Applications of policy analysis on health outcomes

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APPLICATIONS OF POLICY ANALYSIS ON HEALTH OUTCOMES by

ZACHARY S. RICHARDSON B.A., University of Colorado Denver, 2009 M.A., University of Colorado Denver, 2011

A dissertation submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment

of the requirements for the degree of Doctor of Philosophy

Health Services Research Program 2019

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This dissertation for the Doctor of Philosophy degree by Zachary S. Richardson

has been approved for the Health Services Research Program

by

Catherine Battaglia, Chair Richard C. Lindrooth, Advisor

Laura M. Argys Beth M. McManus

Elizabeth Brooks

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Richardson, Zachary S. (Ph.D., Health Services Research) Applications of Policy Analysis on Health Outcomes Dissertation directed by Professor Richard C. Lindrooth

ABSTRACT

Policy analysis as a tool for determining the effects of health outcomes is an increasingly common practice but has been limited in scope to considering largely federal or state law changes only. My dissertation demonstrates the versatility of policy analysis beyond the typical federal and/or state studies by examining the impact of different policy changes on health outcomes at the county, zip code, and industry levels. Each of my three studies meaningfully adds to the literature in their specific area of interest. Combined, the three studies I complete, demonstrate the versatility of policy analysis regardless if the change occurs at the federal, state, local, or industry level, and regardless of the health outcome the policy change could affect.

Using the traditional natural experiment framework, I first examine the impact of racetrack casino openings post commercial gambling legalization on individual alcohol use, alcohol abuse, and alcohol-impaired-driving fatalities. Findings from this study suggest that the opening of racetrack casinos post commercial gambling legalization is associated with significant increases in multiple binge drinking occasions, heaving drinking among males, and fatal driving crashes where at least one driver has a positive blood-alcohol-consumption-level.

My second study estimates the effect of gambling legalization and increased casino access on individual financial health. I estimate that gambling legalization and increased casino access significantly increases the likelihood of an individual having at least one

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account severely delinquent, the number of accounts severely delinquent, and decreases an individual’s credit score. Given the significant links between financial distress and mental illness, these findings suggest that gambling legalization and increased casino access may have larger overall social costs in the form of increased mental illnesses.

In my final study I look at an industry specific policy change, the NFL and NCAA’s rule changes for kickoffs, and the effect this change has on specific health outcomes, changes in concussions and other injuries within the NFL. Using a natural experiment framework, I find that the NFL’s kickoff rule change is associated with fewer kickoff returns which led to a significant reduction in the number of concussions post rule change.

The form and content of this abstract are approved. I recommend its publication. Approved: Richard C. Lindrooth

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DEDICATION

This dissertation is dedicated to four people, who have profoundly affected my life and have supported me throughout the process me getting my PhD.

First, I dedicate this dissertation to my wonderful wife Lisa. You have been my rock despite all the challenges this process has presented. I could not ask for a more caring person to help me through this program and the process of completing this dissertation. I love you and cannot wait to see what the future has in store.

I dedicate this dissertation to my parents, Pam and David, who have been among my biggest cheerleaders and supporters. Your help and support to make this dream of mine to achieve my PhD is something I will truly never forget. Thank you both for listening to me ramble about each of my papers, even if you didn’t understand a word I was saying. I love you both dearly from the bottom of my heart.

Finally, I would like to dedicate this dissertation to my late grandfather, Flick Hodges, who passed away shortly before I could complete it. I hope I made you proud even if you never were able to read the finished product. I love and miss you, thank you for always being my biggest fan, even when you couldn’t understand what I was doing. I hope everything I did and will do will continue to make you proud.

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ACKNOWLEDGEMENTS

I want to thank all my committee members, Drs. Rich Lindrooth, Cathy Battaglia, Laura Argys, Beth McManus, and Elizabeth Brooks, for their constant feedback, support, and guidance. Thank you so much for all the meetings, emails, and conversations that pushed me to become the best researcher I could be. I am honored to include each of you as a co-author on my studies, and I am forever indebted to you for your invaluable insights and countless hours of editing, commenting, and helping me revise this dissertation so it was just right. Each of you has influenced me more than I can say, I only hope to make you proud with whatever the future holds for me.

I would also like to thank my co-author Melinda Pitts. Your support went far beyond being a simple co-author with access to key data. I will forever value our conversations and your ability to push me to think harder about all the research I complete. Thank you for everything you have done to help, I hope to one day find a way to repay you for your infinite kindness that you have shown me.

This project/publication is supported in part by NIH/NCATS Colorado CTSA Grant Number UL1 TR001082. Contents are the authors’ sole responsibility and do not necessarily represent official NIH views

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vii TABLE OF CONTENTS CHAPTER I. INTRODUCTION ... 1 Introduction ... 1 Statement of Problem(s) ... 4

Gambling Legalization & Mental Health Impacts ... 4

Football, Kickoffs, and Injuries ... 5

Study Aims ... 6

Aim 1: Gambling Legalization, Alcohol Abuse, and Fatal Traffic Crashes ... 7

Hypothesis ... 7

Approach... 7

Rationale ... 8

Impact ... 8

Aim 2: Gambling Legalization, Financial Hardship, and Mental Health ... 9

Hypothesis ... 9

Approach... 9

Rationale ... 9

Impact ... 10

Aim 3: Football, Kickoff Returns, and Injuries ... 10

Hypothesis ... 10

Impact ... 11

Significance ... 11

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Definition of Terms ... 13

II. LITERATURE REVIEW ... 16

Introduction ... 16

Literature Search Methodology ... 17

Literature Search Results ... 19

Review of Literature ... 19

Aim 1 Literature Review ... 20

Pathological and Problematic Gambling ... 21

Gambling Disorders and Comorbid Conditions ... 22

Similar Studies ... 25

Knowledge Gaps ... 26

Financial and Economic Impacts of Casino Opening... 27

Casinos and Bankruptcy ... 28

Role of Access in Measurement of Outcomes ... 30

Financial and Mental Health ... 34

Football, Injuries, and Concussions ... 37

Rule Changes and Methodology Guidance ... 42

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III. METHODOLOGY AND DATA ... 50

Aim 1 – The Impact of Gambling Legalization and Racetrack Casino Opening on Alcohol Abuse and Alcohol-Impaired-Driving-Fatal Crashes ... 50

Identification Strategy ... 50

Sample and Data ... 52

Data Sources ... 52

Population and Sample ... 53

Outcomes... 54 Covariates ... 56 Model Specifications ... 58 Interpretation ... 59 Specifications Tests ... 60 Sensitivity Analysis ... 61

Assumptions and Limitations/ Delimitations ... 62

Assumptions ... 62

Limitations/ Delimitations ... 63

Aim 2 – Rolling the Dice: Financial Health and Casino Exposure - ... 65

Data Sources ... 65

Outcomes... 68

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Model Specification ... 70

Casino Legalization and Financial Impact ... 70

Casino Access and Financial Health... 71

Casino Access by Casino Type and Financial Health ... 75

Interpretation ... 77

Assumptions ... 77

Aim 3 – The Impact of NFL Kickoff Rule Changes on Player Injuries: Forgoing Excitement to Reduce Injuries? ... 79

Data Sources ... 82

Outcomes... 83

Covariates ... 84

Model Specifications ... 85

Probability of touchback occurring ... 85

Changes in the probability of injuries ... 87

Interpretation ... 90

Specification Tests and Sensitivity Analysis ... 92

Specification Tests. ... 92

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Assumptions ... 94

Summary ... 97

IV. THE IMPACT OF GAMBLING LEGALIZATION AND RACINO OPENING ON ALCOHOL ABUSE AND ALCOHOL RELATED TRAFFIC FATALITIES ... 98

Manuscript for Aim 1 ... 98

Abstract ... 98

Introduction ... 98

Background ... 100

Gambling Legalization Background ... 100

Link between Gambling and Alcohol Abuse... 101

Data and Sample ... 102

Data ... 102

Sample ... 105

Methods and Estimation Strategy ... 106

BRFSS Alcohol Use Estimation ... 106

FARS Drunk Driving Fatalities Estimation ... 108

Results ... 111

Sample Characteristics... 111

Alcohol Use/Abuse Results ... 113

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Sensitivity Analysis ... 117

Conclusion... 120

Tables and Figures ... 122

V. ROLLING THE DICE: FINANCIAL HEALTH AND CASINO EXPOSURE ... 133

Abstract ... 133

Introduction ... 133

Background ... 136

Financial and Economic Impacts of Casino Opening... 136

Casinos and Bankruptcy ... 137

Measuring Access in Financial Health Outcomes ... 139

Relationship between Financial- and Mental-Health ... 141

Data ... 142

Sample Selection ... 144

Outcomes and Characteristics... 145

Methods and Results ... 148

Overarching Question ... 148

Casino Legalization and Financial Health ... 149

Methods ... 149

Results ... 151

Casino Access and Financial Health ... 152

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Results ... 156

Casino Access by Casino Type and Financial Health ... 160

Methods ... 160

Results ... 161

Sensitivity and Sub-Group Analysis ... 163

Sub-Group Analyses ... 166

Discussion/Conclusion ... 169

VI. THE IMPACT OF NFL KICKOFF RULE CHANGES ON PLAYER INJURIES: FORGOING EXCITEMENT TO REDUCE INJURIES? ... 187

Abstract ... 187

Introduction ... 187

Background ... 189

Health Impacts of Kickoffs ... 189

Kickoffs and Strategy ... 191

NFL and NCAA Kickoff Rule Change History ... 193

Data ... 195

Sample ... 196

Empirical Strategy ... 197

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Probability of a Touchback ... 198

Estimating the Effect of Rule Changes on Injuries ... 200

Specification Tests and Sensitivity Analysis ... 204

Results ... 206

Descriptive Statistics ... 206

Effects of Rule Changes on Touchback Probability ... 208

Effects of the NFL Rule Change on Player Injuries ... 211

Discussion ... 217

VII. DISCUSSION AND CONCLUSION ... 229

Intended and Unintended Consequences ... 229

Balancing Benefits and Trade-Offs ... 231

Future Policy Implications from Findings ... 232

Future Areas of Research ... 234

Conclusion... 236

REFRENCES ... 237

A. APPENDIX TABLES FOR AIM 1 (CHAPTER 4) ... 245

B. APPENDIX TABLES AND FIGURES FOR AIM 2 (CHAPTER 5) ... 246

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CHAPTER I INTRODUCTION

Introduction

This dissertation serves two primary purposes. First, it demonstrations the various applications that policy analysis can have on health outcomes utilizing advanced statistical techniques. Second, it addresses several critically important public health problems using rigorous statistical methods and changes of different policy levers to explore subsequent changes in health outcomes. While policy analysis has been widely utilized by social science and health research fields alike, shifts in the landscape of health care policy the usefulness of applied analysis has expanded significantly for fields such as health services research. Such analysis is exemplified by the growing number of studies that health services researchers have undertaken measuring the numerous policy changes that have either occurred or are currently underway. These studies often focus on various health topics such as: health outcomes, related healthcare utilization, and subsequent costs resulting from changes in outcomes and utilization. Applying policy analysis through statistical methods, allow researchers to evaluate the impact of the implemented policies. For this dissertation, the overarching goal demonstrates that the application and versatility of policy analysis is a powerful tool in explaining changes in the various health-related topics that can be attributed to various policy changes; therefore, presenting how policy analyses can be applied and how the results of such analyses can serve to inform future decisions around policy changes.

The flexibility of applied policy analyses is best viewed through the lens of structural policy changes and their impact on a targeted outcome. While typically only policies that are implemented at the federal or state level garner the attention of researchers, this dissertation

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demonstrates that regardless of the level at which a policy change occurs, the subsequent impact is likely to be felt due to that policy. This dissertation examines the effects of several policy changes: 1) a state level change that legalizes commercial casino gambling, 2) the opening and closing of casinos within these states after legalization, and 3) rule changes for college and professional football. Each policy change has its own unique set of health-related outcomes that can be associated with these structural shocks to their respective systems. Leveraging these three different policy changes allows this dissertation to demonstrate the power that policy analysis can have at varying scales, these individual research projects are significant as each adds valuable information for future decision makers to consider prior to any additional changes being made.

To display the strengths of applied policy analysis, this dissertation takes a macro to micro level examination in terms of the scope that a change in policy may have. It begins at the highest macro level undertaken. Examining the impact that state’s legalization of commercial gambling (and the subsequent opening of these casinos) has on mental illness before and after legalization, specifically with respect to the development of a mental illness, the worsening or complication of an existing mental illness, as well as the subsequent costs and service utilization associated with these changes in mental illness. While there is a wide range of literature illustrating the numerous types of mental illnesses associated with

problematic gambling, the focus for this dissertation is on the most commonly linked mental illnesses that the research has found to be related to destructive gambling patterns: alcohol abuse and subsequent alcohol related fatal traffic crashes.

Legalization of commercial casinos at the state level is only one way to examine and analyze the impact such a policy change may have. Another measure of commercial casino

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legalization is to examine more individual level effects than at the state-county level. Specifically, the focus of the second aim of this analysis is on the negative effects that changes in casino access have on individual financial health. As described in the literature review, there is a known relationship between the development and worsening of mental illnesses and the common link with severe financial hardship. This serves to illustrate that it is not only legalization of commercial casinos, but legalization leading to increased access to casinos that can lead to decreases in financial health and subsequently increasing the

likelihood of developing/worsening mental illnesses.

A more finite application of policy analysis is completed in Aim 3 of this dissertation. This application of policy analysis is at an industry specific level, examining the impact that rule changes that were undertaken college and professional football with respect to kickoffs impact on reducing injuries and increasing player safety. The National Collegiate Athletic Association (NCAA) and the National Football League (NFL) commonly make rule changes before the start of each season; however, due to growing pressure and the dangerous nature of the sport, both leagues instituted rule changes directed specifically at kickoffs and kickoff returns which are widely regarded as the most dangerous play in football. Typically, the rule changes in the NCAA and NFL tend to mirror one another, but the kickoff rule changes the NCAA that were instituted prior to the 2012 season went one step beyond the NFL’s 2011 kickoff rule changes. As discussed later in this chapter as well as in Chapters 2 and 3, it is this difference that provides the opportunity to complete a micro level policy analysis with respect to rule changes and the effects on player injury rates.

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Statement of Problem(s) Gambling Legalization & Mental Health Impacts

This portion of the dissertation focuses on two key areas with respect to the legalization of commercial casinos. The objective of the first analysis is to examine the impact of

gambling legalization by states and the opening of racetrack casinos (racinos) on alcohol abuse and alcohol related traffic fatalities. The objective of the second analysis is to determine the impact that the opening and closings of casinos has on individual financial health, with significant changes in financial health being highly associated with the development and worsening of mental illnesses.

Mental illness is pervasive and costly. Legalization of commercial gambling and casino openings present unique policy levers to examine how these changes can affect aspects of mental health prevalence such as alcohol/substance abuse as well as the impact on personal financial health. Mental illness is one of the few health-related fields where current

legislative changes in policies have under addressed the need to drastically improve care. This lack of increased quality and access to care directly contradicts what is widely

recognized as one of the largest areas of need in healthcare. Surprisingly, despite the varied literature and knowledge by the states recognizing and acknowledging the risks to mental illness[27] posed by gambling legalization, states have steadily moved forward with commercial casino openings regardless of their impact to health outcomes such as alcohol abuse and subsequent alcohol related traffic fatalities. States have widely legalized

commercial gambling while failing to add or to supply additional funding for the

treatment/prevention of these associated health outcomes. Given the literature that has shown that gambling has been significantly associated with a variety of mental illnesses[19, 31, 48]

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and the costs mental healthcare treatment in the United States estimated to cost more than $38.0 billion annually; any lack or significant gap in the funding provided after legalization to mental health outcomes like alcohol abuse and alcohol related fatal traffic crashes

alarming and needs to be studied before future changes are made.[73]

Potentially of even greater concern is that little research has examined the impact that gambling legalization has on individual financial wellness, except for analyses of

bankruptcy. The highly significant findings showing the ties between financial distress and development/worsening mental illness make this a crucial area of research. The onset and continuation of financial distress, from debt delinquency to bankruptcy has far-reaching consequences. Studies that have examined associations between mental health and gambling have failed to examine the pathway from legalization to financial instability to negative impacts on mental health.

Football, Kickoffs, and Injuries

The focus for this portion of the dissertation is to evaluate the policy changes

implemented by the NCAA and NFL through changes to kickoff rules and the association these changes had on injuries to players. These rule changes implemented by each league are evaluated to determine the relationship that each change had on the probability of a

touchback1_{occurring and in turn the impact that these probability changes have on player} safety.

Only recently has public focus been drawn to the dramatic risks that accompany playing football. Safety concerns exist at all levels of football from children as young as eight to

1 A ball that is ruled dead if the receiving team chooses to not return a kickoff, kneeling down inside their own end zone without exiting or if the kickoff travels through the back of the endzone.

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those playing professionally in the NFL. Media coverage and academic studies have led to pressure to make the game safer, particularly at the highest levels of the sport, games played either in the NCAA or NFL. These recent studies have increased pressure on both the NFL and NCAA to improve the safety of their games, especially when it comes to protecting and preventing player concussions. The findings from these studies as well as increasing public pressure have led the NCAA and NFL to adopt rule changes specifically targeting the most dangerous plays, attempting to make the game safer.

While the NCAA and NFL adopted several rules aimed at decreasing player injures few studies have focused on the effects of the rule changes themselves. Instead, the studies surrounding football and player injuries have focused on the rates at which injuries occur overall but not with respect to instituted rule changes.[7, 17, 18, 95, 112, 113] These studies show that certain position groups are more prone to suffering varying injuries, and that special teams players in particular are more likely to suffer concussions as well as other common injuries at a higher rate compared to other position groups. Despite the findings of injury rates these studies fall short of evaluating the different policy changes instituted by the NCAA and NFL. A common discussion topic in these studies is the acknowledgement that a study that examines injuries with respect to the differing rule changes would be a valuable contribution to the literature. To truly measure the impact of the kickoff rule changes in the NCAA and NFL as well as the association of the differences between the implemented rules for each respective league, a quantitative analysis must be completed.

Study Aims

The purpose of this dissertation is to demonstrate that applied policy analysis has a wide variety of areas it can be applied. This is demonstrated through three unique studies. Specific

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objectives for each of these studies illustrating the versatility of policy analysis are: (1) Provide insight to the ramifications that occur due to gambling legalization with respect to alcohol abuse and alcohol related traffic fatalities; (2) Conduct a focused analysis of the effects of casino legalization and openings on individual financial health; (3) Examine the impact kickoff rule changes in the NCAA and NFL have on touchbacks and the subsequent impact these changes have on player injuries. Each of these studies has its own specific aim and hypotheses. These are discussed, by study, in the remainder of this chapter.

Aim 1: Gambling Legalization, Alcohol Abuse, and Fatal Traffic Crashes

Estimate the association of racino opening after gambling legalization on alcohol abuse and alcohol related traffic fatalities. The goal of this analysis is to test whether racino opening is associated with increases in alcohol abuse and alcohol related traffic fatalities. Hypothesis

Opening of racinos that were previously racetracks after gambling legalization in Maine, New York, and Pennsylvania between 2004 – 2007 resulted in increased rates of alcohol abuse and alcohol related traffic fatalities compared to counties in Maryland, Massachusetts, and Ohio where racetracks became racinos after 2010.

Approach

A natural experiment is performed to take advantage of the natural variation due to the change in policy of gambling legalization to determine the association of between racino opening on changes in alcohol abuse and alcohol related traffic fatalities. The analysis is completed using a set of logistic and fixed-effects models measured at the county-time level.2

2 For alcohol abuse it is technically measured at an individual-county-time level but the individual level, as discussed later, is omitted due to the data being cross-sectional (i.e. cannot follow individuals over the course of the entire study).

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To complete this study two different sets of data are utilized. Using multiple data sets allows for the results of each to be compared so that any detected changes will reflect meaningful changes due to the introduction of racinos in the selected counties.

Rationale

Unintended increases in alcohol abuse related to gambling legalization and casino openings is an area that is not well studied. Existing studies are primarily epidemiologic, centering around associations between gambling and mental illness. The findings from these studies suggest that there are strong ties between problematic gambling, alcohol abuse, and other mental health outcomes.[59, 80] Few studies have attempted to explain the association between gambling legalization, mental illness, and comorbid conditions such as alcohol abuse. Most of the literature has focused on pointing out the potential risks of gambling legalization and mental illness, with few papers focusing on the quantitative analysis of this relationship.[27, 80, 88, 100] Casino legalization and alcohol related fatalities has been examined, but only up until 2000.[30] Rapid growth of gambling legalization and the gap in the literature between gambling legalization and mental health outcomes such as alcohol abuse and alcohol related traffic fatalities, presents an urgent need for such a study like this one.

Impact

Results from this aim serve to inform policy makers on the potential impact that

legalization of gambling can have on mental health consequences and fills a necessary gap in the literature that has been suggested but not examined explicitly up until this point.

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Aim 2: Gambling Legalization, Financial Hardship, and Mental Health

Estimate the impact of gambling legalization and increased casino access on personal financial health.

Hypothesis

Gambling legalization and increased casino access lead to increases in both economic benefits through added jobs and local revenue as well as potential decreases in individual financial stability such that the costs to individuals outweigh the overall economic benefits. Approach

Individual financial data is used to perform a natural experiment measuring the effect of casino openings after state gambling legalization on financial health, specifically measuring the impact of these changes on credit-worthiness, payment delinquency and bankruptcy. Analysis for this study examines financial outcomes that occur in three distinct potential periods: when gambling is legalized, when casinos opens relative to an individual’s place of residence, and when a casino opens that is closer than the previous closest casino relative to the individual’s place of residence. Each of these structural changes are then used to

approximate the association with the financial outcomes. This approximated association can then be translated to estimate the effects that the policy and financial strain has on potential increases in mental illnesses.

Rationale

Due to strong ties between problematic/pathological gambling and poor individual financial health, this study suggests an association that access to gambling has on financial health with implications for the subsequent development of mental illness. Recent studies have demonstrated that a decline in individual financial stability is associated with an

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increase in mental illness.[28, 103, 110] These studies find that this is particularly true for problematic gamblers owing these individuals utilizing gambling as a distraction often to temporarily suppress other mental health conditions they may be experiencing. Research suggest that in the long term this tends to exacerbate their mental illness(es). Another key finding in the literature holds that extreme financial hardship often leads to either the

development or exacerbating of various mental illnesses. In estimating the financial impact at the individual level, the study estimates the net effect of gambling legalization and

subsequent casino access has on financial strain and the relationship from access to financial strain to mental illness.

Impact

Results for this aim serve to inform policy makers on the consequences of opening casinos in specific locations as well as the expected impact that gambling legalization has on individual financial health. Negative changes in personal financial health stemming from gambling legalization and increased access suggest impacts on worsening mental health. Aim 3: Football, Kickoff Returns, and Injuries

Estimate the likelihood of a touchback occurring with respect to the rule changes

instituted by the NFL and the NCAA; estimate the impact that moving the kickoff location in the NFL has on concussions and other associated injuries.

Hypothesis

The 2011 kickoff NFL rule change led to a decrease in the number of kickoff returns and the 2012 NCAA kickoff rule change decreased kickoff returns to a lesser extent than if only the kickoff location was moved. Injuries in the NFL decreased after the kickoff rule change due to the averted kickoff returns stemming from the 2011 kickoff rule change.

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Impact

Inform football rule-makers at all levels as to the potential consequences that can result from changing too many rules at the same time without careful consideration of the possible changes, they may influence with respect to strategic decision making and the unintended health consequences of these decisions.

Significance

This dissertation has significance at two key levels: a broad application of policy

analysis in varying fields of health outcomes at differing scopes of impact and the addition of meaningful research to fill the knowledge gaps that exist within the scope of each aim. Using three distinct topics each with their own distinct approaches (state-to-state, county-to-county, zip code-to-zip code, and industry-to-industry policy change comparisons) helps illustrate the resourcefulness of applying policy analysis at varying levels.

Each aim reflects an opportunity to inform and influence policy makers on the potential risks associated with the implementation of different structural changes carry if these

decision makers fail to consider all the potential risks their policies pose. Aim 1 aides in understanding the influence that gambling has on alcohol abuse and severity of depressive symptoms as well as the associated utilization and costs associated with treatment, filling an important gap in the literature. Aim 2 takes this state level legalization and examines the individual financial impact of casino openings and closings after legalization measuring both the individual financial implications of such policy changes as a potential path to the impact of mental health changes. Aim 3 demonstrates that policy shifts, and health outcome risks are not exclusive to government policy changes, examining the impact of rule changes initiated

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in the NCAA and NFL. This aim fills the gap in the literature by examining not just injury rates but the impact that rule changes for each league have on these injury rates.

Each aim demonstrates the flexibility that applied policy analysis has. Presenting how policy analysis can be applied with respect to vastly different population levels and provide meaningful implications for varying health outcomes that arise from the structural changes stemming from policy changes. This dissertation therefore derives its overall significance in broadly demonstrating the numerous ways policy analysis can be applied with respect to diverse health outcomes; while it derives its specific significance within each aim, adding to the existing literature by filling gaps for each aim using methodology and approaches that have been widely unused.

Summary

Policy analysis is a rigorously methodologic, but useful tool with many applications in the evaluation of health outcomes. This dissertation will evaluate the effect of changes in policy on several health outcomes of high public health importance and will demonstrate the application of different policy analyses approaches. Each aim applies its own fundamental approach to fill gaps in the respective literature, with the combined goal of demonstrating how versatile policy analysis can be; particularly with respect to health outcomes and

regardless of the level that policy changes may occur at. Chapter One presented an overview of the various topics, applications, and aims of this dissertation. Chapter Two presents a thorough literature review for each aim and discusses what is currently known in the literature regarding each aim and details how each study adds to the existing literature. Chapter Three details the methodological approach used for each aim including details for

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the strategies used in the analysis and discussion of the data, population, and sample for each study.

Definition of Terms

The following defined terms are provided to ensure understanding of the common terms that are used throughout this dissertation. This is not a comprehensive list but includes those terms that are most important. Any terms not accompanied by a citation are those developed for this dissertation specifically or are industry specific terms.

- Alcohol-Impaired-Driving-Fatality (AIDF) – Traffic crashes where at least one fatality is reported due to at least driver of an automobile being under the influence of alcohol.[6]

- Athlete-Exposure – Number of times a player participates in a particular sports related event (has also been referred to as Player-Exposure).[37]

- Casino Opening – Opening of a new casino, particularly but not limited to a casino beginning operations after legalization.

- Commercial Casino – Private-Sector establishment offering games of chance regulated and taxed by the state it is located in. Commonly includes land-based, riverboat, dockside, limited-stacks, or racetrack casino designations.[13]

- Credit (Risk) Score -- Equifax Credit Risk Score: a composite score that ranges from 280 – 850 where higher numbers equal less risk of default.

- Dockside Casino – A casino that is on a body of water but not required to cruise and may be permanently moored.[13]

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- Electronic Gaming Device (EGD) – Any mechanical or electronic game of chance, including slot machines, video lottery terminals (VLTs) and video bingo, video pull-tabs and video poker machines.[13]

- Externality – Commonly used term in economics which refers to a side effect or consequence that affects other parties without being reflected in the initial cost of the goods or services.

- Gambling Legalization – Passage of a law that legalizes casinos to operate within a state where law did previously not permit this.

- Kickoff – A kick putting the ball in play that occurs at the start of each half, at the start of overtime (NFL only), after each touchdown, and after a successful field goal.[44]

- Land-based Casino – Casino built on a foundation that is not water-based.[13] - Limited-stakes Casino – Casinos where the allowable bet for a single action has a

limited maximum wager.[13]

- NCAA – National Collegiate Athletic Association, the governing body for all college athletics.

- NFL – National Football League, the only full-time professional American football league currently in operation.

- Pari-Mutual Gambling – Any system of betting on a race where the winners divide the total amount bet minus the management expenses in proportion to the sum individually wagered. [13]

- Power 5 Conference – Colloquial term used for NCAA football conferences and the teams that play in them that are widely considered to be the best and most

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competitive. Conferences considered to fall into this group has changed over time and includes some independent schools but for the study a school was considered

included if they were a member of the Atlantic Coast Conference, Big 12 Conference, Pac 12 Conference (previously known in the sample period as the Pacific 10

Conference), or the Southeastern Conference as well as independent school Notre Dame as these schools were given priority to high profile bowl games.[23] - Native American Casino – Native American owned and operated gambling

establishments that offer games of chance that are considered legal by the state the reservation where the casino operates in but are not considered or governed otherwise by any non-tribal entity.[40]

- Racetrack Casino, or Racino – Hybrid pari-mutuel venue (often a horse track, dog track, or jai alai court) and a casino wherein the ‘casino’ of the racino offers primarily only slot machine games.[13]

- Severely Delinquent Debt – A credit account with a payment more than 90 days past due.

- Touchback – A ball that is ruled dead if the receiving team chooses to not return a kickoff, kneeling down inside their own end zone without exiting or if the kickoff travels through the back of the endzone.[44]

- Video Lottery Terminal (VLT) – Electronic game of chance played on an EGD often networked and monitored, controlled, and audited by a central computer system. Typically authorized through a state lottery system and considered by law to be a form of lottery and not commercial gambling.[13]

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CHAPTER II LITERATURE REVIEW

Introduction

Policy analysis has been tool utilized from time to time in the analysis in terms of the impact of various policy changes for healthcare and health outcomes. However, the use of policy analysis methods greatly increased recently owing to the passage of the Affordable Care Act. Passage of the ACA provided researchers with a new policy lever that allowed for the study of various healthcare issues. These studies after the passage of the ACA have used these new policy levers to particularly on critical issues for individual’s healthcare, with a primary focus on access to care issues. Similarly, this dissertation leverages three different policy changes to examine key public health problems surrounding mental health and football injuries. In examining three different policy changes at three differing levels this dissertation demonstrates the impact of policy changes can have on critical public health problems regardless of the level in which such policies are adopted. Combining each aim of this dissertation serves to demonstrate the impact of policy analysis at these varying levels, taking advantage of the varying unique policy levers to determine the impact of specific policy changes on critical public health issues such as mental health and football injuries.

This chapter summarizes the current literature of each individual aim. It includes a brief introduction to the search methodology and results and then provides a comprehensive review of the relevant literature for each specific aim. This chapter begins with a brief overview of the terms and methods that were used to search for existing literature and then moves to a brief overview of the results from these searches. Section 2.4 “Review of Literature” presents majority of the material for this chapter presenting information on the

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relevant literature for each aim and discussing the gaps in knowledge for each aim. This is section is broken into individual parts to correspond to each aim specifically.

Literature Search Methodology

To review the relevant literature related to each aim, keyword searches were completed, and the articles returned from this search were evaluated to determine the scope of work that had previously been completed for each individual aim. Searches began broadly using keywords for the corresponding aim using Google Scholar, limiting the search results of the relevant literature to studies completed in the past 20 years. Each of these articles that were deemed relevant were then accessed using available resources provided by the University of Colorado Anschutz Medical Campus’s Health Sciences Library.‡_{For Aim 1, the keywords/} terms used were: gambling legalization, mental health, mental illness, costs, utilization, depression, suicide, alcoholism, and alcohol abuse. For Aim 2, the keywords/terms used were: Federal Reserve, tax returns, bankruptcy, casino opening, casino access, distance to opening, financial health, mental health, and mental illness. For Aim 3, the keywords/terms used were: kickoff rule changes, football rule changes, football injuries, concussions, policy analysis, speed, kickoff returns, and touchbacks. Each article was evaluated to determine its relevance to the specific aim. If the article was not considered relevant than it was removed. This categorization of relevancy was completed for each specific aim using the following exclusion criteria.

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For Aim 1 the exclusion criteria was:

- The article did not evaluate gambling with respect to alcohol use/abuse, fatal driving crashes, or comorbid mental illnesses associated with either of these.

- The article was not aimed or did not have a broader aim at United States gambling and focused primarily on gambling in another country.

- The literature was primarily a process piece and did not focus on gambling and the aforementioned outcomes.

- The article did not evaluate casino access or personal financial health as related to gambling

- The article did not assess any meaningful change with respect to casino access or access in general, instead primarily focusing as a policy brief with redundant review of other already published articles.

- The article did not evaluate the injuries or rule changes in football specifically. - The article primary focus was on alternative measures than policy analysis or player

injury, often found in articles that were concerned with rule changes impact for gambling purposes.

All articles were first evaluated based on their title and the information provided in the abstract. For those that were not discarded based on the exclusion criteria, the entire article was then evaluated to determine its relevancy. For Aim 1 and Aim 2 there is some overlap owing to the nature of evaluating similar topics but using differing methodologies. When possible the literature for each aim was compared to determine if any key articles for that aim

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had been overlooked. Any subsequent article that were possibly overlooked were then evaluated using the same procedure and included or excluded accordingly.

Literature Search Results

Search results for Aim 1 using the search criteria resulted in twenty-two journal articles, as well as government documents and reports that provide supplementary information. The overall reference database of Aim 1 consists of thirty-eight different resources. Of the

twenty-two journal articles three did not meet the inclusion criteria. The primary focus of the literature in Aim 1 was concentrated on the most recent studies in addition to two studies that focused on social and economic impacts of gambling.[90, 110] These two studies are

relevant for both Aim 1 and Aim 2 and were government prepared reports that included key information and detailed annotated literature reviews that helped identify other articles that may have been overlooked.[90, 110] Aim 2 has some overlap when it comes to the mental illness aspect of the study, it therefore includes several article included in the literature search results for Aim 1. Initial search results for Aim 2 found nineteen additional articles. No articles were discarded due to the relevance each had with respect to some other aspect of the study. The literature search for Aim 3 found nineteen unique journal articles, it also found news articles, league rulebooks, and pamphlets produced by the NCAA. There were twenty-eight unique data sources found, of these five were excluded due to the exclusion criteria for Aim 3.

Review of Literature

For the following sections, the review of the literature summarizes and analyzes the current standing of the literature with respect to each aim. Discussion of the literature for each aim is broken into two key parts. First, there is a general overview of the current

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literature specific to each aim which is separated by the key aspects for the specific aim. Second, there is a discussion for each aim on where the current knowledge gaps are in the literature and how the specific aim fills one or more of these gaps.

Aim 1 Literature Review

In the past eight years, ten different states have legalized commercial gambling.[66] Legalization of gambling is an easy way for legislators to increase a state’s revenue without introducing new taxes. This year alone, states are expected to collect in excess of $38 million of additional revenue from commercial casinos.[98] While such increases are beneficial to the states in terms of increases revenue, the association between mental illness and gambling is largely ignored during the legalization process. The apathy of policy makers to consider the considerable number of studies which show the association between gambling disorders and various other physical and mental health conditions necessitates and explicit study as to the direct association between gambling legalization and individual mental illness. The clinical and social impacts with regards to gambling are not entirely ignored, two

governmental reports conducted on behalf of the Scottish Executive Research[90] and the Canadian Consortium for Gambling Research[110] detail the potential benefits and costs of casino legalization. Despite these extensive government reports, no other studies have attempted to examine the association between gambling and mental illness. Though no other studies have been done directly in this area, background for this study comes from three key areas which are essential in understanding this studies scope and impact. These three key areas are: 1) research that has been completed to date on gambling specific mental health conditions, 2) studies that have examined the relationship between these gambling specific

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mental illnesses and other comorbid conditions, and 3) policy studies that are related to the proposed methodology of Aim 1.

Pathological and Problematic Gambling

As this aim specifically wants to understand what happens to gambling disorders after casino legalization, it is imperative to have a firm definition of what gambling specific mental health outcomes should be considered. Researchers have spent considerable time studying the links between gambling and mental illness. The literature has had a primary focus on the recognized mental illness specific to gambling, Pathological Gambling. Pathological gambling was first introduced as a clinical diagnosis in the Diagnostic and Statistical Manual of Mental Disorders: DSM-III.[8] It is defined as “a chronic progressive failure to resist impulses to gamble and gambling heavier that compromises, disrupts, or damages personal, family, or vocation pursuits.” While pathological gambling would seem to be a natural primary outcome to consider for this study, there is an ongoing debate whether it is defined too narrowly. Specifically, the pathological gambling diagnosis omits a group of gamblers that may not meet the criteria for pathological gambling but have gambling problems affecting their daily life.

This disagreement in the definition of what constitutes gambling specific mental disorders is necessary to understand. If pathological gambling is indeed too narrow, only using it as the primary outcome measure would likely result in no effect from legalization being detected regardless of whether there was or not. The narrow definition of pathological gambling has led to a current debate which centers on the distinction between pathological gambling diagnosis and the newer diagnosis of problem/problematic gambling. While in the past this debate over a broad versus narrow definition for gambling mental illness was hotly

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contested, the inclusion of problem gambling in the DSM-V[9] has led a wider acceptance of both diagnosis being valid. Acceptance of the differencing diagnosis has also in part been driven by policy studies such as this one. As Hinchliffe[51] discusses, inclusion of a broader spectrum for gambling disorders allows studies to capture those “…at an elemental period, or which leads to more minimal issues than the developed stage “or more severe problems, or caused by those gamblers who are clinically diagnosed as pathological gamblers.”[51]

Including both pathological and problem gambling as primary outcomes of interest is not just key for the identification analysis for Aim 1. It is key when considering the literature that Williams et al.[110] reviewed in their report. Defining a preferred outcome is essential to any study. For Aim 1 it is critical, not only in defining a preferred set of outcome measures for the analytical modeling, but to also glean a clear picture as to the scope of the literature as it relates to this study.

Gambling Disorders and Comorbid Conditions

One of the primary difficulties for this study is the lack of specific data available which measures: gambling disorders and individual’s place of residence. The inability to measure gambling disorders with respect to gambling legalization requires that an alternative approach to the outcomes that are selected. This is not a new idea; researchers have often used proxy variables and comorbid conditions to substitute for pathological or problem gambling disorders. The use of proxy variables and comorbid conditions allows for a broader definition in the outcomes which allows for more studies to be included to guide this study’s analysis.

To find these comorbid outcome variables we turn to the epidemiological literature. When it comes to the associations between gambling disorders and other potential comorbid

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conditions, the epidemiological literature is extensive. Using proxy variables in place of the directly measured gambling outcomes requires that the chosen proxies be consistently associated with one or both gambling disorders. Based on the literature, the comorbid conditions that consistently show the strongest associations with the two gambling disorders are alcohol consumption disorders and depression.[84]

In their review of the literature, Shaffer & Korn[99] discuss that among all the studies they examined, the ties between gambling disorders, alcohol consumption, and depression are the most common to be significant and have a large effect. These are not new assertions by Shaffer & Korn that these three conditions are so strongly tied throughout the literature; the 1996 study by Becora et al. [19] demonstrated that there was a statistically significant correlation between pathological gambling and depression. The results from their study have been replicated around the globe including a 2006 study completed in in New Zealand.§ Findings from this study showed that gamblers were significantly more likely to indicate struggling with depression, anxiety, and anger control issues compared to non-gamblers. [46]

Owing to the frequency in which the association between gambling disorders and depression have been studied, Kim et al.[60] published a review of the literature that had been completed up until that point. Reviews such as this do bring up important notes for using depression as a comorbid condition. Primarily the most common method for examining comorbid gambling specific mood disorders was to find subjects who self-identified as having a gambling problem, then testing for the presence of other mood disorders for these individuals. Such findings influence this analysis in the delicate nature that using proxy

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variables defined by previous studies may pose. While the studies the authors reviewed did bring slight pause in the identification strategy some utilized, the general premise remains unchanged. Other mood disorders may have strong associations within different articles that were reviewed, only depression was consistently and significantly associated with

pathological gambling.

We examine one final study to confirm that both gambling disorders that are

significantly associated with depression and not only pathological gambling. As previously discussed, pathological gambling may not capture those who have a potential gambling problem and therefore very little was known about the comorbid mental illnesses for these individuals. Okunna et al.[80] specifically address this in their study which “evaluates the prevalence of recreational gambling, and co-occurring conditions prior to gambling expansion in Massachusetts (MA), and assesses associations between gambling and co-occurring behavioral, and mental health disorders.” As their study uses the 2008 Massachusetts Behavioral Risk Factor Surveillance System data and attempts to find

associations between gamblers and other comorbid conditions; it is an ideally suited study to serve as a guide in performing the analysis of Aim 1. Their findings, even for recreational gamblers, showed that those who gambled in the past year are 1.5 more likely to report poor mental health status over the past 30 days compared to good mental health status.

Depression and severity of depressive symptoms provides on set of significantly

associated proxy measures to use in the analysis. Despite the meaningful relationship each of these has with gambling disorders, the most significant of the various comorbid conditions is alcohol abuse. The strong association between gambling and substance abuse disorders is generally agreed upon, this is highlighted in the reports by Reigth[90] and Williams et

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al.[110]; while gambling and other mental illnesses may spark debate as to the validity of the association between each, gambling disorders and alcohol abuse share no such skepticism. The findings in the literature suggest that if depression is a good initial proxy variable, alcohol abuse may in fact be stronger. [84]

Despite the breadth of the literature in this area, it is the 1998 epidemiologic study of problem gambling and other disorders by Cunningham-Williams et al.[31] that is most cited when discussing the associations between gambling disorders and alcohol abuse. While this study does measure the association between problem gambling and depression, its greatest influence is the findings on the association between problem gambling and alcohol use and/or alcohol abuse. Conducted in 1981, this study estimated that the adjusted odds of alcohol use 3.9 times more likely for recreational gamblers than non-gamblers and 7.2 times more likely for problem gamblers compared to non-gamblers. Studies like those completed by Welte et al.[107] built upon the results of this seminal study. These studies generally find that pathological and problem gambling symptoms tend to increase as alcohol consumption increases. Like depressive symptoms, alcohol abuse is not exclusive to those with a gambling diagnosis. Okunna et al.[80] measure the association between recreational gamblers and alcohol consumption, finding that a recreational gambler is 1.3 more times likely to have an alcohol consumption disorder compared to non-gambler.

Similar Studies

We consider the literature that has attempted a policy analysis similar to Aim 1. Policy analysis has been overwhelmingly understudied in when it comes to the association of gambling legalization and mental health. As Williams et al.[110] note, policy analysis is woefully underrepresented in the literature regardless of the outcome utilized in the

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modeling. Of the 492 studies that they reviewed, only 24 had some relevance to gambling policy changes and policy analysis. This implies that there are only 24 studies, and among these only one that is health related, that can serve as a tentative guide in the analysis for Aim 1. Yet, this too is a misnomer since Aim 1 employs a multi-state approach and only 5 of the 24 relevant policy analysis studies attempted to use multiple states. Even expanding the search of the literature to include both pathological and problem gambling disorders does little to expand the possible references that would serve as guides. [28, 31, 74, 75, 88, 90, 110] This essentially is a double-edged sword for Aim 1. On one hand, a lack of literature means a lack of guidance moving forward in the analysis. On the other, the lack of literature provides for a great opportunity to add to the literature in a meaningful manner.

Knowledge Gaps

Aim 1 fills the knowledge gap in the literature by moving beyond the known epidemiologic associations discussed. This study shifts the focus away from the

epidemiologic approach, instead utilizing a policy analysis approach to determine impact of gambling legalization on each outcome. This is not only a meaningful area of study in terms of the applications it has with regards to policy analysis; it is generally acknowledged in the literature as an area that is considered worthwhile to study. Okuna et al. support this notion in the conclusion of their study, which is also the study that most closely parallels this portion of Aim 1. [80]

Aim 2 Literature Review

Gambling legalization does not itself mean that an individual will immediately be able to gamble and potentially develop a mental illness. Development and treatment of mental illness tends to be the final stage in the process, the end outcome. Similarly, legalization of a

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casino does not instantaneously make one appear. Both development of mental illness and the availability of a casinos takes time. Not only does it take time, the two go hand in hand. An individual’s ability to gamble, develop a potential gambling problem, and then have this problem become severe enough to seek a diagnosis is related to personal characteristics as well as physical casino proximity. Given the known links between financial strain and poor mental health; the effects to personal financial health after an increase in access to casinos must be studied as it may be the intermediate step between legalization and development in mental illness. To study the effect increased access may have, it is critical to understand the state of literature in four specific areas: 1) the relationship between financial health and casino openings, 2) the relationship between bankruptcy and casinos, 3) the way in which increased access to casinos as well as common measures of access are measured, and 4) the link between financial and mental health.

Financial and Economic Impacts of Casino Opening

Unlike mental health outcomes, the relationship between individual financial health and the introduction of new gambling opportunities is more clearly understood. When the reports by Reith [90] and Williams et al.[110] discuss social impacts of gambling; both reports are discussing the impact to individuals that can occur due to gambling legalization and

increased access to casinos. For Aim 2, this focus on the impact to financial health serves as both a primary outcome as well as a precursor for potential mental health problems. As a primary outcome, changes in financial health due to legalization and openings of casinos is an important factor at a local and community level.[28]

Consider an individual who is not financially stable initially. Now introduce a casino close to that individual who sees the advertising to get rich quick and starts to visit that

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casino regularly. It is not farfetched to end that story with this individual getting themselves into an untenable financial situation wherein they perhaps must declare bankruptcy at the end of it all. This type of story is actually one that is backed by the literature including the study performed by Boardman & Perry.[21] This study found that pari-mutual gambling increased bankruptcy rates for counties within 25 miles of a gambling facility by 9.25%; the study also concluded that there was no impact for counties more than 25 miles from pari-mutual

gambling facilities nor was there a significant impact to bankruptcy for casino style gambling regardless of the distance from the specific facility.

As Reith [90] and Williams et al.[110] highlight in their reports on the social and economic impacts of gambling, where a casino is opened has as much to do with the impact on individual financial health as any other factor. This idea is further supported by the study by Welte et al.[108] where they look at the effects of neighborhood disadvantage and

gambling availability. Their findings suggest that when casinos are located within 10 miles of respondent’s home, neighborhood disadvantage was positively related to frequency of

gambling. Results from this study validate what is already considered to be common

knowledge, an increase in individual’s probability of gambling is linked with an increase of financial trouble. There are, however, other aspects of proximity to a casino that my also affect financial well-being. Casinos have been found to increase employment (Cotti, 2008) and income (Walker and Jackson, 1998). To this end it is an empirical question to understand what happens to a person’s financial health when new casinos open.

Casinos and Bankruptcy

To date, examination of the impact of casinos on personal finances has been concentrated primarily in studies linking casino activity to bankruptcy. In the 1990s,

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prompted by anecdotal reports that legalizing gambling was associated with up to 20% of all bankruptcy filings, the National Opinion Research Corporation at the University of Chicago provided a report based on data sets that included national telephone surveys, adults

intercepted in gaming facilities, and adolescents at home via telephone. They also collected data from 100 communities and conducted ten detailed community case studies on the effects of casino openings. [42] Comparing pre- and post-casino data, they concluded that legalizing casino gambling did not play a significant role in increasing personal bankruptcy filings. Follow up surveys did implicate the expanded casino access in financial issues among previously identified problem gamblers. [16, 21, 34, 77] Another survey by the National Gambling Impact Policy Commission (1999) found that 19% of Chapter 13 bankruptcies in Iowa were directly related to gambling debt. [28]

Additional studies have been conducted since that time. Nichols et al. (2000), used matched samples of counties gaining casinos to control counties and found significant increases in the per capita bankruptcy filing rate in 5 of the 8 cities in the treatment sample. [77] Using a similar methodology, Evans and Topeleski (2002) suggest that bankruptcy rates increased among non-Native Americans living within 50 miles of a Native-American casino. [40] Daraban (2011) examined aggregate bankruptcy filings in judicial districts between 1999 and 2007 and, using revenue generated from newly opened casinos as a measure of casino activity, found that new casinos were associated with a 2-percentage point increase in bankruptcy filings. [34]

Negative financial impacts from casino openings also extends to the housing market, according to economists at the National Association of Realtors the opening of a casino in

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local neighborhoods can actual harm property values due to increases in housing foreclosures due to excessive gambling losses. [38, 61]

In much of the literature, those most prone to bankruptcy after casino legalization are those who are diagnosed with pathological gambling. Returning to the report by NORC, the increases in bankruptcy that were found largely came not just from gamblers but were driven almost entirely by problem gamblers. [34, 42] These associations extend to the public health literature, specifically Grant et al. (2010) found that gamblers who declared bankruptcy were more likely to have experienced earlier ages of gambling onset and suffer from other

comorbid mental health conditions. [47]

While there is extensive research that has linked gambling and bankruptcy, these studies have focused almost entirely on the county or larger geographic areas and focus on

bankruptcy as the primary outcome measure. Our study builds on the current literature by examining the impact of casino openings on a wide range of personal financial health variables that are intermediate to bankruptcy and are more likely to be felt in the short term. Role of Access in Measurement of Outcomes

The primary goal of this study is to understand what happens to an individual’s financial health when the distance to the nearest casino changes. We also aim to test what role general distance to the nearest casino has on personal financial health. The common practice of placing casinos close to disadvantaged neighborhoods[28, 108] and previous studies that have used differing distance measures, necessitate this study to thoroughly examine the impact of casino openings on financial well-being.

Casino access for individuals has been measured at varying geographic levels. As Welte et al. [108] note, different studies have attempted to explain geographic distance of individual

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to casino using varying measures, but most fall short of supplying satisfactory measurements. Even the use of coordinate specific data by Welte et al. [108] suffers from a typical issue that plagues these studies; the lack of specificity when it comes the geographic variation forces authors to simplify the distance measures into categorical variables, in this studies case the authors reduce distance to a simple categorical variable that is representative of an individual living ten miles or less to a casino.[108] Categorization is quite common in the literature largely owing to the level at which geographic and financial information is available, often this means that distance is therefore with at the county level or higher.[16, 21, 108, 110] Within the literature this is not something that has been entirely ignored. Studies like the one completed by Shaffer et al.[100] attempt to explain this distance specificity issue by

measuring distance between individual and casino as an exogenous exposure variable in the context of gambling examined through an environmental toxicological approach. While this study successfully develops a regionally based exposure tool to measure distance in a more accurate fashion this tool also falls victim again to measurement only at the county level which results in a lack of ideal specificity in the modeling.

As Barron et al.[16] discuss it is not uncommon in the literature to attempt to predict bankruptcy filing rates by measuring the proximity of individuals with respect to casinos. One key element differentiating this study from those previously discussed in the way in which we measure distance of individual to casino. We accomplish this more specific distance measurement using zip-code to zip-code distance for each subject in the data to the nearest casino.

This proposed method of zip-code level distance measurement is powerful but does suffer in terms of guidance due to no other directly relatable studies having been completed.

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We overcome this lack of supporting studies by drawing from other areas to help form the methodological basis for how distance measurement as a form of access is best calculated. When examining the literature in this broader measurement of geographic variation and access for differing outcomes, we find that there is an extensive number of studies that can be called upon as useful resources. For example, the 1993 study by David Card[25] examined the impact that the geographic proximity of an individual to a college had as a determinant for individual education level. Treating distance to college as an instrumental variable, Card found that returns to schooling were much more predictive than the standard OLS models that did not account for geographic variation. Studies like this by Card provide

methodological basis both in terms of distance as an instrumental variable but also as a guide on how distance can be best measured when it comes to a specific outcome of interest.

Utilizing distance measures to access is also a widely used measure when it comes to of health and healthcare specific outcomes. Currie & Reagan[32] demonstrate this in their study by utilizing continuous distance measured in miles to the nearest hospital as a determinant of childhood preventative care. Their study’s findings show that as distance from care increases the likelihood of childhood preventative care visits decreases, essentially treating distance as proxy variable to measure barriers to access for necessary care for each individual.

Unlike the casino access and financial hardship literature, which typically measures distance between casino and individual at a county to county level; health utilization typically measures distance of individual to facility using zip-code to zip-code distance measures. These health access studies then provide guidance on the appropriate way to measure distance to access using the more precise zip-code to zip-code distance