Associate Professor Maclean, who recently became a Co-Editor at the Journal of Policy Analysis and Management (JPAM), has two recent papers in this journal. The objective of JPAM is to publish and disseminate high-quality and timely policy-relevant work.
Title: The effect of medical marijuana laws on the labor supply and health of older adults: Evidence from the Health and Retirement Study
Authors: Lauren Hersh Nicolas and Johanna Catherine Maclean
Summary: Legalization of medical marijuana is highly controversial in the United States. While federal law prohibits the use of marijuana for any purpose, 34 states – beginning with California in 1996 – permit legal medical use of this substance for patients meeting specific criteria. Advocates contend that medical marijuana offers an effective medication that allows patients to treat painful symptoms associated with chronic and acute health conditions for which traditional medications and procedures are unable to adequately manage. Critics argue that legalization will result in recreation, not medical, use of marijuana and, in turn, cause substance use disorders, crime and violence, and other social ills.
A number of studies have examined the effect of state legalization of medical marijuana laws (‘MMLs’) on marijuana use, use of other substances (e.g., alcohol and cocaine), use of related healthcare (e.g., prescription medications that are used to treat symptoms for which marijuana is often used), health outcomes (e.g., days in poor mental health), and crime (e.g., traffic accidents). Overall, these studies suggest that MMLs lead to both increased medical and recreational marijuana use, and improve many, but not all, health outcomes, suggesting a complex relationship between legal access to marijuana and social outcomes.
There are no studies, however, that examine how legal access to marijuana conferred through MMLs affects older adults. Older adults are important to study as this group is much more likely to experience health conditions with symptoms which can be effectively treated with medical marijuana based on clinical trial evidence (e.g., chronic pain). Further, older adults are at elevated risk of leaving the labor market due to poor health. Given the health conditions experienced by older adults and associated implications for labor market attachment, failure to study MML effects on older adults represents an important omission within the literature.
Our study seeks to address the above-noted dearth. We use data on older adults, defined as those ages 51 years and above, from the Health and Retirement Study to examine the effects of MMLs on health and labor supply over the period 1992 to 2012. We find that when a state adopts an MML older adult self-assessed health improves, chronic pain declines, and labor supply – measured as the number of hours worked per week and propensity to work fulltime – increases. In terms of labor supply, our findings imply that while MMLs do not prompt retired workers to return to the labor market, MMLs allow working older adults to work more. Using unique data on health histories available within the Health and Retirement Study, we show that our effects are driven by older adults most likely to use medical marijuana to treat health condition symptoms. These findings offer new evidence on the full effects of state legalization of marijuana for medical purposes.
Title: The effect of public insurance expansions on substance use disorder treatment: Evidence from the Affordable Care Act
Authors: Johanna Catherine Maclean and Brendan Saloner
Summary: Problems associated with substance use disorders (SUDs) are a major public health concern within the United States. SUDs are clinical conditions that impose substantial costs on both the individual and on greater society. For the individual, SUDs impede health, interpersonal relationships, and employment, and in some cases can lead to incarceration and even death. The costs to society – which represent increased healthcare and social service costs, a less productive labor force, and criminal justice system costs – are over $500B each year. SUDs are common, in 2016 over 20M individuals in the U.S. met diagnostic criteria for an SUD. Indeed, the U.S. is in the midst of an unprecedented illicit drug epidemic, largely related to opioids. Each day over 115 Americans die from an opioid-related overdose, representing a quadrupling of the death rate since 1999. Moreover, the prevalence rate varies across demographic groups with lower income and uninsured populations at elevated risk for an SUD.
While effective treatment is available, only one in ten individuals who would benefit from such treatment receive any care each year. While there are a wide range of reasons for not receiving care, a commonly cited reason is lack of insurance coverage and inability to pay for treatment. The Affordable Care Act (ACA) of 2010 represents a major transformation of the healthcare delivery system. Health scholars note that no health condition is likely to be more affected by this historic Act than SUDs. Of particular relevance for SUDs is Medicaid expansion. Medicaid, which is jointed funded and operated by state and federal governments, is the primary insurer of poor people in the U.S. However, prior to the ACA, in most states Medicaid covered only poor parents and the disabled. Many individuals, regardless of their income level and health needs, were not eligible for Medicaid. The ACA provided additional funding for states to expand Medicaid to all individuals with income up to 138% of the Federal Poverty Level (FPL). As of February 2019, 37 states (including DC) have expanded Medicaid. Medicaid generously covers a wide-range of SUD treatments. For many ‘newly eligible’ individuals, Medicaid expansion offers access to insurance for the first time and this population has elevated rates of SUDs.
We study the effect of Medicaid expansion on use and financing of SUD treatment using government data on use of specialty treatment (e.g., inpatient rehabilitation services) and medications obtained in outpatient settings (e.g., private doctors’ offices) to treat SUDs. We find that, after a state expands Medicaid in conjunction with the ACA, treatment use increases and treatment financing shifts from state and local governments – which provided the majority of funding for SUD treatment through targeted grants historically – to Medicaid programs.
In summary, our findings suggest that Medicaid expansion allowed more people to receive treatment for their SUDs and that the financing of this treatment was provided by state and federal governments through Medicaid programs. Given the very low incomes of individuals who gained Medicaid eligibility through the ACA expansions – 138% of FPL for a family of two is roughly $23,000 per year – this change in financing likely offers critical financial protection for vulnerable members of society. Further, this new treatment utilization plausibly reduces SUDs within the population and reduces social costs.