State-level Characteristics Research Articles

Factors associated with state legislators’ support for opioid use disorder parity laws

BackgroundIn the United States, state behavioral health parity laws play a crucial role in ensuring equitable insurance coverage and access to substance use disorder treatment and services for people that need them. State legislators have the exclusive authority to adopt these laws. The purpose of this study was to identify legislator beliefs independently associated with “strong support” for opioid use disorder (OUD) parity. MethodsData were from a 2017 cross-sectional, state-stratified, multi-modal survey of state legislators (N = 475). The dependent variable was “strong support” for OUD parity. Primary independent variables were beliefs about state parity laws. Bivariate analyses and mixed effects logistic regression were conducted. ResultsLegislators who “strongly supported” OUD parity were significantly more likely than legislators who did not “strongly support” OUD parity to be female (64.1% vs. 46.5%, p<.001) , Democrat (76.2% vs. 29.3%, p<.001), and have liberal, compared to conservative, ideology (85.6% vs. 27.1%, p<.001). After adjusting for legislator demographics and state-level covariates, beliefs such as agreeing that state parity laws do not increase health insurance premium costs (aOR=6.77, p<.01) and that substance use disorder treatments can be effective (aOR=5.00, p<.001) remained associated with “strong support” for OUD parity. These state legislators’ beliefs were more strongly associated with “strong support” for OUD parity than political party, ideology, and other demographic and state-level characteristics. ConclusionsDissemination materials and communication strategies to cultivate support for OUD parity laws among state legislators should focus on the fiscal impacts of parity laws and the effectiveness of substance use disorder treatments.

The political economy of differentiated integration: The case of common agricultural policy

The past and arguably the future of the European Union (EU) are characterized by Differentiated Integration (DI). Whereas a number of studies examine country variance in the realization of DI due to state-level characteristics, scholars have rarely addressed sector-specific differentiation. We select Common Agricultural Policy (CAP) for such an analysis – the policy domain with the largest budget, most contestation in the Council of Ministers, most redistribution, and most differentiated legal acts. Building on liberal intergovernmentalism, we develop a demand and supply model to explain the number of opt-outs a country realizes in CAP legislation. We hypothesize that the member states’ demand for differentiation is driven by agricultural lobbyism and by the political receptiveness of governments; the supply-side is driven by member states’ voting or bargaining power; and the realized differentiations are a consequence of the interaction of demand and supply. Using all differentiations in new CAP legal acts from 1993 to 2012, we test these hypotheses in a time-series cross-section design. We find that the domestic level of agricultural protectionism, conservative parties in government and voting power are robust predictors of the realization of differentiation in CAP. Our results support the general claim of liberal intergovernmentalism, that domestic societal and economic interests and political bargaining power shape the course of (differentiated) integration.

Access to and use of finance in India: does religion matter?

The role and relevance of religion in influencing the access to and use of finance has been an evolving area of research. In this context, exploiting disaggregated household-level data for India, we analyze the role of religion in influencing such behavior. Our findings suggest a significant disparity in both the access to as well as the use of finance by religion. On average, Muslim households are 17% less likely to own a bank account, after controlling for other relevant household and state-level characteristics. Similarly, Muslim households are 8% less likely to use bank account. Finally, we find that the interest rate is a key factor driving the use of formal finance by Muslims in the Indian context.

Changes in community mental health services availability and suicide mortality in the US: a retrospective study

BackgroundDespite the fact that the overwhelming majority of mental health services are delivered in outpatient settings, the effect of changes in non-hospital-based mental health care on increased suicide rates is largely unknown. This study examines the association between changes in community mental health center (CMHC) supply and suicide mortality in the United States.MethodsRetrospective analysis was performed using data from National Mental Health Services Survey (N-MHSS) and the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) (2014–2017). Population-weighted multiple linear regressions were used to examine within-state associations between CMHCs per capita and suicide mortality. Models controlled for state-level characteristics (i.e., number of hospital psychiatric units per capita, number of mental health professionals per capita, age, race, and percent low-income), year and state.ResultsFrom 2014 to 2017, the number of CMHCs decreased by 14% nationally (from 3406 to 2920). Suicide increased by 9.7% (from 15.4 to 16.9 per 100,000) in the same time period. We find a small but negative association between the number of CMHCs and suicide deaths (− 0.52, 95% CI − 1.08 to 0.03; p = 0.066). Declines in the number of CMHCs from 2014 to 2017 may be associated with approximately 6% of the national increase in suicide, representing 263 additional suicide deaths.ConclusionsState governments should avoid the declining number of CMHCs and the services these facilities provide, which may be an important component of suicide prevention efforts.

Analysis of Out-of-Pocket Cost of Lung Cancer Screening for Uninsured Patients Among ACR-Accredited Imaging Centers.

To determine the variability in out-of-pocket costs of lung cancer screening (LCS) for uninsured patients and assess accessibility of this information by telephone or Internet. LCS centers from the ACR's LCS database were randomly selected. Centers were called between July and August 2019 to determine out-of-pocket cost. Telephone call variables, accessibility of cost information on screening centers' websites, screening centers' chargemasters, and publicly available facility and state insurance coverage variables were obtained. Cost information was summarized using descriptive analyses. Multiple variable linear regression analyses were conducted to evaluate effects of facility and state-level characteristics on out-of-pocket costs. Fifty-five ACR-accredited LCS centers were included with 78% (43 of 55) willing to provide out-of-pocket cost. Average out-of-pocket cost was $583 ± $607 (mean ± standard deviation), range $49 to $2,409. Average telephone call length 6 ± 3.8 min. Two of fifty-five screening centers' websites provided out-of-pocket cost information, and one matched cost given over the telephone. A chargemaster was found for 30 of 55 screening centers. No statistically significant differences in out-of-pocket costs were found by geographic region, state percentages of uninsured residents, state percentages of residents with public insurance, or facility safety net hospital affiliation. Out-of-pocket LCS costs for uninsured patients and availability of this information is highly variable. Radiology practices should be aware of this variability that may influence participation rates among uninsured patients.

Willingness to protest over resource extraction in Latin America

Protests over resource extraction have increased in Latin America in recent years. However, significant variation exists in the region in terms of citizen's willingness to protest against resource extraction. We argue that this variation is based on the interaction of factors at both the individual and state levels. Individual-level characteristics, such as social engagement, influence the likelihood of protest activity. State-level characteristics, such as the quality of governance, also present opportunities for engaged individuals to challenge resource extraction. Following political mediation theory, we argue that collective action strategies are likely to be more productive in some political contexts than in others. Thus socially-engaged citizens in high-quality governance environments are more willing to participate in protests over resource extraction vis-a-vis their counterparts in low-quality governance settings. We utilize survey data and state-level governance data across Latin America to determine why some individuals are willing to demonstrate against resource extraction while others are not.

Households and work in their economic contexts: State-level variations in gendered housework performance before, during, and after the great recession

ABSTRACT Women remain largely responsible for the management and performance of domestic labor despite many shifts in both women’s and men’s economic activities. The Great Recession changed the economic landscape in the United States in important ways, affecting men’s economic experiences substantially. Some states were affected less by the recession, thereby providing households a buffer against its harmful effects. Understanding the social and economic contexts of housework such as those influenced by the Great Recession can yield important insights for contemporary American family life and make significant contributions to occupational science as a discipline. The purpose of this project is two-fold. First, we use 2003-2015 American Time Use Study data to examine housework performance before, during, and after the Great Recession. To what extent did the changing economic conditions associated with the Recession change how women and men allocated time to housework? Second, we situate households into geographic context to determine whether and how state-level employment opportunities (e.g., unemployment rate) and policies (e.g., minimum wage) shape women’s and men’s housework performance and how these state-level characteristics provided different contexts for housework before, during, and after the Great Recession. The results indicate that men’s housework hours increased over the three time periods, while women’s housework hours decreased. Individuals living in Census divisions characterized by less traditional gender ideologies reported performing less housework. This project demonstrates the power of social norms around housework performance and documents how housework remains a gendered occupation in the United States and thus a social problem related to the inequitable distribution of unpaid labor worth examining.

Simulating the Impact of a Cigarette Minimum Floor Price Law on Adult Smoking Prevalence in California.

Minimum floor price laws (MFPLs) are an emerging tobacco control policy that sets a minimum price below which a specific tobacco product cannot be sold. MFPLs target cheaper products and may disproportionately impact consumers choosing low price brands or using discounts to reduce prices. We developed a static microsimulation model for California, United States to project short-term effects of different MFPL options for a 20-stick pack of cigarettes on adult smoking behaviors. We simulated 300 000 individuals defined by race and ethnicity, sex, age, and poverty status. Smoking behaviors and cigarette prices were assigned based on demographic distributions in the 2014-2016 California Behavioral Risk Factor Surveillance System. We drew 100 random samples (n = 30 000), weighted to state-level California demographic characteristics. We simulated six MFPL options and modeled impacts on smoking prevalence and cigarette consumption, in general, and separately for those in households below or above 250% of the federal poverty level, assuming a price elasticity of -0.4. Predicted changes in prices, prevalence, and consumption increased exponentially as the floor price increased from $7.00 to $9.50. Assuming 15% policy avoidance, projected increases in average cigarette prices ranged from $0.19 to $1.61. Decreases in smoking prevalence ranged from 0.05 to 0.43 percentage points, and decreases in average monthly cigarette consumption ranged from 1.4 to 12.3 cigarettes. Projected prices increased, and prevalence and consumption decreased, more among individuals in households below 250% federal poverty level. MFPLs are a promising tobacco control strategy with the potential to reduce socioeconomic disparities in cigarette smoking prevalence and consumption. Despite reductions in adult smoking prevalence, significant socioeconomic disparities remain, with lower-income groups smoking at substantially higher levels than higher-income groups. Policies that set a floor price below which a tobacco product cannot be sold could reduce socioeconomic disparities in smoking, depending on variation in prices paid by smokers prepolicy. By using a microsimulation model to predict changes in smoking for different population groups in California under several floor price scenarios, this study demonstrates that MFPLs have the potential to reduce adult smoking prevalence overall, and especially for lower-income tobacco users.

Solar Bait: How U.S. States Attract Solar Investments from Large Corporations

Past solar adoption literature has focused primarily on households without significant attention to the potential of commercial properties as sites for solar generation. We examine firms’ decisions to install solar panels on their properties using state and firm level data from the U.S. We are interested in the effects of state level characteristics, including policies and regulations, on firm decisions regarding solar investments. We find that state characteristics that influence the return-on-investment from solar installations, most notably solar intensity, are important for commercial adoption decisions. Further, the results suggest that certain state level policies, including solar carve-outs in renewable portfolio standards, financing programs and tax breaks, can incentivize firms to install solar panels. Across different model specifications, we observe that firm installation decisions are correlated with personal electric vehicle ownership rates. This may indicate a ‘green’ business marketing strategy, whereby firms install solar to improve their social responsibility image.

Effect of Religion and Education on Fertility in the EAG States of India: Evidence from NFHS-4

The study seeks to explore the relationship between the level of education of women and its influence on the fertility in Empowered Action Group (EAG) states of India. In addition, the interplay of education and fertility is further affected by religion, which acts as the determinants of fertility. The birth intervals, age at first birth, desire for another child are major determinants of fertility which are taken into consideration for the study. It is pertinent to understand how the level of education and religion of an individual affects the fertility and to what extent. The broader objective of the study is to determine the association between education, religion, and fertility and to further examine the proximate factors that influence the fertility of a woman. The study utilizes the Demographic and Health Surveys, that includes basic information about the household and women in the childbearing ages. This study focuses on the survey of women in reproductive age which would provide active information about fertility. The population defined in the study are the north Indian states that are categorized as EAG (Empowered Action Group) states. Multivariate regression analysis was used to examine the variation in the relationship between fertility and individual and state-level characteristics. DOI: 10.5958/2347-6869.2020.00005.9

Employed Vocational Rehabilitation Applicants with Visual Disabilities: Factors Associated with Timely Service Delivery

Introduction: Employed applicants for vocational rehabilitation need timely services to improve the likelihood of their successful job retention or career advancement. Little research exists that examines timeliness of services among employed applicants, particularly for applicants with visual disabilities. This study investigated time from vocational rehabilitation application to a signed Individualized Plan for Emplolyment (IPE) for employed applicants with visual disabilities. Method: The sample of 5,096 competitively employed vocational rehabilitation applicants from the FY2015 RSA-911 report was combined with survey responses from 51 vocational rehabilitation agencies about services to persons with visual disabilities. Multilevel modeling was used to examine effects of state-level and individual-level characteristics and cross-level interactions on the length of waiting time from vocational rehabilitation application to signed IPE. Results: The time from application to IPE was shorter for employed applicants with visual disabilities who received services from separate vocational rehabilitation agencies compared to that of combined vocational rehabilitation agencies. Employed vocational rehabilitation applicants with visual disabilities waited longer if they were younger, non-White, or received disability benefits. Official job-retention policies in state vocational rehabilitation agencies appeared to reduce the delay of IPE implementation for persons with secondary disabilities, for applicants who received disability benefits, and for persons who worked more hours per week. Discussion: Additional research to determine how vocational rehabilitation can provide services to employed persons as soon as possible after application is indicated, particularly for persons applying to combined agencies. Implications for practitioners: Vocational rehabilitation providers should explore ways to expedite service delivery, particularly for persons who are younger, non-White, or receiving disability benefits. Implementing official vocational rehabilitation policies for addressing job-retention and career-advancement cases may be one avenue to expedite services to some employed applicants.

A Mexican State-Level Perspective on COVID-19 and its Economic Fallout

Mexico has had one of the highest death tolls from Covid-19 and among the largest declines in output compared to peers. This paper utilizes data on Mexico's thirty-two states to better understand the relationship between health and economic outcomes. For instance, did the states with worse pandemic outcomes suffer more economically? What state-level characteristics impacted health and economic outcomes? Among the findings are: individual traits such as age and certain pre-existing conditions were associated with higher illness and fatality risks. States with higher initial health expenditure and capacity on average had a lower case fatality rate. The economic fallout was widespread well beyond the direct impact of the pandemic. Tourism-heavy states were particularly badly affected, while states with larger exposures to manufacturing exports performed better. These findings support the case for adequate health spending, fiscal lifelines for hard-hit workers and sectors, and further integration into global value chains to bolster economic outcomes and resilience.

Civil Money Penalty Enforcement Actions for Quality Deficiencies in Nursing Homes

Civil money penalties (CMP) are fines collected by CMS and then redistributed to states for the sole purpose of improving resident care and quality of life through reinvestment in quality improvement projects. This study examined state variation in civil money penalty enforcement actions for quality of life (QOL) and quality of care (QOC) deficiencies in nursing homes. 2015-2016 cross-sectional CASPER nursing home survey data obtained from the CMS QCOR database were used to explore the pattern of enforcement actions for QOL and QOC deficiencies across states. Fixed effects regression models examined relationships between state-level characteristics, quality deficiencies, and enforcement actions imposed by states. State enforcement actions resulting in a CMP were more likely for QOC deficiencies (M = 0.143, SD = 0.097) than for QOL deficiencies (M = 0.070, SD = 0.056) and states exhibited variability in imposing enforcement actions. The presence of severe QOC deficiencies resulting in actual resident harm contributed to CMP enforcement actions for both QOL and QOC deficiencies. States with primarily for-profit status providers had more enforcement actions. The variability noted in state enforcement for quality deficiencies actions parallels inconsistencies in state regulatory oversight of nursing homes.

Changes in Medicaid Acceptance by Substance Abuse Treatment Facilities After Implementation of Federal Parity.

Adequate access for mental illness and substance use disorder (SUD) treatment, particularly for Medicaid enrollees, is challenging. Policy efforts, including the Mental Health Parity and Addiction Equity Act (MHPAEA), have targeted expanded access to care. With MHPAEA, more Medicaid plans were required to increase their coverage of SUD treatment, which may impact provider acceptance of Medicaid. To identify changes in Medicaid acceptance by SUD treatment facilities after the implementation of MHPAEA (parity). Observational study using an interrupted time series design. 2002-2013 data from the National Survey of Substance Abuse Treatment Services (N-SSATS) for all SUD treatment facilities was combined with state-level characteristics. Primary outcome is whether a SUD treatment facility reported accepting Medicaid insurance. Implementation of MHPAEA was associated with a 4.6 percentage point increase in the probability of an SUD treatment facility accepting Medicaid (P<0.001), independent of facility and state characteristics, time trends, and key characteristics of state Medicaid programs. After parity, more SUD treatment facilities accepted Medicaid payments, which may ultimately increase access to care for individuals with SUD. The findings underscore how parity laws are critical policy tools for creating contexts that enable historically vulnerable and underserved populations with SUD to access needed health care.

State-level income inequality and mortality among infants born in the United States 2007\u20132010: A Cohort Study

BackgroundUnited States state-level income inequality is positively associated with infant mortality in ecological studies. We exploit spatiotemporal variations in a large dataset containing individual-level data to conduct a cohort study and to investigate whether current income inequality and increases in income inequality are associated with infant and neonatal mortality risk over the period of the 2007–2010 Great Recession in the United States.MethodsWe used data on 16,145,716 infants and their mothers from the 2007–2010 United States Statistics Linked Infant Birth and Death Records. Multilevel logistic regression was used to determine whether 1) US state-level income inequality, as measured by Z-transformed Gini coefficients in the year of birth and 2) change in Gini coefficient between 1990 and year of birth (2007–2010), predicted infant or neonatal mortality. Our analyses adjusted for both individual and state-level covariates.ResultsFrom 2007 to 2010 there were 98,002 infant deaths: an infant mortality rate of 6.07 infant deaths per 1000 live births. When controlling for state and individual level characteristics, there was no significant relationship between Gini Z-score and infant mortality risk. However, the observed increase in the Gini Z-score was associated with a small but significant increase likelihood of infant mortality (AOR = 1.03 to 1.06 from 2007 to 2010). Similar findings were observed when the neonatal mortality was the outcome (AOR = 1.05 to 1.13 from 2007 to 2010).ConclusionsInfants born in states with greater changes in income inequality between 1990 and 2007 to 2010 experienced a greater likelihood of infant and neonatal mortality.

Universalisation versus targeting in maternal and child health care provisioning: Evidence from India.

To eradicate the persistent inequality in utilisation of Maternal Health Care Services (MHCS), India's Government has adopted various programmes under the National Rural Health Mission (NRHM) in 2005. The Janani Suraksha Yojana (JSY), a demand-side intervention, is one of the flagship programmes under the NRHM. Using two rounds of the nationally representative National Family Health Survey (NFHS) data collected in 2005–06 and 2015–16, respectively, we attempt to map the extent to which inequality in MHCS utilisation has changed over time across states after the implementation of NRHM; analyse whether there are differences in the patterns of inequality prevalent in the universal and targeted states; and find evidence to decide whether universalisation is more effective than targeting in reducing inequality in MHCS utilisation. We measure relative inequality and use the difference in difference technique to answer the research questions. For analysis, we have considered five outcome variables spanning across three stages of the continuum of care in maternal health. We find that relative inequality in MHCS utilisation declined across states during the period 2006–16, though in varying degrees. Universal states experienced a higher level of inequality as compared to the targeted states. However, universal states observed a higher decline in inequality over time relative to the targeted states controlling for other state-level characteristics. The study establishes that the programme implementation strategy and conditional cash transfer programmes influence the reduction of inequality in MHCS utilisation. This study makes an important contribution to the literature on public health policy and inequality in health care utilisation by highlighting the differential impact of universalisation and targeting on reducing inequality in the use of MHCS.

Facility and state-level factors associated with telemental health (TMH) adoption among mental health facilities in the United States

Introduction Telemental health (TMH) is a promising approach to increase access to mental healthcare. This study examined the TMH adoption rates and associations with facility- and state-level factors among US mental health (MH) facilities. Methods This retrospective, cross-sectional study used linked data for 2016 from the National Mental Health Services Survey (N = 11,833), Area Health Resources File, and national reports for broadband access and telehealth policies. The associations of facility and state-level characteristics with TMH adoption were examined with multi-level logistic regressions. Results Overall, 25.9% had used TMH. Having veteran affiliation [Adjusted Odds Ratio (AOR) = 18.53, 95% Confidence Interval (95%CI): 10.66–32.21] and greater Information Technology (IT) capacity [AOR(95%CI): 2.89(2.10–3.98)] were the strongest correlates of TMH adoption. Other facility characteristics associated with higher likelihood of TMH adoption were: public ownership, high patient volumes, having comprehensive MH treatments or Quality Improvement practices, having private or non-Medicaid public payers, and treating elderly patients (AORs: 1.16–2.41). TMH adoption was less likely among facilities treating more African Americans or patients with substance abuse disorders. TMH adoption varied substantially across states, with adoption more likely in states issuing special telehealth licences and those with more rural counties. Discussion One in four MH facilities adopted TMH in 2016. TMH adoption varied by multiple facility- and state-level factors. Our findings suggest that: legal/regulatory burden and lower facility IT capacity may discourage TMH adoption; significant racial disparities exist in TMH adoption; and there is a need to increase TMH use for substance abuse disorders.

Identifying Novel Predictors of State Legislative Action to Address Obesity.

There is wide variation in the number and types of obesity policies enacted across states, and prior studies suggest that partisan factors may not fully explain this variation. In this exploratory analysis, we examined the association of a broad array of state-level factors with the number and types of obesity policies across states. We analyzed 32 predictor variables across 7 categories of state-level characteristics. We abstracted data from 1652 state obesity policies introduced during 2009-2014. We used multilevel regression models and principal component analysis to examine the association between state-level characteristics and policy outcomes. Our outcome measures included whether bills involved topics that were public health-oriented or business interest-oriented, whether bills were enacted into law, and the number of introduced bills and enacted laws per state. Numerous state-level characteristics were associated with obesity-related bill introduction and law enactment, and different state characteristics were associated with public health-oriented versus business interest-oriented policies. For example, state-level demographics, economic factors, policy environment, public programs, and the prevalence of obesity's downstream consequences were associated with the number of public health laws whereas obesity prevalence and policy environment were associated with the number of business interest laws. Our results support the hypothesis that a variety of factors contribute to a complex state obesity policymaking environment, highlighting the need for future research to disentangle these key predictors.

State Gun Laws and Pediatric Firearm-Related Mortality

Firearms are the second leading cause of pediatric death in the United States. There is significant variation in firearm legislation at the state level. Recently, 3 state laws were associated with a reduction in overall deaths from firearms: universal background checks for firearm purchases, universal background checks for ammunition purchases, and identification requirement for firearms. We sought to determine if stricter firearm legislation at the state level is associated with lower pediatric firearm-related mortality. This was a cross-sectional study in which we used 2011-2015 Web-based Injury Statistics Query and Reporting System and Census data. We measured the association of the (1) strictness of firearm legislation (gun law score) and (2) presence of the 3 aforementioned gun laws with pediatric firearm-related mortality. We performed negative binomial regression accounting for differences in state-level characteristics (population-based race and ethnicity, education, income, and gun ownership) to derive mortality rate ratios associated with a 10-point change in each predictor and predicted mortality rates. A total of 21 241 children died of firearm-related injuries during the 5-year period. States with stricter gun laws had lower rates of firearm-related pediatric mortality (adjusted incident rate ratio 0.96 [0.93-0.99]). States with laws requiring universal background checks for firearm purchase in effect for ≥5 years had lower pediatric firearm-related mortality rates (adjusted incident rate ratio 0.65 [0.46-0.90]). In this 5-year analysis, states with stricter gun laws and laws requiring universal background checks for firearm purchase had lower firearm-related pediatric mortality rates. These findings support the need for further investigation to understand the impact of firearm legislation on pediatric mortality.

Quantifying the impact of targeted regulation of abortion provider laws on US abortion rates: a multi-state assessment

ObjectivesIn this paper, we estimate the average effect of two common TRAP (targeted regulation of abortion providers) laws on abortion rates using a novel longitudinal database of state-level policy shifts. Study designWe merged several sources of policy, abortion, and sociodemographic data from 1991–2014. We used a difference-in-differences design to control for time-fixed state-level characteristics and common factors affecting abortion trends across all states, as well as measured time-varying state-level factors that may impact TRAP enforcement and abortion rates. We used generalized linear models with cluster-robust standard errors to obtain our estimates. ResultsEnforcement of ambulatory surgical center (ASC) laws reduced the abortion rate by 1.25 abortions per 1000 women aged 15–44 (95% CI: −3.39, .89), and admitting privilege laws increased the abortion rate by .57 abortions per 1000 women aged 15–44 (95% CI: −.68, 1.83), but neither effect was statistically distinguishable from zero. Our findings were robust to the inclusion of covariates and various sensitivity analyses. ConclusionOur results suggest that ASC and admitting privilege laws did not, on average, lead to a meaningful change in abortion rates. ImplicationsUS abortion rates are currently at record lows, but our findings suggest that TRAP laws are not a meaningful driver of this trend. However, this does not mean that these laws are without consequence in a particular state (or a given year). Researchers should assess the average long-run impact of TRAP laws on other outcomes in the future.