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Dominic Hodgkin and Hilary S. Connery
Drug and alcohol use disorders, also called substance use disorders (SUD), are among the major health problems facing many countries, contributing a substantial burden in terms of mortality, morbidity, and economic impact. A considerable body of research is dedicated to reducing the social and individual burden of SUD.
One major focus of research has been the effectiveness of treatment for SUD, with studies examining both medication and behavioral treatments using randomized, controlled clinical trials. For opioid use disorder, there is a strong evidence base for medication treatment, particularly using agonist therapies (i.e., methadone and buprenorphine), but mixed evidence regarding the use of psychosocial interventions. For alcohol use disorder, there is evidence of modest effectiveness for two medications (acamprosate and naltrexone) and for various psychosocial treatments, especially for less severe alcohol use disorder syndromes. An important area for future research is how to make treatment more appealing to clients, given that client reluctance is an important contributor to the low utilization of effective treatments.
A second major focus of research has been the availability of medication treatments, building on existing theories of how innovations diffuse, and on the field of dissemination and implementation research. In the United States, this research identifies serious gaps in both the availability of SUD treatment programs and the availability of effective treatment within those programs. Key barriers include lack of on-site medical staff at many SUD treatment programs; restrictive policies of private insurers, states, and federal authorities; and widespread skepticism toward medication treatment among counseling staff and some administrators. Emerging research is promising for providing medication treatment in settings other than SUD treatment programs, such as community mental health centers, prisons, emergency departments, and homeless shelters.
There is still considerable room to make SUD treatment approaches more effective, more available, and—most importantly—more acceptable to clients.
The Effect of Education on Health and Mortality: A Review of Experimental and Quasi-Experimental Evidence
Titus Galama, Adriana Lleras-Muney, and Hans van Kippersluis
Education is strongly associated with better health and longer lives. However, the extent to which education causes health and longevity is widely debated. We develop a human capital framework to structure the interpretation of the empirical evidence and review evidence on the causal effects of education on mortality and its two most common preventable causes: smoking and obesity. We focus attention on evidence from randomized controlled trials, twin studies, and quasi-experiments. There is no convincing evidence of an effect of education on obesity, and the effects on smoking are only apparent when schooling reforms affect individuals’ track or their peer group, but not when they simply increase the duration of schooling. An effect of education on mortality exists in some contexts but not in others and seems to depend on (i) gender, (ii) the labor market returns to education, (iii) the quality of education, and (iv) whether education affects the quality of individuals’ peers.
Ayman Chit and Paul Grootendorst
Drug companies are profit-maximizing entities, and profit is, by definition, revenue less cost. Here we review the impact of government policies that affect sales revenues earned on newly developed drugs and the impact of policies that affect the cost of drug development. The former policies include intellectual property rights, drug price controls, and the extension of public drug coverage to previously underinsured groups. The latter policies include regulations governing drug safety and efficacy, R&D tax credits, publicly funded basic research, and public funding for open drug discovery consortia.
The latter policy, public funding of research consortia that seek to better understand the cellular pathways through which new drugs can ameliorate disease, appears very promising. In particular, a better understanding of human pathophysiology may be able to address the high failure rate of drugs undergoing clinical testing. Policies that expand market size by extending drug insurance to previously underinsured groups also appear to be effective at increasing drug R&D. Expansions of pharmaceutical intellectual property rights seem to be less effective, given the countervailing monopsony power of large public drug plans.
Chao Gu, Han Han, and Randall Wright
The effects of news (i.e., information innovations) are studied in dynamic general equilibrium models where liquidity matters. As a leading example, news can be announcements about monetary policy directions. In three standard theoretical environments—an overlapping generations model of fiat currency, a new monetarist model accommodating multiple payment methods, and a model of unsecured credit—transition paths are constructed between an announcement and the date at which events are realized. Although the economics is different, in each case, news about monetary policy can induce volatility in financial and other markets, with transitions displaying booms, crashes, and cycles in prices, quantities, and welfare. This is not the same as volatility based on self-fulfilling prophecies (e.g., cyclic or sunspot equilibria) studied elsewhere. Instead, the focus is on the unique equilibrium that is stationary when parameters are constant but still delivers complicated dynamics in simple environments due to information and liquidity effects. This is true even for classically-neutral policy changes. The induced volatility can be bad or good for welfare, but using policy to exploit this in practice seems difficult because outcomes are very sensitive to timing and parameters. The approach can be extended to include news of real factors, as seen in examples.
Hope Corman, Dhaval Dave, and Nancy E. Reichman
Prenatal care, one of the most frequently used forms of healthcare in the United States, involves a series of encounters during the gestational period, educates women about pregnancy, monitors existing medical conditions, tests for gestational health conditions, and refers expectant mothers to services such as support groups and social services. However, an increasingly methodologically rigorous literature suggests that the effects of prenatal care timing and quantity on birth outcomes, particularly low birthweight, are modest at the population level. A review and synthesis of the literature suggests that the questions typically being asked may be too narrow and that more attention should be paid to the characterization of infant health, characterization of the content and quality of prenatal care, potential heterogeneous effects, potential indirect effects on health behaviors that may benefit offspring, potential long-term effects, potential spillover effects (i.e., on mothers and their subsequent children), effects of preconceptional and lifetime care, and intergenerational effects.
The literature on the employment effects of minimum wages is about a century old, and includes hundreds of studies. Yet the debate among researchers about the employment effects of minimum wages remains intense and unsettled. Questions have arisen in the past research that, if answered, may prove most useful in making sense of the conflicting evidence. However, additional questions should be considered to better inform the policy debate, in particular in the context of the very high minimum wages coming on line in the United States, about which past research is quite uninformative.
Florence Jusot and Sandy Tubeuf
Recent developments in the analysis of inequality in health and healthcare have turned their interest into an explicit normative understanding of the sources of inequalities that calls upon the concept of equality of opportunity. According to this concept, some sources of inequality are more objectionable than others and could represent priorities for policies aiming to reduce inequality in healthcare use, access, or health status.
Equality of opportunity draws a distinction between “legitimate” and “illegitimate” sources of inequality. While legitimate sources of differences can be attributed to the consequences of individual effort (i.e. determinants within the individual’s control), illegitimate sources of differences are related to circumstances (i.e. determinants beyond the individual’s responsibility).
The study of inequality of opportunity is rooted in social justice research, and the last decade has seen a rapid growth in empirical work using this literature at the core of its approach in both developed and developing countries. Empirical research on inequality of opportunity in health and healthcare is mainly driven by data availability. Most studies in adult populations are based on data from European countries, especially from the UK, while studies analyzing inequalities of opportunity among children are usually based on data from low- or middle-income countries and focus on children under five years old.
Regarding the choice of circumstances, most studies have considered social background to be an illegitimate source of inequality in health and healthcare. Geographical dimensions have also been taken into account, but to a lesser extent, and more frequently in studies focusing on children or those based on data from countries outside Europe. Regarding effort variables or legitimate sources of health inequality, there is wide use of smoking-related variables.
Regardless of the population, health outcome, and circumstances considered, scholars have provided evidence of illegitimate inequality in health and healthcare. Studies on inequality of opportunity in healthcare are mainly found in children population; this emphasizes the need to tackle inequality as early as possible.
Widely used modified least squares estimators for estimation and inference in cointegrating regressions are discussed. The standard case with cointegration in the I(1) setting is examined and some relevant extensions are sketched. These include cointegration analysis with panel data as well as nonlinear cointegrating relationships. Extensions to higher order (co)integration, seasonal (co)integration and fractional (co)integration are very briefly mentioned. Recent developments and some avenues for future research are discussed.
Trade policy is one determining factor of 19th-century globalization, alongside transport and communication innovations and broader institutional changes that made worldwide commodity and factor flows possible.
Four broad periods, or trade policy regimes, can be discerned at the European level. The first starts at the end of the French Revolutionary and Napoleonic wars that had led to many disruptions in trade relations. Governments tried to recover from the financial impact of the wars and to mitigate the adjustment shocks to domestic producers that came with the end of the wars. Very restrictive trade policies were thus adopted in most places and only slowly dismantled over the following decades as some of the welfare costs of, for example, agricultural protection became evident.
The second period dated from the mid-1840s, which saw the liberalization of protective grain tariffs in many European countries, to the mid-1870s, when trade liberalization reached its maximum. This period witnessed unilateral trade liberalizations, but is most famous for the spread of a network of bilateral trade agreements across Europe in the wake of the Cobden–Chevalier treaty between France and the United Kingdom in 1860.
From the 1870s, industrial and commercial crises and falling prices in agriculture due to global market integration led governments to search for solutions to these policy challenges. Many European countries thus increased protection for agriculture and manufactured goods in which domestic import-competing producers struggled. At the same time, demands for renegotiations threatened the treaty network, and lapsing agreements were only provisionally prolonged.
From the late 1880s, the struggle between protection for import-competing producers and market access abroad for export-oriented producers led to internal and external conflicts over trade policy in many countries, including trade (or tariff) “wars.” A renewed network of less ambitious trade treaties than those of the 1860s restored a fragile equilibrium from the early 1890s, to be renewed and renegotiated roughly every 12 years as treaties approached their expiration date.
When looking at the country and commodity level it can easily be appreciated that the more or less common shifts during these periods at the European level were more pronounced in some countries than in others. For example, the United Kingdom, the Netherlands, Switzerland, and Belgium shifted more decisively to free trade and remained there, while liberalization was much less pronounced and more decisively undone in Portugal, Spain, Russia, and the Habsburg monarchy. The experiences of the Scandinavian countries, Germany, and France lie somewhere in between. Turkey and the countries that gained independence from the Ottoman Empire in the 19th century started as (forced) free traders and from the 1880s increased their duties, in part to meet growing fiscal demands. At the commodity level, tariffs on raw materials remained generally low and did not follow the protectionist backlash that affected foodstuffs. One exception was (initially) “tropical” goods such as sugar, coffee, tea, and tobacco, where many countries levied high tariffs to extract fiscal revenue. For manufactured goods, liberalization and protectionist backlash were milder than in agriculture, although there are many exceptions to this rule.
Mental illnesses are highly prevalent and can have considerable, enduring consequences for individuals, families, communities, and economies. Despite these high prevalence rates, mental illnesses have not received as much public policy commitment or funding as might be expected. One result is that mental illness often goes unrecognized and untreated. The resultant costs are felt not only in healthcare systems, but across many other sectors, including housing, social care, criminal justice, welfare benefits, and employment.
This article sets out the basic principles of economic evaluation, with illustrations in this mental health context. It also discusses the main practical challenges when conducting and interpreting evidence from such evaluations.
Decisions about whether to spend resources on a treatment or prevention strategy are based on whether it is likely to be effective in avoiding, reducing, or curing symptoms, improving quality of life, or achieving other individual-level outcomes. The economic evaluation question is whether the outcomes achieved are sufficient to justify the cost that is incurred in delivering the intervention.
An economic evaluation has five elements: clarification of the question to be addressed; specification of the intervention to be evaluated and with what alternative it is being compared; the outcomes to be measured; the costs to be measured (including the cost of implementing the intervention and any savings that might accrue); and finally, how outcome and cost findings are to be blended to make a recommendation to the decision-maker. Sometimes, if an evaluation finds that one intervention has better outcomes but higher costs, then the evaluation should also how one (the outcomes) might be trade-off for the other (the costs).
The article illustrates how economic evaluations have been undertaken and employed to address a range of questions, from the very strategic issue to the more specific clinical question. The purpose of the study can, to some extent, determine the type of evaluation that is needed.
Examples of evaluations are given in a number of areas: perinatal maternal mental illness; parenting programs for conduct disorder; anti-bullying programs in schools; early intervention services for psychosis; individual placement and support; collaborative care for physical health problems; and suicide prevention. The challenges of economic evaluation are discussed, specifically in the mental health field.
Knut Are Aastveit, James Mitchell, Francesco Ravazzolo, and Herman K. van Dijk
Increasingly, professional forecasters and academic researchers in economics present model-based and subjective or judgment-based forecasts that are accompanied by some measure of uncertainty. In its most complete form this measure is a probability density function for future values of the variable or variables of interest. At the same time, combinations of forecast densities are being used in order to integrate information coming from multiple sources such as experts, models, and large micro-data sets. Given the increased relevance of forecast density combinations, this article explores their genesis and evolution both inside and outside economics. A fundamental density combination equation is specified, which shows that various frequentist as well as Bayesian approaches give different specific contents to this density. In its simplest case, it is a restricted finite mixture, giving fixed equal weights to the various individual densities. The specification of the fundamental density combination equation has been made more flexible in recent literature. It has evolved from using simple average weights to optimized weights to “richer” procedures that allow for time variation, learning features, and model incompleteness. The recent history and evolution of forecast density combination methods, together with their potential and benefits, are illustrated in the policymaking environment of central banks.
Ingela Alger and Donald Cox
Which parent can be expected to be more altruistic toward their child, the mother or father? All else equal, can we expect older generation members to be more solicitous of younger family members or vice versa? Policy interventions often target recipients by demographic status: more money being put in the hands of mothers, say, or transfers of income from young to old via public pensions. Economics makes predictions about pecuniary incentives and behavior but tends to be agnostic about how, say, a post-menopausal grandmother might behave, just because she is a post-menopausal grandmother. Evolutionary theory fills this gap by analyzing how preferences of family members emerge from the Darwinian exigencies of “survive and reproduce.” Coin of the realm is so-called “inclusive fitness,” reproductive success of oneself plus that of relatives, weighted by closeness of the relationship. Appending basic biological traits onto considerations of inclusive fitness generates predictions about preferences of family members. A post-menopausal grandmother with a daughter just starting a family is predicted to care more about her daughter than the daughter cares about her, for example. Evolutionary theory predicts that mothers tend to be more altruistic toward children than fathers, and that close relatives would be inclined to provide more support to one another than distant relatives. An original case study is provided, which explains the puzzle of diverging marriage rates by education in terms of heterogeneity in preferences for commitment. Economists are justifiably loathe to invoke preferences to explain trends, since preference-based explanations can be concocted to explain just about anything. But the evolutionary approach does not permit just any invocation of preferences. The dictates of “survive and reproduce” sharply circumscribe the kinds of preference-related arguments that are admissible.
Eduardo Levy Yeyati
While traditional economic literature often sees nominal variables as irrelevant for the real economy, there is a vast body of analytical and empirical economic work that recognizes that, to the extent they exert a critical influence on the macroeconomic environment through a multiplicity of channels, exchange rate policies (ERP) have important consequences for development.
ERP influences economic development in various ways: through its incidence on real variables such as investment and growth (and growth volatility) and on nominal aspects such relative prices or financial depth that, in turn, affect output growth or income distribution, among other development goals. Additionally, ERP, through the expected distribution of the real exchange rate indirectly, influences dimensions such as trade or financial fragility and explains, at least partially, the adoption of the euro—an extreme case of a fixed exchange rate arrangement—or the preference for floating exchange rates in the absence of financial dollarization. Importantly, exchange rate pegs have been (and, in many countries, still are) widely used as a nominal anchor to contain inflation in economies where nominal volatility induces agents to use the exchange rate as an implicit unit of account. All of these channels have been reflected to varying degrees in the choice of exchange rate regimes in recent history.
The empirical literature on the consequences of ERP has been plagued by definitional and measurement problems. Whereas few economists would contest the textbook definition of canonical exchange rate regimes (fixed regimes involve a commitment to keep the nominal exchange rate at a given level; floating regimes imply no market intervention by the monetary authorities), reality is more nuanced: Pure floats are hard to find, and the empirical distinction between alternative flexible regimes is not always clear. Moreover, there are many different degrees of exchange rate commitments as well as many alternative anchors, sometimes undisclosed. Finally, it is not unusual that a country that officially declares to peg its currency realigns its parity if it finds the constraints on monetary policy or economic activity too taxing. By the same token, a country that commits to a float may choose to intervene in the foreign exchange market to dampen exchange rate fluctuations.
The regime of choice depends critically on the situation of each country at a given point in time as much as on the evolution of the global environment. Because both the ERP debate and real-life choices incorporate national and time-specific aspects that tend to evolve over time, so does the changing focus of the debate. In the post-World War II years, under the Bretton Woods agreement, most countries pegged their currencies to the U.S. dollar, which in turn was kept convertible to gold. In the post-Bretton Woods years, after August 1971 when the United States abandoned unilaterally the convertibility of the dollar, thus bringing the Bretton Woods system to an end, the individual choices of ERP were intimately related to the global and local historical contexts, according to whether policy prioritized the use of the exchange rate as a nominal anchor (in favor of pegged or superfixed exchange rates, with dollarization or the launch of the euro as two extreme examples), as a tool to enhance price competitiveness (as in export-oriented developing countries like China in the 2000s) or as a countercyclical buffer (in favor of floating regimes with limited intervention, the prevalent view in the developed world). Similarly, the declining degree of financial dollarization, combined with the improved quality of monetary institutions, explain the growing popularity of inflation targeting with floating exchange rates in emerging economies. Finally, a prudential leaning-against-the-wind intervention to counter mean reverting global financial cycles and exchange rate swings motivates a more active—and increasingly mainstream—ERP in the late 2000s.
The fact that most medium and large developing economies (and virtually all industrial ones) revealed in the 2000s a preference for exchange rate flexibility simply reflects this evolution. Is the combination of inflation targeting (IT) and countercyclical exchange rate intervention a new paradigm? It is still too early to judge. On the one hand, pegs still represent more than half of the IMF reporting countries—particularly, small ones—indicating that exchange rate anchors are still favored by small open economies that give priority to the trade dividend of stable exchange rates and find the conduct of an autonomous monetary policy too costly, due to lack of human capital, scale, or an important non-tradable sector. On the other hand, the work and the empirical evidence on the subject, particularly after the recession of 2008–2009, highlight a number of developments in the way advanced and emerging economies think of the impossible trinity that, in a context of deepening financial integration, casts doubt on the IT paradigm, places the dilemma between nominal and real stability back on the forefront, and postulates an IT 2.0, which includes selective exchange rate interventions as a workable compromise. At any rate, the exchange rate debate is still alive and open.
The uncovered interest parity (UIP) condition states that the interest rate differential between two currencies is the expected rate of change of their exchange rate. Empirically, however, in the 1976–2018 period, exchange rate changes were approximately unpredictable over short horizons, with a slight tendency for currencies with higher interest rates to appreciate against currencies with lower interest rates. If the UIP condition held exactly, carry trades, in which investors borrow low interest rate currencies and lend high interest rate currencies, would earn zero average profits. The fact that UIP is violated, therefore, is a necessary condition to explain the fact that carry trades earned significantly positive profits in the 1976–2018 period. A large literature has documented the failure of UIP, as well as the profitability of carry trades, and is surveyed here. Additionally, summary evidence is provided here for the G10 currencies. This evidence shows that carry trades have been significantly less profitable since 2007–2008, and that there was an apparent structural break in exchange rate predictability around the same time.
A large theoretical literature explores economic explanations of this phenomenon and is briefly surveyed here. Prominent among the theoretical models are ones based on risk aversion, peso problems, rare disasters, biases in investor expectations, information frictions, incomplete financial markets, and financial market segmentation.
Johanna Gereke and Klarita Gërxhani
Experimental economics has moved beyond the traditional focus on market mechanisms and the “invisible hand” by applying sociological and socio-psychological knowledge in the study of rationality, markets, and efficiency. This knowledge includes social preferences, social norms, and cross-cultural variation in motivations. In turn, the renewed interest in causation, social mechanisms, and middle-range theories in sociology has led to a renaissance of research employing experimental methods. This includes laboratory experiments but also a wide range of field experiments with diverse samples and settings. By focusing on a set of research topics that have proven to be of substantive interest to both disciplines—cooperation in social dilemmas, trust and trustworthiness, and social norms—this article highlights innovative interdisciplinary research that connects experimental economics with experimental sociology. Experimental economics and experimental sociology can still learn much from each other, providing economists and sociologists with an opportunity to collaborate and advance knowledge on a range of underexplored topics of interest to both disciplines.
Gerard J. van den Berg and Maarten Lindeboom
Modern-day famines are caused by unusual impediments or interventions in society, effectively imposing severe market restrictions and preventing the free movement of people and goods. Long-run health effects of exposure to famine are commonly studied to obtain insights into the long-run effects of malnutrition at early ages. This line of research has faced major methodological and data challenges. Recent research in various disciplines, such as economics, epidemiology, and demography, has made great progress in dealing with these issues. Malnutrition around birth affects a range of later-life individual outcomes, including health, educational, and economic outcomes.
Alfred Duncan and Charles Nolan
In recent decades, macroeconomic researchers have looked to incorporate financial intermediaries explicitly into business-cycle models. These modeling developments have helped us to understand the role of the financial sector in the transmission of policy and external shocks into macroeconomic dynamics. They also have helped us to understand better the consequences of financial instability for the macroeconomy. Large gaps remain in our knowledge of the interactions between the financial sector and macroeconomic outcomes. Specifically, the effects of financial stability and macroprudential policies are not well understood.
Maria Soledad Martinez Peria and Mu Yang Shin
The link between financial inclusion and human development is examined here. Using cross-country data, the behavior of variables that try to capture these concepts is examined and preliminary evidence of a positive association is offered. However, because establishing a causal relationship with macro-data is difficult, a thorough review of the literature on the impact of financial inclusion, focusing on micro-studies that can better address identification is conducted. The literature generally distinguishes between different dimensions of financial inclusion: access to credit, access to bank branches, and access to saving instruments (i.e., accounts). Despite promising results from a first wave of studies, the impact of expanding access to credit seems limited at best, with little evidence of transformative effects on human development outcomes. While there is more promising evidence on the impact of expanding access to bank branches and formal saving instruments, studies show that some interventions such as one-time account opening subsidies are unlikely to have a sizable impact on social and economic outcomes. Instead well-designed interventions catering to individuals’ specific needs in different contexts seem to be required to realize the full potential of formal financial services to enrich human lives.
Financial protection is claimed to be an important objective of health policy. Yet there is a lack of clarity about what it is and no consensus on how to measure it. This impedes the design of efficient and equitable health financing. Arguably, the objective of financial protection is to shield nonmedical consumption from the cost of healthcare. The instruments are formal health insurance and public finances, as well as informal and self-insurance mechanisms that do not impair earnings potential. There are four main approaches to the measurement of financial protection: the extent of consumption smoothing over health shocks, the risk premium (willingness to pay in excess of a fair premium) to cover uninsured medical expenses, catastrophic healthcare payments, and impoverishing healthcare payments. The first of these does not restrict attention to medical expenses, which limits its relevance to health financing policy. The second rests on assumptions about risk preferences. No measure treats medical expenses that are financed through informal insurance and self-insurance instruments in an entirely satisfactory way. By ignoring these sources of imperfect insurance, the catastrophic payments measure overstates the impact of out-of-pocket medical expenses on living standards, while the impoverishment measure does not credibly identify poverty caused by them. It is better thought of as a correction to the measurement of poverty.
One of the most fundamental results in health economics is that a greater socio-economic status is associated with better health outcomes. However, the experience of financial pressure and lack of resources transcends the notion of low income and poverty. Families of all income categories can experience financial pressure and lack of resources. This article reviews the literature examining the relationship between financial strain and various health outcomes. There are three main approaches to the measurement of financial strain found in the research literature, each one capturing a slightly different aspect: the family’s debt position, the availability of emergency funds, and inability to meet current financial obligations.
There are two main hypotheses explaining how financial strain may affect health. First, financial strain indicates a lower amount of financial resources available to individuals and families. This may have a dual impact on health. On the one hand, lower financial resources may lead to a decrease in consumption of substances such as tobacco that are harmful to health. On the other hand, lower financial resources may also negatively affect healthcare access, healthcare utilization, and adherence to treatment, with each contributing to a decline in health. Second, financial strain may produce greater uncertainty with regard to the availability of financial resources at present as well as in the future, thereby resulting in elevated stress, which may, in turn, result in poorer health outcomes. Examining the relationship between financial strain and health is complicated because it appears to be bidirectional. It is not only the case that financial strain may impact health but that health may impact financial strain.
The research literature consistently finds that financial strain has a detrimental impact on a variety of mental health outcomes. This relationship has been documented for a variety of financial strain indicators, including non-collateralized (unsecure) debt, mortgage debt, and the inability to meet current financial obligations. The research on the association between financial strain and health behavior outcomes is more ambiguous. As one example, there are mixed results concerning whether financial strain results in a higher likelihood of obesity. This research has considered various indicators of financial strain, including credit card debt and the inability to meet current financial obligations. It appears that both among adults and children there is no consistent evidence on the impact of financial strain on body weight. Similarly, the results on the impact of financial strain on alcohol use and substance abuse are mixed.
A number of significant questions regarding the relationship between financial strain and health remain unresolved. The majority of the existing studies focus on health outcomes among adults. There is a lack of understanding regarding how family exposure to financial strain can affect children. Additionally, very little is known about the implications of long-term exposure to financial strain. There are also some very important methodological challenges in this area of research related to establishing causality. Establishing causality and learning more about the implications of the exposure to financial strain could have important policy implications for a variety of safety net programs.