Three Essays in Health Economics

State governments play a major role in the United States health care market. Moreover, states administer much of the regulation, budgeting, and policy for their own markets, which creates idiosyncratic differences across states. This dissertation contributes to the literature by evaluating those differences to analyze the effectiveness of certain regulations and policies and to explore the relationship between state health care markets and other state obligations. The first chapter uses state differences in the nurse practitioner (NP) market to evaluate the effects of state laws allowing NPs to prescribe controlled substances on prescription opioid use. I study these effects by merging nationwide data from the Medical Expenditure Panel Survey (MEPS) over 18 years (1996-2013) with data on state laws. I then exploit variation in these laws over time to create a quasi-natural experiment and to estimate the causal impact of NP deregulation on prescription opioid use. I find, relative to patients living in more restrictive states, that patients who live in states with more flexible NP laws emph{reduce} their prescription opioid use by 7 percent to 9 percent. I also find that health outcomes either slightly improve or remain unaffected by the enactment of these laws. Taken together, these results indicate that NP deregulation slows the trend in prescription opioid growth while potentially improving patient outcomes. Furthermore, suggestive evidence implies that these effects may be even larger for the least restrictive states, opening the door for future reforms. The second chapter (co-authored with Andrew Litten) seeks to identify the causal relationship between increased state Medicaid obligations and higher education spending. After several decades of federal mandates and high rates of health cost inflation, Medicaid spending has taken an increasingly larger share of state budgets, forcing states to make offsetting cuts elsewhere. We argue that state governments are likely to cut higher education in response to these changes, as institutions of higher education have the capacity to find additional revenues elsewhere. We use federally administered Supplemental Security Income (SSI) enrollments to instrument for state Medicaid spending. We find that a one dollar increase in Medicaid costs leads to a decrease in higher education subsidies of 20 cents to 37 cents. Our approach provides estimates which are both more credible and more precise than those which have previously been used in the literature. The third chapter studies the effectiveness of Prescription Drug Monitoring Programs (PDMPs). These programs are widely considered to be a promising tool for preventing prescription opioid misuse. Using a nationally representative sample that spans the majority of PDMP implementation, I find little evidence that PDMP implementation is effective in preventing prescription opioid misuse. Nonetheless, I find that when states pair PDMPs with policies mandating health care provider use ("must access" laws), they can successfully reduce high-volume opioid prescriptions. States that add "must access" laws reduce high-volume prescriptions by about 20 percent. In addition, these states do not appear to affect overall prescribing behavior, suggesting that PDMPs with "must access" laws can target potential misuse without hindering medically appropriate access.PHDEconomicsUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttps://deepblue.lib.umich.edu/bitstream/2027.42/138556/1/hamiltmr_1.pd

The Magnetic Field of the Solar Corona from Pulsar Observations

We present a novel experiment with the capacity to independently measure both the electron density and the magnetic field of the solar corona. We achieve this through measurement of the excess Faraday rotation due to propagation of the polarised emission from a number of pulsars through the magnetic field of the solar corona. This method yields independent measures of the integrated electron density, via dispersion of the pulsed signal and the magnetic field, via the amount of Faraday rotation. In principle this allows the determination of the integrated magnetic field through the solar corona along many lines of sight without any assumptions regarding the electron density distribution. We present a detection of an increase in the rotation measure of the pulsar J1801$-$2304 of approximately 160 \rad at an elongation of 0.95$^\circ$ from the centre of the solar disk. This corresponds to a lower limit of the magnetic field strength along this line of sight of $> 393\mu\mathrm{G}$. The lack of precision in the integrated electron density measurement restricts this result to a limit, but application of coronal plasma models can further constrain this to approximately 20mG, along a path passing 2.5 solar radii from the solar limb. Which is consistent with predictions obtained using extensions to the Source Surface models published by Wilcox Solar ObservatoryComment: 16 pages, 4 figures (1 colour): Submitted to Solar Physic

Sequestration of Martian CO2 by mineral carbonation

Carbonation is the water-mediated replacement of silicate minerals, such as olivine, by carbonate, and is commonplace in the Earth’s crust. This reaction can remove significant quantities of CO2 from the atmosphere and store it over geological timescales. Here we present the first direct evidence for CO2 sequestration and storage on Mars by mineral carbonation. Electron beam imaging and analysis show that olivine and a plagioclase feldspar-rich mesostasis in the Lafayette meteorite have been replaced by carbonate. The susceptibility of olivine to replacement was enhanced by the presence of smectite veins along which CO2-rich fluids gained access to grain interiors. Lafayette was partially carbonated during the Amazonian, when liquid water was available intermittently and atmospheric CO2 concentrations were close to their present-day values. Earlier in Mars’ history, when the planet had a much thicker atmosphere and an active hydrosphere, carbonation is likely to have been an effective mechanism for sequestration of CO2

Interventions for treating depression after stroke

Background: Depression is an important consequence of stroke that impacts on recovery yet is often not detected or inadequately treated. This is an update of a Cochrane review first published in 2004. Objectives: To determine whether pharmaceutical, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome. Search strategy: We searched the trials registers of the Cochrane Stroke Group (last searched October 2007) and the Cochrane Depression Anxiety and Neurosis Group (last searched February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006) and other databases. We also searched reference lists, clinical trials registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies. Selection criteria: Randomised controlled trials comparing pharmaceutical agents with placebo, or various forms of psychotherapy or ECT with standard care (or attention control), in patients with stroke, with the intention of treating depression. Data collection and analysis: Two review authors selected trials for inclusion and assessed methodological quality; three review authors extracted, cross-checked and entered data. Primary analyses were the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects. Main results: Sixteen trials (17 interventions), with 1655 participants, were included in the review. Data were available for 13 pharmaceutical agents, and four trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was some evidence of benefit of pharmacotherapy in terms of a complete remission of depression and a reduction (improvement) in scores on depression rating scales, but there was also evidence of an associated increase in adverse events. There was no evidence of benefit of psychotherapy. Authors' conclusions: A small but significant effect of pharmacotherapy (not psychotherapy) on treating depression and reducing depressive symptoms was found, as was a significant increase in adverse events. More research is required before recommendations can be made about the routine use of such treatments

Observation of Higgs boson production in association with a top quark pair at the LHC with the ATLAS detector

The observation of Higgs boson production in association with a top quark pair (tt H¯ ), based on the analysis of proton–proton collision data at a centre-of-mass energy of 13 TeV recorded with the ATLAS detector at the Large Hadron Collider, is presented. Using data corresponding to integrated luminosities of up to 79.8 fb−1, and considering Higgs boson decays into b¯ b, W W ∗, τ +τ −, γγ , and Z Z∗, the observed significance is 5.8 standard deviations, compared to an expectation of 4.9 standard deviations. Combined with the tt H¯ searches using a dataset corresponding to integrated luminosities of 4.5 fb−1 at 7 TeV and 20.3 fb−1 at 8 TeV, the observed (expected) significance is 6.3 (5.1) standard deviations. Assuming Standard Model branching fractions, the total tt H¯ production cross section at 13 TeV is measured to be 670 ± 90 (stat.) +110 −100 (syst.) fb, in agreement with the Standard Model prediction

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

An integrated view of the chemistry and mineralogy of martian soils

The mineralogical and elemental compositions of the martian soil are indicators of chemical and physical weathering processes. Using data from the Mars Exploration Rovers, we show that bright dust deposits on opposite sides of the planet are part of a global unit and not dominated by the composition of local rocks. Dark soil deposits at both sites have similar basaltic mineralogies, and could reflect either a global component or the general similarity in the compositions of the rocks from which they were derived. Increased levels of bromine are consistent with mobilization of soluble salts by thin films of liquid water, but the presence of olivine in analysed soil samples indicates that the extent of aqueous alteration of soils has been limited. Nickel abundances are enhanced at the immediate surface and indicate that the upper few millimetres of soil could contain up to one per cent meteoritic material.Additional co-authors: Thanasis E Economou, Amitabha Ghosh, Brian C Hahn, Kenneth E Herkenhoff, Larry A Haskin, Joel A Hurowitz, Bradley L Joliff, Jeffrey R Johnson, Göstar Klingelhöfer, Morten Bo Madsen, Scott M McLennan, Harry Y McSween, Lutz Richter, Rudi Rieder, Daniel Rodionov, Larry Soderblom, Steven W Squyres, Nicholas J Tosca, Alian Wang, Michael Wyatt, Jutta Zipfe