.4% (95% CI: -2.8% to 0.1%), 4.5% (95% CI: -5.8% to -3.2%), and 1.2% (95% CI: -4.2% to 1.8%) lower opioid overdose mortality in 2005-2009, 2010-2014, and 2015-2017, respectively. The association between positive population growth and lower opioid mortality rates was stronger in larger CZs.

CONCLUSIONS

Opioid overdose mortality in the USA was disproportionately higher in mid-sized and large CZs, particularly those affected by declines in population over time, regardless of the region where they are located.

Macroeconomic conditions and health-related outcomes in the United States: A metropolitan and micropolitan statistical area-level analysis between 2004 and 2017

We study the relationship between macroeconomic conditions and health in the United States using data from the Behavioral Risk Factor Surveillance System between 2004 and 2017. Unlike many existing studies that use state or county as the level of aggregation, our analysis uses a sample of metropolitan and micropolitan statistical areas. Our results suggest strong associations between worsening macroeconomic conditions and reduced access to care and health insurance coverage. While we do not detect any robust relationships between business cycles and health outcomes in the general population, we do find consistent evidence of worse self-reported health during economic downturns among minorities and less-educated individuals. In addition, there is some suggestive evidence of countercyclicality of healthier lifestyle choices. However, the findings for health behavior outcomes are not robust to adjusting for multiple hypothesis testing.

The effect of gender-specific labor market conditions on children's weight

BACKGROUND

Macroeconomic conditions are widely known to influence health outcomes through direct behavioral change or indirect mental effects of individuals. However, they have not received much attention in relation to childhood obesity.

METHODS

Using gender-specific predicted employment growth rates as an index for labor market conditions, we analyze how economic shocks affect children's weight status in Arkansas. To understand the underlying mechanisms behind these results, we use data on individual time use to examine how economic shocks are related to activities related to children's weight.

RESULTS

Improvement in the female labor market is associated with an increase in body mass index (BMI) and the probability that a child is overweight or obese, while an improvement in the male labor market has no significant effects on children's weight. This impact is particularly evident among female children, older children, and African-American children. We also find a negative effect of improvements in the female labor market on time spent on preparation for foods at home.

CONCLUSIONS

These results suggest that a decrease in time spent preparing home-cooked foods might be a plausible explanation for the pro-cyclical relationship between children's weight and improvement in the labor market conditions. Thus, the policy implications of our paper should be aimed at mitigating the adverse effects of women's labor participation.

The business cycle, health behavior, and chronic disease: A study over Three decades

The effect of macroeconomic fluctuations on individual health remains highly debated. We estimate the effect of the business cycle on health and health behavior in the U.S. using the NLSY79 panel data for 11,406 respondents between 1979 and 2014. Most of our survey respondents have no chronic illness in 1979, and develop these conditions during the sample period. This allows us to estimate the true effect of economic fluctuation on the likelihood of developing chronic conditions. The results indicate a considerable difference in the cyclic variation of chronic diseases. After controlling for innate individual characteristics such as family health history, and unobserved regional characteristics, we find that obesity decreases during economic downturns, while diabetes, hypertension, and congestive heart failure increase. Sub-sample analyses show that Blacks are more likely to develop diabetes and hypertension and are less likely to develop obesity during economic downturns than other racial groups. The incidence of obesity declines during recessions for women, while males are more likely to develop diabetes. Income loss, particularly among Blacks, and lack of change in physical activity mediate these differential effects.

The effects of trade-induced worker displacement on health and mortality in Mexico

Recent research in the U.S. links trade-induced job displacement to deaths of despair. Should we expect the same mortality response in developing countries? This paper analyzes the effect of a trade-induced negative shock to manufacturing employment on leading causes of mortality in Mexico between 1998 and 2013. I exploit cross-municipality variation in trade exposure based on differences in industry specialization before China's accession to the WTO in 2001 to identify labor-demand shocks that are concentrated in manufacturing. I find trade-induced job loss increased mortality from diabetes, raised obesity rates, reduced physical activity, and lowered access to health insurance. These deaths were offset by declines in mortality from ischemic heart disease and chronic pulmonary disease. These findings highlight that negative employment shocks have heterogeneous impacts on mortality in developing countries, where falling incomes lead to less access to health care and nutritious food, but also reduce alcohol and tobacco use.

New(spaper) evidence of a reduction in suicide mentions during the 19th century US gold rush

I analyze the relationship between state-level economic shocks and suicides using gold mined in the United States (US) between 1840 and 1860 as a large unexpected economic shock. Mined gold was an unexpected and large economic shock of up to 3.5% of GDP. This provides as good as random variation to the local economy that I use to estimate the effect of economic changes on suicides. Comprehensive mortality data by state and year does not exist for the US for 1840-1860. Thus, I use web-scraped data from a newspaper archive and use suicide mentions per 100,000 pages to proxy for suicides. Overall, results show that mined gold is linked with an apparent reduction in newspaper suicide mentions in line with previous research.

Rising unemployment reduces the demand for healthcare services among people with cardiovascular disease: an Australian cohort study

Cardiovascular diseases (CVDs) remain a global health challenge due to number of deaths and use of healthcare services related to the condition. Although a plethora of studies have shown the impact of unemployment on health outcomes, evidence on the unemployment effects on the demand for expensive cardiac healthcare services is rare. This study exploits longitudinal cohort dataset to examine the impact of variations in local level unemployment rate on the demand for healthcare services among working aged people with CVD in Australia. Our findings show an inverse relationship between unemployment and the demand for healthcare services. Specifically, we find that a rising unemployment reduces the demand for primary and secondary healthcare services, with the largest effect observed for hospital admissions and hospitalisation days. We further show that rising unemployment at the local level has a greater impact on CVD patients with comorbidities and those who live in nonremote areas. Finally, our estimates suggest that increasing local level unemployment averts a substantial number of healthcare services use, leading to an unintended cost savings of $1.2 million to the health sector.

Did Medicaid slow declines in access to health care during the great recession?

Objective

We examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007‐2009 Great Recession.

Data Source

2004‐2010 Behavioral Risk Factor Surveillance System (BRFSS).

Study Design

Flexible difference‐in‐difference regressions were used to compare the impact of county‐level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines.

Data Collection/Extraction Methods

Nonelderly adults (aged 19‐64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics’ Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state's 2007 Medicaid guidelines using data from the 2007 Current Population Survey's Annual Social and Economic Supplement.

Principal Findings

A percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9‐1.6, P < .01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6‐1.1, P < .01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P < .01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county‐level unemployment were associated with a 0.68 PPT (P < .10) increase in unmet medical needs due to cost—a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines.

Conclusions

Increased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income.

The economic underpinnings of the drug epidemic

U.S. labor markets have experienced transformative change over the past half century. Spurred on by global economic change, robotization, and the decline of labor unions, state labor markets have shifted away from an occupational regime dominated by the production of goods to one characterized by the provision of services. Prior studies have proposed that the deterioration of employment opportunities may be associated with the rise of substance use disorders and drug overdose deaths, yet no clear link between changes in labor market dynamics in the U.S. manufacturing sector and drug overdose deaths has been established. Using restricted-use vital registration records between 1999 and 2017 that comprise over 700,000 drug deaths, I test two questions: First, what is the association between manufacturing decline and drug and opioid overdose mortality rates? Second, how much of the increase in these drug-related outcomes can be predicted by manufacturing decline? The findings provide strong evidence that the restructuring of the U.S. labor market has played an important upstream role in the current drug crisis. Up to 92,000 overdose deaths for men and up to 44,000 overdose deaths for women are predicted by the decline of state-level manufacturing over this nearly two-decade period. These results persist in models that adjust for other social, economic, and policy trends changing at the same time. Critically, the findings signal the value of policy interventions that aim to reduce persistent economic precarity experienced by individuals and communities, especially the economic strain placed upon the middle class.

Economy-Sensitive Conditions: Are Some Pediatric Hospitalizations Triggered By Economic Recessions?

The impact of economic recessions on child health is complex and varied. Here we examine associations between county-level unemployment and pediatric hospitalizations in fourteen states every third year from 2002 to 2014. After adjusting for state-specific effects of unemployment across all counties and years, we found that increased unemployment was associated with increased pediatric hospitalizations for four potentially economy-sensitive conditions, such that a 1 percent increase in unemployment was associated with a 5 percent increase in hospitalizations for substance abuse, a 4 percent increase for diabetes mellitus, and a 2 percent increase both for children with medical complexity and for poisoning and burns. Mean pediatric all-cause hospitalizations increased by 2 percent for every 1 percent increase in unemployment (or 54,177 excess hospitalizations in 2011 compared with 2005). Hospitalizations for mental health, despite the increased severity of these conditions during recessions, were not associated with unemployment. Further research is needed to examine potential federal, state, and local policies that may mitigate the influence of unemployment on child health and pediatric hospitalizations.

Austerity, healthcare provision, and health outcomes in Spain

The recession that started in the United States in December 2007 has had a significant impact on the Spanish economy through a large increase in the unemployment rate and a long recession which led to tough austerity measures imposed on public finances. Taking advantage of this quasi-natural experiment, we use data from the Spanish Ministry of Health from 1996 to 2015 to provide novel causal evidence on the short-term impact of changes in healthcare provision and regulations on health outcomes. The fact that regional governments have discretionary powers in deciding healthcare budgets and that austerity measures have not been implemented uniformly across Spain helps isolate the impact of these policy changes on health indicators of the Spanish population. Using Ruhm's (Q J Econ 115(2):617-650, 2000) fixed effects model, we find that medical staff and hospital bed reductions account for a significant increase in mortality rates from circulatory diseases and external causes, but not from other causes of death. Similarly, mortality rates do not seem to be robustly affected by the 2012 changes in retirees' pharmaceutical co-payments and access restrictions for illegal immigrants. Our results are robust to changes in model specification and sample selection and are primarily driven by accidental and emergency deaths rather than in-hospital mortality, which suggests a larger role for decreases in accessibility rather than decreases in healthcare quality as impact channels.

Global hotspots and future prospects of chimeric antigen receptor T-cell therapy in cancer research: a bibliometric analysis

Aim: Our study aimed to analyze the characteristics of papers published on CAR T-cell in the field of cancer and explore the existing hot topics and prospects. Materials & methods: We explored the global hotspots and future prospects regarding CAR T-cell therapy in cancer research. Papers of CAR T-cell research were retrieved from the Web of Science database. Analysis was performed using VOSviewer, CiteSpace and Excel software. Results: A total number of 1994 papers related to CAR T-cell research of cancer were included. Molecular Therapy published the most papers (n = 85, 4.26%). A total of 9792 authors participated in the publication of all papers. 62 countries and 2065 institutions have participated in the publication of all papers. Conclusion: Research trends are to improve the immunosuppressive microenvironment of cancer, optimize the structure of CAR T-cells and develop ‘super CAR T-cell’ by using gene-editing technology.

Mortality and Macroeconomic Conditions: What Can We Learn From France?

This study uses aggregate panel data on French départements to investigate the relationship between macroeconomic conditions and mortality from 1982 to 2014. We find no consistent relationship between macroeconomic conditions and all-cause mortality in France. The results are robust across different specifications, over time, and across different geographic levels. However, we find that heterogeneity across age groups and mortality causes matters. Furthermore, in areas with a low average educational level, a large population, and a high share of migrants, mortality is significantly countercyclical. Similar to the case in the United States, the relationship between the unemployment rate and mortality seems to have moved from slightly procyclical to slightly countercyclical over the period of analysis.

How do economic downturns affect the mental health of children? Evidence from the National Health Interview Survey

Research linking economic conditions and health often does not consider children's mental health problems, which are the most common and consequential health issues for children and adolescents. We examine the effects of unemployment rates and housing prices on well-validated child and adolescent mental health outcomes and use of special education services for emotional problems in the 2001-2013 National Health Interview Survey. We find that the effects of economic conditions on children's mental health are clinically and economically meaningful; children's mental health outcomes worsen as the economy weakens. The effects of economic conditions on child and adolescent mental health are pervasive, found in almost every subgroup that we examine. The use of special education services for emotional problems also rises when economic conditions worsen. Our analyses of possible mechanisms that link economic conditions to child mental health suggest that parental unemployment cannot fully explain the relationship between economic conditions and child mental health.

Economic Downturns and Inequities in Birth Outcomes: Evidence From 149 Million US Births

Using birth certificate data for nearly all registered US births from 1976 to 2016 and monthly data on state unemployment rates, we reexamined the link between macroeconomic variation and birth outcomes. We hypothesized that economic downturns reduce exposure to work-related stressors and pollution while increasing exposure to socioeconomic stressors like job loss. Because of preexisting inequalities in health and other resources, we expected that less-educated mothers and black mothers would be more exposed to macroeconomic variation. Using fixed-effect regression models, we found that a 1-percentage-point increase in state unemployment during the first trimester of pregnancy increased the probability of preterm birth by 0.1 percentage points, while increases in the state unemployment rate during the second/third trimester reduced the probability of preterm birth by 0.06 percentage points. During the period encompassing the Great Recession, the magnitude of these associations doubled in size. We found substantial variation in the impact of economic conditions across different groups, with highly educated white women least affected and less-educated black women most affected. The results highlight the increased relevance of economic conditions for birth outcomes and population health as well as continuing, large inequities in the exposure and impact of macroeconomic fluctuations on birth outcomes.

Economic conditions during pregnancy and preterm birth: A maternal fixed-effects analysis

BACKGROUND

Making causal inference regarding impacts of macrolevel economic conditions during pregnancy on pregnancy outcomes is hampered by the presence of unmeasured variables that may influence women's probability of giving birth under certain economic conditions (ie, exposure) as well as her pregnancy outcomes. Maternal fixed-effects (FE) analyses, in which the association between exposure and outcomes is estimated within mothers who had discordant outcomes, can control for such unmeasured variables when they are invariant across pregnancies.

METHODS

We utilised a maternally linked data set of all singleton births in Michigan from 1990 to 2012 (n = 2 657 272 for full sample; n = 269 943 for FE analytic sample) to examine the relationship between state-level unemployment rates during pregnancy and preterm birth (PTB, <37 weeks' gestation). Measured maternal characteristics that change across pregnancies, for example, age, marital status, education, parity, and infant sex, were included as covariates in the model.

RESULTS

Using an FE approach, we found that each one percentage point increase in state unemployment in the first trimester of pregnancy was associated with a modest 3% increase in odds of PTB. Our results were consistent with previously published results in a national sample and held across random- versus fixed-effect models, analytic samples, and outcome measures.

CONCLUSIONS

Our findings provide further evidence that economic downturn during early pregnancy may be associated with modest increases in PTB.

The Great Recession and Children's Mental Health in Australia

This paper analyzes the effects of “shocks” to community-level unemployment expectations, induced by the onset of the Great Recession, on children’s mental well-being. The Australian experience of the Great Recession represents a unique case study as despite little change in actual unemployment rates, levels of economic uncertainty grew. This affords us the ability to examine the effects of shocks to economic expectations independent of any actual changes to economic conditions. We draw on and link data from multiple sources, including several waves of the Longitudinal Study of Australian Children (2004–2010), a consumer sentiment survey, and data on local economic conditions. Using our purpose-built data set, we estimate difference-in-differences models to identify plausibly causal effects. We find, for boys, there is no detectable effect of community-level unemployment expectations shocks on mental health. For girls, however, there are modest increases in mental health problems and externalizing behaviors, as measured by the Strengths and Difficulties Questionnaire (SDQ). We additionally find no discernible change in mother’s psychological distress as a result of expectations shocks. These results are stable after controlling for actual labor market conditions.

Effect of the Great Recession on regional mortality trends in Europe

Previous studies have consistently shown the recurrent relationship between macroeconomic cycles and changes in mortality trends, so that recessions are generally associated with periods of faster life expectancy rise, and periods of economic growth with slower reductions or even increases in mortality trends. Here we analyze the link between annual per capita estimates of gross domestic product and daily atmospheric temperatures and standardized death rates for a large ensemble of European regions to describe the effect of the Great Recession on annual and seasonal changes in all-cause human mortality trends. Results show that the countries and regions with the largest (smallest) economic slowdown were also those with the largest (smallest) strengthening of the declining mortality trend. This procyclical evolution of mortality rates is found to be stronger during the cold part of the year, showing that it also depends on the seasonal timing of the underlying causes of death.

Cardiovascular Risk Factors, Depression, and Alcohol Consumption During Joblessness and During Recessions Among Young Adults in CARDIA

Research has shown that recessions are associated with lower cardiovascular mortality, but unemployed individuals have a higher risk of cardiovascular disease (CVD) or death. We used data from 8 consecutive examinations (1985-2011) of the Coronary Artery Risk Development in Young Adults (CARDIA) cohort, modeled in fixed-effect panel regressions, to investigate simultaneously the associations of CVD risk factors with the employment status of individuals and the macroeconomic conditions prevalent in the state where the individual lives. We found that unemployed individuals had lower levels of blood pressure, high-density lipoprotein cholesterol, and physical activity, and they had significantly higher depression scores, but they were similar to their counterparts in smoking status, alcohol consumption, low-density lipoprotein cholesterol levels, body mass index, and waist circumference. A 1-percentage-point higher unemployment rate at the state level was associated with lower systolic (-0.41 mm Hg, 95% CI: -0.65, -0.17) and diastolic (-0.19, 95% CI: -0.39, 0.01) blood pressure, higher physical activity levels, higher depressive symptom scores, lower waist circumference, and less smoking. We conclude that levels of CVD risk factors tend to improve during recessions, but mental health tends to deteriorate. Unemployed individuals are significantly more depressed, and they likely have lower levels of physical activity and high-density lipoprotein cholesterol.

Health and health inequality during the great recession: Evidence from the PSID

We estimate the impact of the Great Recession of 2007-2009 on health outcomes in the United States. We show that a one percentage point increase in the unemployment rate resulted in a 7.8-8.8% increase in reports of poor health. In addition, mental health was adversely impacted. These effects were concentrated among those with strong labor force attachments. Whites, the less educated, and women were the most impacted demographic groups.

Macroeconomic conditions and health: Inspecting the transmission mechanism

We study the relationship between macroeconomic conditions and self-reported health in a large sample of Italian individuals, focusing on the mediating role played by health behaviors (smoking, alcohol consumption, physical activity, eating habits) and economic stress. Our findings indicate that, overall, higher local unemployment is negatively related to individuals' health conditions. A one percentage point increase in the province-level unemployment rate is associated with a significant increase in the probability of experiencing diabetes (0.03 percentage points), infarction (0.01), ulcer (0.06), cirrhosis (0.01) and nervous disorders (0.07), with a time lag that differs across individual health conditions. Employment status and educational level play a significant role as moderators of these relationships. Eating habits, in addition to economic stress, play a key role as mediators, by enhancing the negative relationship between macroeconomic conditions and health outcomes, while physical exercise is found to play a dampening role.

Mortality and the business cycle: Evidence from individual and aggregated data

There has been much interest recently in the relationship between economic conditions and mortality, with some studies showing that mortality is pro-cyclical, while others find the opposite. Some suggest that the aggregation level of analysis (e.g. individual vs. regional) matters. We use both individual and aggregated data on a sample of 20-64 year-old Swedish men from 1993 to 2007. Our results show that the association between the business cycle and mortality does not depend on the level of analysis: the sign and magnitude of the parameter estimates are similar at the individual level and the aggregate (county) level; both showing pro-cyclical mortality.

Population health and the economy: Mortality and the Great Recession in Europe

We analyze the evolution of mortality-based health indicators in 27 European countries before and after the start of the Great Recession. We find that in the countries where the crisis has been particularly severe, mortality reductions in 2007-2010 were considerably bigger than in 2004-2007. Panel models adjusted for space-invariant and time-invariant factors show that an increase of 1 percentage point in the national unemployment rate is associated with a reduction of 0.5% (p < .001) in the rate of age-adjusted mortality. The pattern of mortality oscillating procyclically is found for total and sex-specific mortality, cause-specific mortality due to major causes of death, and mortality for ages 30-44 and 75 and over, but not for ages 0-14. Suicides appear increasing when the economy decelerates-countercyclically-but the evidence is weak. Results are robust to using different weights in the regression, applying nonlinear methods for detrending, expanding the sample, and using as business cycle indicator gross domestic product per capita or employment-to-population ratios rather than the unemployment rate. We conclude that in the European experience of the past 20 years, recessions, on average, have beneficial short-term effects on mortality of the adult population.

Macroeconomic conditions and opioid abuse

We examine how deaths and emergency department (ED) visits related to use of opioid analgesics (opioids) and other drugs vary with macroeconomic conditions. As the county unemployment rate increases by one percentage point, the opioid death rate per 100,000 rises by 0.19 (3.6%) and the opioid overdose ED visit rate per 100,000 increases by 0.95 (7.0%). Macroeconomic shocks also increase the overall drug death rate, but this increase is driven by rising opioid deaths. Our findings hold when performing a state-level analysis, rather than county-level; are primarily driven by adverse events among whites; and are stable across time periods.

Economic Conditions During Pregnancy and Adverse Birth Outcomes Among Singleton Live Births in the United States, 1990-2013

We know little about the relationship between the macroeconomy and birth outcomes, in part due to the methodological challenge of distinguishing effects of economic conditions on fetal health from effects of economic conditions on selection into live birth. We examined associations between state-level unemployment rates in the first 2 trimesters of pregnancy and adverse birth outcomes, using natality data on singleton live births in the United States during 1990-2013. We used fixed-effect logistic regression models and accounted for selection by adjusting for state-level unemployment before conception and maternal characteristics associated with both selection and birth outcomes. We also tested whether associations between macroeconomic conditions and birth outcomes differed during and after (compared with before) the Great Recession (2007-2009). Each 1-percentage-point increase in the first-trimester unemployment rate was associated with a 5% increase in odds of preterm birth, while second-trimester unemployment was associated with a 3% decrease in preterm birth odds. During the Great Recession, however, first-trimester unemployment was associated with a 16% increase in odds of preterm birth. These findings increase our understanding of the effects of the Great Recession on health and add to growing literature suggesting that macro-level social and economic factors contribute to perinatal health.

Recessions and health revisited: New findings for working age adults

A series of influential papers have documented that state level mortality rates decrease during economic downturns. In this paper, we estimate the effect of education specific unemployment rates on mortality, which provide a more exact measure of the likelihood of being directly impacted by a recession. We find that the unemployment rate of an education group in a given state is positively related to mortality in that group. A 1% increase in the group-specific unemployment rate is associated with an approximately 0.015% increase in the group-specific mortality rate, which is consistent with the hypothesis that, while state-level unemployment may have indirect health benefits, being personally affected by a recession has a detrimental effect on health.

Did the Great Recession affect mortality rates in the metropolitan United States? Effects on mortality by age, gender and cause of death

OBJECTIVES

Mortality rates generally decline during economic recessions in high-income countries, however gaps remain in our understanding of the underlying mechanisms. This study estimates the impacts of increases in unemployment rates on both all-cause and cause-specific mortality across U.S. metropolitan regions during the Great Recession.

METHODS

We estimate the effects of economic conditions during the recent and severe recessionary period on mortality, including differences by age and gender subgroups, using fixed effects regression models. We identify a plausibly causal effect by isolating the impacts of within-metropolitan area changes in unemployment rates and controlling for common temporal trends. We aggregated vital statistics, population, and unemployment data at the area-month-year-age-gender-race level, yielding 527,040 observations across 366 metropolitan areas, 2005-2010.

RESULTS

We estimate that a one percentage point increase in the metropolitan area unemployment rate was associated with a decrease in all-cause mortality of 3.95 deaths per 100,000 person years (95%CI -6.80 to -1.10), or 0.5%. Estimated reductions in cardiovascular disease mortality contributed 60% of the overall effect and were more pronounced among women. Motor vehicle accident mortality declined with unemployment increases, especially for men and those under age 65, as did legal intervention and homicide mortality, particularly for men and adults ages 25-64. We find suggestive evidence that increases in metropolitan area unemployment increased accidental drug poisoning deaths for both men and women ages 25-64.

CONCLUSIONS

Our finding that all-cause mortality decreased during the Great Recession is consistent with previous studies. Some categories of cause-specific mortality, notably cardiovascular disease, also follow this pattern, and are more pronounced for certain gender and age groups. Our study also suggests that the recent recession contributed to the growth in deaths from overdoses of prescription drugs in working-age adults in metropolitan areas. Additional research investigating the mechanisms underlying the health consequences of macroeconomic conditions is warranted.

Economic conditions, illicit drug use, and substance use disorders in the United States

We provide the first analysis of the relationship between economic conditions and the use of illicit drugs other than marijuana. Drawing on US data from 2002 to 2015, we find mixed evidence on the cyclicality of illicit drug use. However, we find robust evidence that economic downturns lead to increases in the intensity of prescription pain reliever use as well as increases in clinically relevant substance use disorders involving opioids. These effects are concentrated among working-age white males with low educational attainment. We conclude that policymakers should consider devoting more, not fewer, resources to treating substance use disorders during economic downturns.

BAD TIMES, SLIMMER CHILDREN?

Although the majority of the literature has confirmed that recessions are beneficial for adults' health and babies' outcomes at delivery, this effect should not necessarily be the same for children. In this paper, we study the effect of business cycle conditions on infant underweight, overweight, and obesity. We exploit eight waves of repeated cross-sectional data (1987-2012) of the Spanish National Health Survey for children aged 2-15 and use the regional unemployment rate of the trimester of the interview as a proxy for the business cycle phase at the local level. We find that an increase in the unemployment rate is associated with lower obesity incidence, especially for children under 6 years old and over 12 years old. However, economic shocks also proof to have potentially negative consequences as they increase the prevalence of infant underweight for the same age groups. Moreover, we show that the possible mechanisms through which the cycle is impacting infant obesity is the nutritional composition of the children's diet, as well as, increases in the frequency of exercise. We provide some evidence that suggests that the impact of business cycle conditions on infant weight disorders have little objective health consequences in the short run. However, the potential long-term effects may become important as underweight during childhood is associated with worse outcomes later in life. Copyright © 2016 John Wiley & Sons, Ltd.

Health Effects of Economic Crises

This analysis summarizes prior research and uses national, US state and county-level data from 1976 to 2013 to examine whether the mortality effects of economic crises differ in kind from those of the more typical fluctuations. The tentative conclusion is that economic crises affect mortality rates (and presumably other measures of health) in the same way as less severe downturns - leading to improvements in physical health. The effects of severe national recessions in the USA appear to have a beneficial effect on mortality that is roughly twice as strong as that predicted by the elevated unemployment rates alone, while the higher predicted rate of suicides during typical periods of economic weakness is approximately offset during severe recessions. No consistent pattern is obtained for more localized economic crises occurring at the state level - some estimates suggest larger protective mortality effects while others indicate offsetting deleterious consequences. Copyright © 2016 John Wiley & Sons, Ltd.

Health Effects of Short-Term Fluctuations in Macroeconomic Conditions: The Case of Hypertension for Older Americans

We investigate the health effects of short-term macroeconomic fluctuations as described by changes in unemployment rate, house, and stock market price indexes. The 'Great Recession' provides the opportunity to conduct this analysis as it involved contemporaneous shocks to the labor, housing, and stock markets. Using panel data from the Health and Retirement Study over the period 2004-2010, we relate changes in hypertension status to changes in state-level unemployment rate and house prices and to changes in stock market prices. We consider hypertension, a disease related to stress and of high prevalence among older adults, that has received little attention in the literature linking macroeconomic conditions to individual health. Our analysis exploits self-reports of hypertension diagnosis as well as directly measured blood pressure readings. Using both measures, we find that the likelihood of developing hypertension is negatively related to changes in house prices. Also, decreasing house prices lower the probability of stopping hypertension medication treatment for individuals previously diagnosed with the condition. We do not observe significant associations between hypertension and either changes in unemployment rate or stock market prices. We document heterogeneity in the estimated health effects of the recession by gender, education, asset ownership, and work status. Copyright © 2016 John Wiley & Sons, Ltd.

Recessions, healthy no more?

Over the 1976-2010 period, total mortality shifted from strongly procyclical to being weakly or unrelated to macroeconomic conditions. The association is likely to be poorly measured when using short (less than 15 year) analysis periods. Deaths from cardiovascular disease and transport accidents continue to be procyclical; however, countercyclical patterns have emerged for fatalities from cancer mortality and external causes. Among the latter, non-transport accidents, particularly accidental poisonings, play an important role.