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Fears of immigrants as a threat to public health have a long and sordid history. At the turn of the 20th century, when millions of immigrants crowded into dense American cities, contemporaries blamed the high urban mortality penalty on the newest arrivals. Nativist sentiments eventually led to the implementation of restrictive quota acts in the 1920s, substantially curtailing immigration. We capture the "missing immigrants" induced by the quotas to estimate the effect of immigration on mortality. We find that cities with more missing immigrants experienced sharp declines in deaths from infectious diseases from the mid-1920s until the late 1930s. The blame for these negative mortality effects lies not with the immigrants, but on the living conditions they endured. We show that mortality declines were largest in cities where immigrants resided in the most crowded and squalid conditions and where public health resources were stretched the thinnest. Though immigrants did die from infectious diseases at higher rates than the US-born, the mortality decline we find is primarily driven by crowding not changes in population composition or contagion, as we show mortality improvements for both US-and foreign-born populations in more quota-affected cities.

There is significant concern about the financial burdens of new insurance plan designs on families, particularly families with children and youth with special health care needs (CYSHCN). With value-based insurance design (VBID) plans growing in popularity, this study examined the implications of selected VBID cost-sharing features on children. METHODS:We studied children's health care spending patterns in 2 data sets that include high deductible and narrow network plans among others. Medical Expenditure Panel Survey data from 2007 to 2013 on 22 392 children were used to study out-of-pocket (OOP) costs according to CYSHCN, family income, and spending. MarketScan large employer insurance claims data from 2007 to 2014 (N = 4 263 452) were used to test for differences in mean total payments and OOP costs across various health plans. RESULTS:Across the data sets, we found that existing health plans place significant financial burdens on families, particularly lower income households and families with CYSHCN; individuals among the top 10% of OOP spending averaged more than $2000 per child. Although high deductible and consumer-driven plans impose substantial OOP costs on children, they do not significantly reduce spending, whereas health maintenance organizations that use network restrictions and tighter management do. CONCLUSIONS:Our results do not support the conclusion that high cost-sharing features that are common in VBID plans will significantly reduce health care spending on children. Insured Americans spend a significant portion of their income on out-of-pocket (OOP) health care expenses such as deductibles, copays, and coinsurance, or for services not covered by their health insurance benefit package. 1 The term "underinsurance" has been used to describe the situation in which health insurance imposes significant financial burdens on, and jeopardizes the provision of adequate health care to, individuals and families. 2,3 Schoen et al 4 defined underinsurance specifically as 1 of 3 indicators of financial exposure relative to income: (1) OOP medical expenses for care amounting to ≥10% of income; (2) among low-income adults (below 200% of the federal poverty level), medical expenses amounting to at least 5% of income; or (3) deductibles ≥5% of income. Children are particularly vulnerable to underinsurance: the number of children who are underinsured (22.7% of all continuously covered children) 5 exceeds the number who are uninsured (∼6% in 2009, fewer today). 6 Financial burdens are of particular concern for families with 1 or more children and youth with special health care needs (CYSHCN), who comprise ∼11.2 million or 15% of all children aged 0 to 18 years. 7 By definition, CYSHCN use more health services than other children 8 and are thus particularly at risk for underinsurance. Although much of the attention on CYSHCN has focused on children with Medicaid or Children's Health Insurance Program coverage, the majority of CYSHCN have private, employer-sponsored health insurance, and a growing number of these p...

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What was the return to education in the US at mid-century? In 1940, the correlation between years of schooling and earnings was relatively low. In this paper, we estimate the causal return to schooling in 1940, constructing a large linked sample of twin brothers to account for differences in unobserved ability and family background. We find that each additional year of schooling increased labor earnings by approximately 4%, about half the return found for more recent cohorts in contemporary twins studies. These returns were evident both within and across occupations and were higher for sons from lower SES families.