Update 1: On May 16, 2024, the U.S. Department of Justice sent a proposed rule to the Federal Register to downgrade marijuana from a Schedule I to a Schedule III drug. This is the first step in a lengthy approval process that starts with a 60-day comment period.

Update 2: Two recent research studies were added to the “Studies on marijuana and driving” section of this piece on July 18, 2024.

As marijuana use continues to rise and state-level marijuana legalization sweeps the U.S., researchers and policymakers are grappling with a growing public safety concern: marijuana-impaired driving.

As of April 2023, 38 U.S. states had legalized medical marijuana and 23 had legalized its recreational use, according to the National Conference of State Legislatures. Recreational or medical marijuana measures are on the ballot in seven states this year.

The issue of marijuana-impaired driving has not been an easy one to tackle because, unlike alcohol, which has well-established thresholds of impairment, the metrics for marijuana’s effects on driving remain rather elusive.

“We don’t have that kind of deep knowledge right now and it’s not because of lack of trying,” says Dr. Guohua Li, professor of epidemiology and the founding director of the Center for Injury Science and Prevention at Columbia University.

“Marijuana is very different from alcohol in important ways,” says Li, who has published several studies on marijuana and driving. “And one of them is that the effect of marijuana on cognitive functions and behaviors is much more unpredictable than alcohol. In general, alcohol is a depressant drug. But marijuana could act on the central nervous system as a depressant, a stimulant, and a hallucinogenic substance.”

Efforts to create a breathalyzer to measure the level of THC, the main psychoactive compound found in the marijuana plant, have largely failed, because “the THC molecule is much bigger than ethanol and its behavior after ingestion is very different from alcohol,” Li says.

Currently, the two most common methods used to measure THC concentration to identify impaired drivers are blood and saliva tests, although there’s ongoing debate about their reliability.

Marijuana, a term interchangeably used with cannabis, is the most commonly used federally illegal drug in the U.S.: 48.2 million people, or about 18% of Americans reported using it at least once in 2019, according to the latest available data from the Centers for Disease Control and Prevention. Worldwide, 2.5% of the population consumes marijuana, according to the World Health Organization.

Marijuana is legal in several countries, including Canada, where it was legalized in 2018. Despite state laws legalizing cannabis, it remains illegal at the federal level in the U.S.

As states grapple with the contentious issue of marijuana legalization, the debate is not just about public health, potential tax revenues and economic interests. At the heart of the discussion is also the U.S. criminal justice system.

Marijuana is shown to have medicinal qualities and, compared with substances like alcohol, tobacco, and opioids, it has relatively milder health risks. However, it’s not risk-free, a large body of research has shown.

Marijuana consumption can lead to immediate effects such as impaired muscle coordination and paranoia, as well as longer-term effects on mental health and cognitive functions — and addiction. As its use becomes more widespread, researchers are trying to better understand the potential hazards of marijuana, particularly for younger users whose brains are in critical stages of development.

Marijuana and driving

The use of marijuana among drivers, passengers and pedestrians has increased steadily over the past two decades, Li says.

Compared with the year 2000, the proportion of U.S. drivers on the road who are under the influence of marijuana has increased by several folds, between five to 10 times, based on toxicology testing of people who died in car crashes, Li says.

A 2022 report from the National Transportation Safety Board finds alcohol and cannabis are the two most commonly detected drugs among drivers arrested for impaired driving and fatally injured drivers. Most drivers who tested positive for cannabis also tested positive for another potentially impairing drug.

“Although cannabis and many other drugs have been shown to impair driving performance and are associated with increased crash risk, there is evidence that, relative to alcohol, awareness about the potential dangers of driving after using other drugs is lower,” according to the report.

Indeed, many U.S. adults perceive daily marijuana use or exposure to its smoke safer than tobacco, even though research finds otherwise.

Several studies have demonstrated marijuana’s impact on driving.

Marijuana use can reduce the drivers’ ability to pay attention, particularly when they are performing multiple tasks, research finds. It also slows reaction time and can impair coordination.

“The combination is that you potentially have people who are noticing hazards later, braking slower and potentially not even noticing hazards because of their inability to focus on competing things on the road,” says Dr. Daniel Myran, an assistant professor at the Department of Family Medicine and health services researcher at the University of Ottawa.

In a study published in September in JAMA Network Open, Myran and colleagues find that from 2010 to 2021 the rate of cannabis-involved traffic injuries that led to emergency department visits in Ontario, Canada, increased by 475%, from 0.18 per 1,000 traffic injury emergency department visits in 2010 to 1.01 visits in 2021.

To be sure, cannabis-involved traffic injuries made up a small fraction of all traffic injury-related visits to hospital emergency departments. Out of 947,604 traffic injury emergency department visits, 426 had documented cannabis involvement.

Myran cautions the increase shouldn’t be solely attributed to marijuana legalization. It captures changing societal attitudes toward marijuana and acceptance of cannabis use over time in the lead-up to legalization. In addition, it may reflect an increasing awareness among health care providers about cannabis-impaired driving, and they may be more likely to ask about cannabis use and document it in medical charts, he says.

“When you look at the 475% increase in cannabis involvement in traffic injuries, rather than saying legalizing cannabis has caused the roads to be unsafe and is a public health disaster, it’s that cannabis use appears to be growing as a risk for road traffic injuries and that there seem to be more cannabis impaired drivers on the road,” Myran says. “Legalization may have accelerated this trend. Faced with this increase, we need to think about what are public health measures and different policy interventions to reduce harms from cannabis-impaired driving.”

Setting a legal limit for marijuana-impaired driving

Setting a legal limit for marijuana-impaired driving has not been easy. Countries like Canada and some U.S. states have agreed upon a certain level of THC in blood, usually between 1 to 5 nanograms per milliliter. Still, some studies have found those limits to be weak indicators of cannabis-impaired driving.

When Canada legalized recreational marijuana in 2018, it also passed a law that made it illegal to drive with blood THC levels of more than 2 nanograms. The penalties are more severe for blood THC levels above 5 nanograms. The blood test is done at the police station for people who are pulled over and are deemed to be drug impaired.

In the U.S., five states — Ohio, Illinois, Montana, Washington and Nevada — have “per se laws,” which set a specific amount of THC in the driver’s blood as evidence of impaired driving, according to the National Conference of State Legislatures. That limit ranges between 2 and 5 nanograms of THC per milliliter of blood.

Colorado, meanwhile, has a “permissible inference law,” which states that it’s permissible to assume the driver was under the influence if their blood THC level is 5 nanograms per milliliter or higher, according to NCSL.

Twelve states, most which have legalized some form of marijuana of use, have zero tolerance laws for any amount of certain drugs, including THC, in the body.

The remaining states have “driving under the influence of drugs” laws. Among those states, Alabama and Michigan, have oral fluid roadside testing program to screen drivers for marijuana and other drugs, according to NCSL.

In May this year, the U.S. Department of Transportation published a final rule that allows employers to use saliva testing for commercially licensed drivers, including truck drivers. The rule, which went into effect in June, sets the THC limit in saliva at 4 nanograms.

Saliva tests can detect THC for 8 to 24 hours after use, but the tests are not perfect and can results in false positives, leading some scientists to argue against using them in randomly-selected drivers.

In a 2021 report, the U.S. National Institute of Justice, the research and development arm of the Department of Justice, concluded that THC levels in bodily fluids, including blood and saliva “were not reliable indicators of marijuana intoxication.”

Studies on marijuana and driving

Over the past two decades, many studies have shown marijuana use can impair driving. However, discussions about what’s the best way to measure the level of THC in blood or saliva are ongoing. Below, we highlight and summarize several recent studies that address the issue. The studies are listed in order of publication date. We also include a list of related studies and resources to inform your audiences.

State Driving Under the Influence of Drugs Laws
Alexandra N. Origenes, Sarah A. White, Emma E. McGinty and Jon S. Vernick. Journal of Law, Medicine & Ethics, July 2024.

Summary: As of January 2023, 33 states and D.C. had a driving under the influence of drugs law for at least one drug other than cannabis. Of those, 29 states and D.C. had a law specifically for driving under the influence of cannabis, in addition to a law for driving under the influence of other drugs. Four states had a driving under the influence of drug laws, excluding cannabis. Meanwhile, 17 states had no law for driving under the influence of drugs, including cannabis.  “The 17 states lacking a DUID law that names specific drugs should consider enacting such a law. These states already have expressed their concern — through legislation — with drug-impaired driving. However, failure to name specific drugs is likely to make the laws more difficult to enforce. These laws may force courts and/or law enforcement to rely on potentially subjective indicators of impairment,” the authors write.

Associations between Adolescent Marijuana Use, Driving After Marijuana Use and Recreational Retail Sale in Colorado, USA
Lucas M. Neuroth, et al. Substance Use & Misuse, October 2023.

Summary: Researchers use data from four waves (2013, 2015, 2017 and 2019) of the Healthy Kids Colorado Survey, including 47,518 students 15 and older who indicated that they drove. They find 20.3% of students said that they had used marijuana in the past month and 10.5% said they had driven under the influence of marijuana. They find that the availability of recreational marijuana in stores was associated with an increased prevalence of using marijuana one to two times in the past month and driving under the influence of marijuana at least once. “Over the study period, one in ten high school age drivers engaged in [driving after marijuana use], which is concerning given the high risk of motor vehicle-related injury and death arising from impaired driving among adolescents,” the authors write.

Are Blood and Oral Fluid Δ9-tetrahydrocannabinol (THC) and Metabolite Concentrations Related to Impairment? A Meta-Regression Analysis
Danielle McCartney, et al. Neuroscience & Biobehavioral Reviews, March 2022.

Summary: Commonly used THC measurements may not be strong indicators of driving impairment. While there is a relationship between certain biomarkers like blood THC concentrations and impaired driving, this correlation is often weak. The study underscores the need for more nuanced and comprehensive research on this topic, especially as cannabis usage becomes more widespread and legally accepted.

The Effects of Cannabis and Alcohol on Driving Performance and Driver Behaviour: A Systematic Review and Meta-Analysis
Sarah M. Simmons, Jeff K. Caird, Frances Sterzer and Mark Asbridge. Addiction, January 2022.

Summary: This meta-analysis of experimental driving studies, including driving simulations, confirms that cannabis impairs driving performance, contrary to some beliefs that it might enhance driving abilities. Cannabis affects lateral control and speed — typically increasing lane excursions while reducing speed. The combination of alcohol and marijuana appears worse than either alone, challenging the idea that they cancel each other out.

Cannabis Legalization and Detection of Tetrahydrocannabinol in Injured Drivers
Jeffrey R. Brubacher, et al. The New England Journal of Medicine, January 2022.

Summary: Following the legalization of recreational marijuana in Canada, there was a notable increase in injured drivers testing positive for THC, especially among those 50 years of age or older. This rise in cannabis-related driving incidents occurred even with new traffic laws aiming to deter cannabis-impaired driving. This uptick began before legalization became official, possibly due to perceptions that cannabis use was soon-to-be legal or illegal but not enforced. The data suggests that while legalization has broad societal impacts, more comprehensive strategies are needed to deter driving under the influence of cannabis and raise public awareness about its risks.

Cannabis and Driving
Godfrey D. Pearlson, Michael C. Stevens and Deepak Cyril D’Souza. Frontiers in Psychiatry, September 2021.

Summary: Cannabis-impaired driving is a growing public health concern, and studies show that such drivers are more likely to be involved in car crashes, according to this review paper. Drivers are less affected by cannabis than they are by alcohol or cocaine, but the problem is expected to escalate with increasing cannabis legalization and use. Unlike alcohol, THC’s properties make it challenging to determine direct impairment levels from testing results. Current roadside tests lack precision in detecting genuine cannabis-impaired drivers, leading to potential wrongful convictions. Moreover, there is a pressing need for research on the combined effects of alcohol and cannabis on driving, as well as the impact of emerging popular forms of cannabis, like concentrates and edibles. The authors recommend public awareness campaigns about the dangers of driving under the influence of cannabis, similar to those against drunk driving, to address misconceptions. Policymakers should prioritize science-based decisions and encourage further research in this domain.

Demographic And Policy-Based Differences in Behaviors And Attitudes Towards Driving After Marijuana Use: An Analysis of the 2013–2017 Traffic Safety Culture Index
Marco H. Benedetti, et al. BMC Research Notes, June 2021.

Summary: The study, based on a U.S. survey, finds younger, low-income, low-education and male participants were more tolerant of driving after marijuana consumption. Notably, those in states that legalized medical marijuana reported driving after use more frequently, aligning with studies indicating a higher prevalence of THC detection in drivers from these states. Overall, while the majority perceive driving after marijuana use as dangerous, not all research agrees on its impairment effects. Existing studies highlight that marijuana impacts motor skills and executive functions, yet its direct correlation with crash risk remains debated, given the variations in individual tolerance and how long THC remains in the system.

Driving Under the Influence of Cannabis: A Framework for Future Policy
Robert M. Chow, et al.Anesthesia & Analgesia, June 2019.

Summary: The study presents a conceptual framework focusing on four main domains: legalization, driving under the influence of cannabis, driver impairment, and motor vehicle accidents. With the growing legalization of cannabis, there’s an anticipated rise in cannabis-impaired driving cases. The authors group marijuana users into infrequent users who show significant impairment with increased THC blood levels, chronic users with minimal impairment despite high THC levels, and those with consistent psychomotor deficits. Current challenges lie in the lack of standardized regulation for drivers influenced by cannabis, primarily because of state-to-state variability and the absence of a federal statutory limit for blood THC levels. European nations, however, have established thresholds for blood THC levels, ranging from 0.5 to 50.0 micrograms per liter depending on whether blood or blood serum are tested. The authors suggest the combined use of alcohol and THC blood tests with a psychomotor evaluation by a trained professional to determine impairment levels. The paper stresses the importance of creating a structured policy framework, given the rising acceptance and use of marijuana in society.

Additional research

Cannabis-Involved Traffic Injury Emergency Department Visits After Cannabis Legalization and Commercialization
Daniel T. Myran, et al. JAMA Network Open, September 2023.

Driving Performance and Cannabis Users’ Perception of Safety: A Randomized Clinical Trial
Thomas D. Marcotte, et al. JAMA Psychiatry, January 2022.

Medicinal Cannabis and Driving: The Intersection of Health and Road Safety Policy
Daniel Perkins, et al. International Journal of Drug Policy, November 2021.

Prevalence of Marijuana Use Among Trauma Patients Before and After Legalization of Medical Marijuana: The Arizona Experience
Michael Levine, et al. Substance Abuse, July 2021.

Self-Reported Driving After Marijuana Use in Association With Medical And Recreational Marijuana Policies
Marco H. Benedetti, et al. International Journal of Drug Policy, June 2021.

Cannabis and Driving Ability
Eric L. Sevigny. Current Opinion in Psychology, April 2021.

The Failings of per se Limits to Detect Cannabis-Induced Driving Impairment: Results from a Simulated Driving Study
Thomas R. Arkell, et al. Traffic Injury Prevention, February 2021.

Risky Driving Behaviors of Drivers Who Use Alcohol and Cannabis
Tara Kelley-Baker, et al. Transportation Research Record, January 2021.

Direct and Indirect Effects of Marijuana Use on the Risk of Fatal 2-Vehicle Crash Initiation
Stanford Chihuri and Guohua Li. Injury Epidemiology, September 2020

Cannabis-Impaired Driving: Evidence and the Role of Toxicology Testing
Edward C. Wood and Robert L. Dupont. Cannabis in Medicine, July 2020.

Association of Recreational Cannabis Laws in Colorado and Washington State With Changes in Traffic Fatalities, 2005-2017
Julian Santaella-Tenorio, et al. JAMA Internal Medicine, June 2020.

Marijuana Decriminalization, Medical Marijuana Laws, and Fatal Traffic Crashes in US Cities, 2010–2017
Amanda Cook, Gregory Leung and Rhet A. Smith. American Journal of Public Health, February 2020.

Cannabis Use in Older Drivers in Colorado: The LongROAD Study
Carolyn G. DiGuiseppi, et al. Accident Analysis & Prevention, November 2019.

Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado
Jayson D. Aydelotte, et al. American Journal of Public Health, August 2017.

Marijuana-Impaired Driving: A Report to Congress
National Highway Traffic Safety Administration, July 2017

Interaction of Marijuana And Alcohol on Fatal Motor Vehicle Crash Risk: A Case–Control Study
Stanford Chihuri, Guohua Li and Qixuan Chen. Injury Epidemiology, March 2017.

US Traffic Fatalities, 1985–2014, and Their Relationship to Medical Marijuana Laws
Julian Santaella-Tenorio, et al. American Journal of Public Health, February 2017.

Delays in DUI Blood Testing: Impact on Cannabis DUI Assessments
Ed Wood, Ashley Brooks-Russell and Phillip Drum. Traffic Injury Prevention, June 2015.

Establishing Legal Limits for Driving Under the Influence of Marijuana
Kristin Wong, Joanne E. Brady and Guohua Li. Injury Epidemiology, October 2014.

Cannabis Effects on Driving Skills
Rebecca L. Hartman and Marilyn A. Huestis. Clinical Chemistry, March 2014.

Acute Cannabis Consumption And Motor Vehicle Collision Risk: Systematic Review of Observational Studies and Meta-Analysis
Mark Asbridge, Jill A. Hayden and Jennifer L. Cartwright. The BMJ, February 2012.

Resources for your audiences

The following resources include explainers from federal agencies and national organizations. You’re free to use images and graphics from federal agencies.

• CDC’s main marijuana page.
• CDC’s marijuana data and statistics.
• Marijuana Drug Facts from the National Institute on Drug Abuse.
• Health Effects of Marijuana from the CDC.
• Learn About Marijuana Risks from the Substance Abuse and Mental Health Services Administration.
• Marijuana and Lung Health from the American Lung Association.
• Substance Use Disorder 101 from the U.S. Department of Health & Human Services.
• What You Need To Know About Marijuana Use and Driving from the CDC.
• Does marijuana use affect driving? from the National Institute on Drug Abuse.
• Drug-Impaired Driving from the National Highway Traffic Safety Administration.

The post Driving under the influence of marijuana: An explainer and research roundup appeared first on The Journalist's Resource.

On July 11, The Journalist’s Resource and the Council for the Advancement of Science Writing’s CASW Connector hosted an online chat discussing how journalists can better cover hot-button topics, focusing on abortion as an example of a medical topic that has become increasingly political. The panelists shared lessons from their research and reporting, offered guidance for journalists covering abortion, and answered questions from the audience.

The event was moderated by Naseem Miller, senior health editor at The Journalist’s Resource, and the panelists were:

• Sarah McCammon, a national political correspondent at NPR who covers abortion policy among other divisive topics.
• Katie Woodruff, a public health social scientist in the Department of Obstetrics, Gynecology, and Reproductive Services at the University of California, San Francisco.

Below you’ll find a recording of the chat and links to resources curated by the panelists, as well as other links and tips provided during the session.

Sign up for CASW Connector’s and The Journalist’s Resource’s newsletters to receive updates about future online events.

Takeaways from Dr. Woodruff’s research:

• Research links:
  • Coverage of Abortion in Select U.S. Newspapers – PMC, Women’s Health Issues, 2019. 
  • Coverage of abortion in major U.S. newspapers, 2022-23, poster presentation for National Abortion Federation annual meeting, April 2024.
  • More details about Dr. Woodruff’s 2022-23 research from the University of California, San Francisco.
• Her 2019 paper found most news coverage treated abortion as a political buzzword without exploring the issue in-depth.
• Stories largely didn’t cover the experiences of people seeking abortion and omitted basic facts, such as that abortion is common and safe and that pregnancy carries a higher risk for women, especially people of color.
• Following the 2022 Supreme Court decision overturning Roe v. Wade, abortion coverage significantly increased. More stories covered the policy and health aspects of this issue in depth.
• Stories of people seeking abortion are more common in news stories in 2022-23 than pre-Dobbs, but news coverage tends to focus on atypical cases. Basic facts about abortion and pregnancy are still rarely included.
• News coverage also rarely focuses on medication abortion, even though this is now the most common method.
• We have an overwhelming body of evidence showing that abortion is safe, and that anti-abortion policies lead to harm. Journalists could do more to ensure these facts are clearly stated in stories.
• Be careful of language used to describe abortion policies; terms like “heartbeat ban” or referring to people seeking abortion as “mothers” can impact readers’ perceptions.

Finding sources, navigating interviews:

• Reproductive health clinics and providers can offer sources, including doctors and patients. Health care providers are good secondary sources if you aren’t able to talk to a patient.
• Abortion funds and advocacy groups can also connect journalists with sources. (Don’t call an abortion hotline; connect with organizers.) However, some of these organizations have been overwhelmed post-Dobbs and may not have the capacity to or be comfortable with sharing patient information. It is also worth taking note of whether any groups pay sources, as a few do this.
• Ethical consent is important during interviews. Make sure the source understands who you are and how their story will be used. Make it clear what it means to be on- or off-the-record, and let sources know they can choose not to answer a question if they’re uncomfortable with it.
• Vetting information from a source can include searching public databases and checking information between patients and providers.
• Expand your perception of who can be a source. Historians and other scholars may be able to offer historical context for news pieces.
• Providing sources with some level of anonymity, such as using a first name only, can help protect those at more risk from speaking out about their experience. Be clear about your outlet’s policy for anonymity during the interview.

McCammon’s other tips for covering hot-button topics:

• A framework to avoid bias: A journalist’s own experiences and perspectives are not nearly as important to a news story as the evidence. Consider your job to be informing the audience and shedding light on different aspects of an issue, not persuading anyone of a particular argument.
• Personal stories from sources can help your audience understand the impacts of policies on real people. These may be tough to find for some stories but are important to include when possible.
• Don’t assume you have all the answers, even if you’re experienced in covering an issue. Be curious and open-minded.
• Aim to be as accurate and specific as possible in language to reduce misinterpretation. For example, some outlets (like NPR) have moved to use “abortion rights supporter” and “abortion rights opponent” over “pro-choice” and “pro-life.”
• Ask rigorous questions of politicians and policy platforms and weigh their positions against scientific evidence and potential health impacts.

Articles & resources:

• Media briefing: Reproductive health and abortion, SciLine, July 11, 2024.
• Abortion pill mifepristone: An explainer and research roundup about its history, safety and future, The Journalist’s Resource, Naseem S. Miller, November 1, 2023.
• Covering abortion as a health care issue in all its complexity, politics aside, Association of Health Care Journalists, Tara Haelle, May 24, 2023.
• Covering abortion as a health care story, not just a political one, Association of Health Care Journalists, Jordan Gass-Pooré, June 12, 2024.
• NPR Public Editor: How abortion language evolves, NPR, Kelly McBride, April 4, 2024.
• Post-Roe: Journalistic “objectivity” meets the heated issue of abortion, Center for Journalism Ethics, Audrey Thibert, November 29, 2022.
• Editing Controversial Science, in Knight Science Journalism Science Editing Handbook, Laura Helmuth.
• Research highlights need for public health approach in news reporting of gun violence, The Journalist’s Resource, Naseem S. Miller, June 25, 2024.
• Trauma-informed journalism: What it is, why it’s important and tips for practicing it, The Journalist’s Resource, Naseem S. Miller, April 13, 2022.
• Covering scientific consensus: What to avoid and how to get it right, The Journalist’s Resource, Denise-Marie Ordway, November 23, 2021.

This tip sheet was published in collaboration with the CASW Connector, where it first appeared. It has been lightly edited for style.

The post Reporting on hot-button topics as a science writer: Lessons from abortion coverage appeared first on The Journalist's Resource.

Migrants often face a variety of health challenges in their host countries, depending on the circumstances of their migration and a host of obstacles such as language barriers, lack of knowledge about the health care system, lack of health insurance and fear of deportation.

During this pivotal election year, when immigration is a hot political topic, it’s important for journalists to help news consumers better understand the specific health challenges that immigrants and refugees encounter in the U.S. and humanize their stories to counter stereotypes, misconceptions and misinformation.

For instance, some states claim that immigrants, especially those who lack legal documentation, are a financial burden on the health care system. However, research suggests the opposite, showing that immigrants, particularly those who lack legal documentation, may subsidize the U.S. health care financing system.

“Immigrants’ substantial contributions to health care funding (despite their relatively low incomes) may be associated with their high labor force participation rate, particularly among men who have recently arrived in the US. Hence, they and their employers (whose benefit payments are widely considered part of the employee’s earned compensation) contribute to health insurance premiums as well as payroll and other taxes,” write the authors of a 2022 study published in JAMA Network Open, noting that “immigrants contributed $58.3 billion more in premiums and taxes in 2017 than insurers and government paid for their health care, and US-born citizens incurred a net deficit of $67.2 billion.”

Immigration is not an issue unique to the United States.

Today, more people than ever live in a country other than the one in which they were born, according to the United Nations. As of July 2020, there were an estimated 281 million international migrants, making up 3.5% of the global population. That’s compared with 2.8% in 2000 and 2.3% in 1980, according to the UN.

In 2022, there were 21.2 million noncitizen immigrants in the U.S., accounting for roughly 7% of the country’s population, according to a June 2024 policy brief by the Kaiser Family Foundation, now called KFF. About 40% are people who lack the legal documents needed to stay in the country.

Immigrant health is strongly shaped by the social, economic and political conditions of their host country, write Michael D. Stein and Sandro Galea in the 2020 book “Pained: Uncomfortable Conversations about the Public’s Health.”

“Legal status in the host country, for example, is associated with access to a broad range of health services and resultant better health,” they write. “Perhaps unsurprisingly, aggressive anti-immigration policies create poor health for the population they target. For example, family separation and detention at our borders traumatize families, deepening the mental health needs of this vulnerable group.”

In addition, as we explain below, research shows many immigrants and refugees experience traumatic events before, during and after their migration, which can lead to mental health problems such as post-traumatic stress disorder, depression and anxiety.

Children and pregnant women often face challenges in accessing pediatric and prenatal care. There is also research on the health risks associated with the types of jobs that immigrants and refugees hold.

But first, a primer on terminology and level of access to health care based on immigration status:

Immigrants, migrants, refugees and asylum seekers

The terms “refugee,” “asylum seeker” and “immigrant” are often used in discussions about people moving from one country to another, but they have distinct meanings based on the reasons for their move and individuals’ legal status.

Immigrant

An immigrant is a person who makes the decision to leave their home country and moves to another country with the intention of settling there, according to the International Rescue Committee, a humanitarian aid nongovernmental organization.

Immigrants move for various reasons, including economic opportunities, family reunification or a desire for a change in lifestyle. Unlike refugees or asylum seekers, immigrants do not typically flee persecution or immediate life-threatening situations. Their move can be either permanent or temporary, and they may go through legal channels to obtain residency rights, work permits or citizenship in the host country.

The AP Stylebook says immigrant, “rather than migrants, is most commonly used for people established in the U.S., which usually is their final destination. It also is used when another specific country is the final destination.”

Migrant

There’s no internationally accepted legal definition for the term ‘migrant.’ But the term generally refers to people who are staying outside of their home country and are not asylum seekers or refugees, according to Amnesty International, a global non-governmental organization focused on human rights.

“While dictionary definitions sometimes distinguish ‘immigrants’ — people who are, or intend to be, settled in their new country — from ‘migrants’ who are temporarily resident, ‘immigrant’ and ‘migrant’ (as well as ‘foreigner’) are often used interchangeably in public debate and even among research specialists,” according to The Migration Observatory at the University of Oxford.

The UN defines an international migrant as any person who has changed their country of residence, regardless of legal status or the nature and motive of their move.

The AP Stylebook says the term also “may be used for those whose reason for leaving their home country is not clear, or to cover people who may also be refugees or asylum-seekers.”

Refugee

A refugee is forced to leave their country to escape war, persecution or natural disaster. Refugees have a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group. Many have been forced to flee with little more than the clothes on their back, according to the UN Refugee Agency UNHCR, formerly the United Nations High Commissioner for Refugees. Today, there are 43.4 million refugees around the world.

People go through a process known as refugee status determination in their host country to establish whether their circumstances make them refugees, according to the UN Refugee Agency.

Refugees have a right to international protection, according to Amnesty International. Those rights and protections include the right not to be expelled from their host country, the right to non-discrimination, the right to housing, education and work, according to the UN Refugee Agency.

To become a refugee in the United States, a person has to apply for protection while outside the U.S., while to become an asylum seeker, the application for protection must be submitted from inside the U.S. or at the border, according to the Migration Policy Institute, a nonpartisan policy and research organization. 

Asylum Seeker

An asylum seeker is someone who is seeking international protection from persecution and serious human rights violations in their home country, according to the UN Refugee Agency and Amnesty International. Their request for refugee status, or complementary protection status, has yet to be processed, or they may not yet have requested asylum but they intend to.

“Seeking asylum is a human right. This means everyone should be allowed to enter another country to seek asylum,” according to Amnesty International.

The length and outcome of this process can vary greatly depending on the laws of the host country and the specifics of the individual’s case. Not all asylum seekers will be found to be refugees, but all refugees were once asylum seekers, according to the UN Refugee Agency.

According to the AP Stylebook, “Asylum, under U.S. and international law, is permission granted to refugees to remain within the country to which they have fled. It is not intended for people leaving for economic reasons.” In addition, “In the United States, people fleeing their home countries who do not qualify for asylum may be eligible for ‘withholding of removal’ or the U.N. Convention Against Torture, which offer similar protections.”

“People who are likely to be asylum-seekers or refugees should not be referred to as migrants,” according to the UN Refugee Agency. “To do so can undermine the legal protections afforded to refugees under international law.”

Asylee

Journalists may come across the term “asylee,” referring to a person who has been granted asylum, but the AP Stylebook recommends against using the word. “We would say she was granted asylum,” according to the Stylebook.

Illegal immigration

The term refers to “entering or living in a country without authorization in violation of civil or criminal law,” according to AP Stylebook. Except in direct quotations, use “illegal” only to refer to an action, not a person, the Stylebook advises: “’illegal immigration’ but not ‘illegal immigrant’.”

Also, “do not use the terms alien, unauthorized immigrant, irregular migrant, an illegal, illegals or undocumented (except when quoting people or government documents that use these terms),” according to the AP Stylebook.

Access to U.S. health care based on immigration status

Health and health care access issues are not the same for all noncitizen immigrants. In the U.S., health care coverage of immigrants is based on their immigration status, as defined by the federal government. This HealthCare.gov page defines the terminology and coverage options.

Immigrants who are lawfully in the U.S. have a five-year waiting period to enroll in Medicaid, a government program primarily serving people with low incomes, or the Children’s Health Insurance Program (CHIP). CHIP is a state-federal insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women, according to HealthCare.gov.

Migrants who lack legal documentation to stay in the country can’t enroll in any federally-funded coverage, including Medicaid, CHIP, Medicare and the Affordable Care Act marketplace, according to KFF.

Refugees and those granted asylum seeker status don’t have to wait five years before enrolling in Medicaid and CHIP, according to HealthCare.gov. Others, including asylum seekers who haven’t been granted asylum status don’t qualify for Medicaid or CHIP, according to KFF.

But some states have tried to close the health coverage gap, especially for children and pregnant people.

So far, 22 states have extended insurance coverage to pregnant people regardless of immigration status through CHIP, according to KFF. Ten states — California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, and Washington — offer extended postpartum coverage for a year regardless of immigration status.

Meanwhile, 35 states, plus D.C., provide Medicaid coverage to children and pregnant people who are in the U.S. legally, without the five-year waiting period, according to HealthCare.gov

As of June 2024, 12 states — California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington — and D.C. cover children through CHIP regardless of immigration status, according to KFF.

The National Immigration Law Center also has maps of states that provide health coverage to immigrant children and pregnant people and a state-by-state list of medical assistance programs available to immigrants.

Six states — California, Colorado, Illinois, New York, Oregon, Washington — plus D.C. have expanded coverage to adults regardless of immigration status, as long as they fall within Medicaid’s income criteria.

In May 2024, the Biden Administration published a new regulation that will include individuals with Deferred Action for Childhood Arrivals (DACA) status as lawfully present in the U.S., so that they will be eligible to gain insurance coverage through the ACA Marketplace, starting this November.

“From a social justice standpoint, we really see legal status as a social determinant of health,” said Dr. Alan Shapiro, during a panel on covering immigrants at the Association of Health Care Journalists’ annual conference in New York City in June. Shapiro is the co-founder and chief strategy officer of Terra Firma National, which provides a range of services to immigrant families.

In a 2023 KFF report based on a joint survey with the LA Times, including 3,358 immigrants 18 years and older, nearly 80% said that they were in good to excellent health, while 20% reported being in fair or poor health. Nearly one in five of those with household incomes below $40,000 per year reported a health condition that required ongoing treatment, compared with about one in ten of those with higher incomes.

“Although most immigrants are healthy and employed, many face challenges to accessing and using health care in the U.S. due to higher uninsured rates, affordability challenges, linguistic and cultural barriers, and immigration-related fears, which has negative implications for their health and financial security,” according to the survey.

Advice for journalists

At the recent AHCJ panel on covering immigration, experts advised journalists to remind their audiences that many people leave their home countries out of necessity for survival.

“Cover migration differently than it’s been covered,” said Shapiro, who is also an assistant professor of pediatrics at Albert Einstein College of Medicine. “I don’t think there’s enough talk about the country conditions and what children and families are really struggling with in their home countries, and I think if the public knew more about how terrible life is for children and families there, and how little protection there is, there would be a lot more empathy and sympathy for [them].”

Dr. Laura Vargas, an assistant professor of psychiatry at the University of Colorado’s Institute of Behavioral Science, who has spent much time speaking to migrants at the U.S.-Mexico border advised journalists to explain the flow of firearms from the U.S. to Latin American countries, a trend that has fueled violence in the region. She has published several studies on the health and mental health of immigrants from Latin America.

“Firearms facilitate the criminal gangs, who are sometimes outgunning the police force and other local law enforcement,” said Vargas. “There’s rampant criminal activity in terms of extortion, robberies, territorial disputes among criminal gangs.”

Those conditions create instability for families and affect the health and mental health of adults and children.

“There’s a lack of future for children and families,” she said. “There’s no employment, and if you graduate with a degree, there’s no job available for you.”

It’s also critical that journalists build trust with the communities they’re covering. At Documented, a nonprofit news site devoted to covering New York City’s immigrants and policies that affect their lives, the staff created a WhatsApp channel to connect with migrants and asylum seekers after learning that the app was the main source of information and communication for them, said Rommel Ojeda, a bilingual journalist, filmmaker and a community correspondent for Documented.

The channel, which has more than 6,000 members, prioritizes privacy by masking phone numbers and offers anonymity to people who agree to be interviewed.

“All of that is to say that we were able to build trust and the trust gave us access so that we can report better,” said Ojeda. “And when I say we can report better, it’s because we can go into the community and really ask for the nuances of each individual who’s talking to us.”

Research roundup

Insurance and Health Care Outcomes in Regions Where Undocumented Children Are Medicaid-Eligible
Julia Rosenberg, Veronika Shabanova, Sarah McCollum and Mona Sharifi. Pediatrics, September 2022.

The study: The study investigates the impact of expanded Medicaid eligibility on children in immigrant families and children who are not in immigrant families. The researchers uses data from the 2019 National Survey of Children’s Health, a nationally representative cross-sectional survey, to compare health care outcomes in states that provide Medicaid eligibility to children regardless of their documentation status (“extended-eligibility states”) with the states that don’t (“nonextended-eligibility states”). There were six extended-eligibility states plus Washington, D.C., at the time of the study. The primary aim was to assess how residing in these different regions affects the rates of uninsured people and health care use among children.

The findings:

• Children in extended-eligibility states had a significantly lower rate of being uninsured (3.7%) compared with those in states that didn’t offer extended eligibility (7.5%).
• Children in immigrant families were more likely to be uninsured compared to those who were not from immigrant families, even if they lived in an extended-eligibility state.
• Children in extended-eligibility states were less likely to forgo medical care (2.2% compared with 3.1%) and dental care (17.1% compared with 20.5%) compared with those in states that didn’t offer extended eligibility.
• There were similar rates of emergency department visits between children in extended- and nonextended-eligibility states.

The takeaway: The study highlights that expanding public health insurance eligibility to all children, regardless of documentation status, is associated with lower rates of being uninsured. “This builds upon the evidence that policies which expand insurance access can improve enrollment within and beyond the target expansion demographic through a ‘welcome mat’ effect,” the authors write. The findings also suggest that states with restrictive health insurance policies for migrant children who lack legal documents to stay in the country may face higher rates of being uninsured and poorer health care use, impacting long-term health and social equity, they add.

Companion commentary: Children in Immigrant Families Deserve Health Care, by Fernando S. Mendoza et al., published in the journal Pediatrics in August 2022.

California’s Health4All Kids Expansion And Health Insurance Coverage Among Low-Income Noncitizen Children
Brandy J. Lipton, Jefferson Nguyen and Melody K. Schiaffino. Health Affairs, July 2021.

The study: Implemented in May 2016, California’s Health4AllKids expanded Medicaid eligibility to all low-income children regardless of their immigration status. The research uses data from the 2012 to 2018 American Community Survey to evaluate the impact of this expansion on health insurance coverage rates among noncitizen children in California compared with eleven states (Delaware, Hawaii, Illinois, Massachusetts, Minnesota, New Jersey, New Mexico, New York, Ohio, Rhode Island, and Washington) plus Washington, D.C.

The findings:

• The rate of noncitizen children lacking health insurance coverage dropped by 34%, translating to a 9 percentage-point increase in any coverage and a 12 percentage-point increase in Medicaid coverage.
• Before the expansion, noncitizen children were significantly less likely to have health insurance compared with citizen children. The Health4All Kids program effectively reduced this disparity by more than half, showcasing the impact of inclusive health policies.
• The study found no significant evidence of a substantial shift from private to public insurance coverage, indicating that the expansion primarily reduced the uninsured rates rather than substituting one form of coverage for another.

The takeaway: “Our analysis provides some of the first evidence on the effects of expanding Medicaid and CHIP to undocumented children. Findings suggest that these policies have the potential to reduce coverage disparities by immigration status,” the authors write.

Publicly-Funded Services Providing Sexual, Reproductive, and Maternal Healthcare to Immigrant Women in the United States: A Systematic Review
Tanvi Jain, Jessica LaHote, Goleen Samari and Samantha Garbers. Journal of Immigrant and Minority Health, June 2022.

The study: The authors review published research about the availability and impact of publicly funded sexual, reproductive and maternal health services on immigrant women in the U.S. The review examines nine studies published from December 2007 to August 2020, focusing on the use of services such as Medicaid, CHIP, and other federally or state-funded programs, particularly among Latina immigrants.

The findings:

• Immigrant women, especially those who lack legal documentation to stay in the country or with low income and education, had higher rates of adequate prenatal care when they had access to Medicaid or CHIP. Six of the nine studies reviewed indicated improved prenatal care adequacy due to access to these programs.
• Immigrant women faced significant barriers to accessing sexual, reproductive, and maternal health services, including cost, language barriers, fear of deportation and lack of knowledge about available services. These barriers often led to delayed or inadequate prenatal care, which can result in severe health outcomes.
• Policies like the “public charge” rule negatively impacted immigrant women’s access to sexual, reproductive, and maternal health services, with many avoiding enrollment in Medicaid due to fear of jeopardizing their immigration status. This led to later initiation of prenatal care and fewer prenatal visits. Public charge is a federal law that determines if a non-citizen applying for a visa or permanent residence is likely to rely on the government for support in the future.

The takeaway: The study underscores the importance of inclusive and comprehensive publicly-funded sexual, reproductive, and maternal health services for immigrant women in the United States. Access to Medicaid and CHIP significantly improves prenatal care adequacy, but numerous barriers still prevent many immigrant women from using those services. Anti-immigrant policies exacerbate challenges, leading to poorer health outcomes. “Similar to women born in the US, immigrant women with low income and educational attainment would most benefit from publicly-funded programming,” the authors write.

More on research funding: Funding for Refugee Health Research From the National Institutes of Health Between 2000 and 2020 by Mehak Kaur, Lana Bridi and Dahlia Kaki, published in JAMA Network Open in January 2024.

The Health of Undocumented Latinx Immigrants: What We Know and Future Directions
India J. Ornelas, Thespina J. Yamanis and Raymond A. Ruiz. Annual Review of Public Health, April 2020.

The study: The authors aim to explore the health outcomes and determinants for Latino migrants who lack legal documentation to stay in the country. The study highlights the social, political and economic factors that impact their health and identifies gaps in current research.

The findings:

• Social and political factors significantly influence the health of migrants who lack legal documentation to be in the country. Factors vary across different stages of migration and are influenced by the immigrants’ country of origin, how they entered the U.S., and changes in their legal and health status over time.
• The study notes that conducting research with migrants who lack legal documentation is challenging due to their precarious living conditions, unstable employment, frequent changes in contact information, and low literacy levels. However, strategies like conducting research at community-based organizations and using social media for communication can help overcome those challenges.

The takeaway: “Public health practitioners can continue to support and advocate for programs and policies that create healthful social and political environments for undocumented Latinx immigrants,” the authors write. They also call for additional research.

Delve deeper: Traumatic Experiences and Place of Occurrence: An Analysis of Sex Differences Among a Sample of Recently Arrived Immigrant Adults from Latin America, by Laura X. Vargas, et al., published in PLOS One in June 2024.

US Immigration Policy Stressors and Latinx Youth Mental Health
Kathleen M. Roche, Rebecca M. B. White and Roushanac Partovi. JAMA Pediatrics, May 2024.

The study: The authors investigate how immigration-related stressors affect parent-child relationships and the subsequent mental health of Latino adolescents. The study includes adolescent-mother duos surveyed at three different time points over four years — 2018, 2020, and 2022, conducted in a suburban Atlanta, Georgia, school district, involving Latino adolescents aged 11 to 16 years.

The findings:

• Immigration-related stressors, such as mothers’ anti-immigrant worries and adolescents’ experiences of family member detention or deportation, were linked to disruptions in parent-child relationships.
• Specifically, anti-immigrant worry was associated with increased parent-child conflict, leading to higher odds of symptoms such as aggression and impulsivity in adolescents.
• For girls, family member detention or deportation led to reduced parental support, which in turn was linked to increased depression and anxiety.

The takeaway: “Our research signals the need for school personnel to address stressors faced by Latinx students and families and for health care institutions to advocate for policies expanding access to affordable, culturally competent mental health services, including for children of immigrants. Congress and both state and local lawmakers have the power to enact policies that reduce risks faced by children in immigrant families. Inclusive immigration policies prioritizing the best interests of children and their families may help protect the mental health of this country’s Latinx youth, the vast majority of whom are US citizens,” the authors write.

Additional reading

• Assessment of Immigrants’ Premium and Tax Payments for Health Care and the Costs of Their Care
  Mark J. Ommerborn, et al. JAMA Network Open, November 2022.
• Health and Health Care Experiences of Immigrants: The 2023 KFF/LA Times Survey of Immigrants
  Drishti. Pillai, et al. KFF, September 2023.
• Medical Care for Newly Arrived Displaced Persons
  Radhika Jain, Geren S. Stone and Matthew G. Gartland. NEJM Evidence, October 2023.
• State-Level Anti-Immigrant Sentiment and Policies and Health Risks in US Latino Children
  Natalie Slopen, et al. Pediatrics, August 2023.
• Understanding the Role of Immigration Status in U.S. Health Coverage: From Barriers to Pathways
  Robert Wood Johnson Foundation, November 2023.
• Living in an Immigrant Family in America: How Fear and Toxic Stress are Affecting Daily Life, Well-Being, & Health
  Samantha Artiga and Petry Ubri. KFF, December 2017.
• The Mental Health of Migrants Living in Limbo: A Mixed-Methods Systematic Review with Meta-Analysis
• Marianne Côté-Olijnyk, J. Christopher Perry, Marie-Ève Paré and Rachel Kronick. Psychiatry Research, July 2024.
• Immigrant and Refugee Health Curricula in US-Based Medical Training: A Scoping Review to Inform Integration Into Pediatric Residency Programs
  Lisa Gantz et al. Academic Pediatrics, July 2024.
• The Impact of Detention on the Health of Asylum Seekers: An Updated Systematic Review: A Systematic Review
  Trine Filges, Elizabeth Bengtsen, Edith Montgomery and Malene Wallach Kildemoes. Campbell Systematic Reviews, July 2024.
• Migrants Come to the U.S. with Trauma. A Broken Mental Health System Adds Stress.
  Anika Nayak and Divya K. Chhabra. Harvard Public Health, February 2024.
• The Health Coverage of Noncitizens in the United States, 2024
  Matthew Buettgens and Urmi Ramchandani. Urban Institute, May 2023.
• 7 Ways to Inform News Coverage of the Southern US Border The Journalist’s Resource, January 2023.

Additional resources

Migration Policy Institute

• This primer on U.S. public benefits (including health care) is a useful resource in sifting through immigrant eligibility by program as well as immigrant legal status.
• The State Immigration Data Profiles have a wealth of data on the immigrant population in the U.S. and state levels, including health insurance coverage for immigrants and U.S.-born overall and by U.S. citizenship status.
• This data tool that looks just at the unauthorized segment of the immigrant population at U.S., state, and top county levels.

Protecting Immigrant Families

Human Rights Watch: Refugees and Migrants

American Immigration Council

ACLU: Immigrants’ Rights

Conscious Style Guide: Ethnicity, Race + Nationality

The post How migrants, asylum seekers and refugees seek health care in the US: A primer and research roundup appeared first on The Journalist's Resource.

We updated this piece on the four-day school week, originally published in June 2018, on July 15, 2023 to include new research and other information.

More than 2,100 public schools in 25 states have switched to a four-day school week, often in hopes of recruiting teachers, saving money and boosting student attendance, researchers estimate.

Small, rural schools facing significant teacher shortages have led the trend, usually choosing to take off Mondays or Fridays to give employees and students a three-day weekend every week. To make up for the lost day of instruction, school officials typically tack time onto the remaining four days.

In some places where schools made the change, school district leaders have marveled at the resulting spikes in job applications from teachers and other job seekers. Teacher shortages, made worse by the COVID-19 pandemic, have plagued public schools nationwide for decades.

“The number of teacher applications that we’ve received have gone up more than 4-fold,” Dale Herl, superintendent of the Independence, Missouri school district, told CBS News late last year.

The impact on students, however, has not been as positive. Although peer-reviewed research on the topic is limited, focusing only on a single state or small group of states, there is evidence that some groups of students learn less on a four-day schedule than on a five-day schedule.

A new analysis of student performance in six states — Colorado, Iowa, Kansas, Montana, North Dakota and Wyoming — finds that students who went to class four days a week, as a whole, made less progress in reading during the academic year than students who went five days a week. Kids on a four-day schedule earned lower reading scores on a spring assessment known as the Measures of Academic Progress Growth, on average.

However, the authors of the paper, published last month, also found that the condensed schedule had little to no effect on the rural students they studied, on average. Schools located in towns and suburbs, on the other hand, saw student performance drop considerably after adopting a four-day week.

The authors also discovered differences among student groups. For example, Hispanic students going to class four days a week made less progress in math during the school year than white students on the same schedule. White students made less progress in math than Native American students during the 11-year study.

“For policymakers and practitioners, this study addresses previous ambiguity about the effects of four-day school weeks on academic outcomes and provides evidence supporting concerns about four-day school week effects on student achievement and growth, particularly for those implemented in non-rural areas,” write the authors, Emily Morton, Paul Thompson and Megan Kuhfeld.

In the spring before the COVID-19 pandemic, a total of 662 public school districts used the schedule — up more than 600% since 1999, Thompson and Morton write in a 2021 essay for the Brookings Institution. That number climbed to 876 during the 2022-23 academic year, they told The Journalist’s Resource in email messages.

In addition to studying the schedule’s effect on student achievement, researchers are also investigating its impact on other aspects of school operations, including education spending, student discipline and employee morale. To make the research easier to find, the University of Oregon’s HEDCO Institute for Evidence-Based Educational Practice has created the Four-Day School Week Research Database.

Anyone can use the interactive platform to sift through research completed as of May 2023. It’s worth noting that most research in the database is not peer-reviewed journal articles. Seventy of the more than 100 papers are student dissertations, theses and other papers.

If you keep reading, you’ll find that we have gathered and summarized several relevant journal articles below. To date, the scholarly literature indicates:

• Some schools cut instructional time when they adopt a four-day schedule.
• The impact of a four-day school week differs depending on a range of factors, including the number of hours per week a school operates, how the school structures its daily schedule and the race and ethnicity of students.
• The condensed schedule does not save much money, considering employee salaries and benefits make up the bulk of school expenses. In a 2021 analysis, Thompson estimates schools save 1% to 2% by shortening the school week by one day.
• Staff morale improves under a four-day school week.
• Fighting and bullying decline at high schools.

Both Thompson and Morton urged journalists to explain that the amount of time schools dedicate to student learning during four-day weeks makes a big difference.

“It’s pretty critical to the story that districts with longer days (who are possibly delivering equal or more instructional time to their students than they were on a five-day week) are not seeing the same negative impacts that districts with shorter days are seeing,” Morton, a researcher at the American Institutes of Research, wrote to JR in late 2023.

In a follow-up conversation with JR in July 2024, Morton pointed out that parents like the four-day schedule despite concerns raised by education scholars. In interviews with researchers, she wrote, “parents mention that they appreciate the additional family time and perceive other benefits of the schedule for their children, and they overwhelmingly indicate that they would choose to keep a four-day schedule over switching back to a five-day schedule.”

Morton would not recommend schools adopt a four-day schedule if their main aim is saving money, boosting student attendance or recruiting and retaining teachers. Research findings “do not provide much support for the argument that four-day school weeks are delivering the intended benefits,” she wrote to JR.

Keep reading to learn more. We’ll update this collection of research periodically.

——————–

A Multi-State, Student-Level Analysis of the Effects of the Four-Day School Week On Student Achievement and Growth
Emily Morton, Paul N. Thompson and Megan Kuhfeld. Economics of Education Review, June 2024.

Summary: This study looks at how switching to a four-day school week affects student achievement over the course of the school year in Colorado, Iowa, Kansas, Montana, North Dakota and Wyoming. A key takeaway: On average, across those six states, students on a four-day schedule learned less during the school year than students who went to class five days a week. However, students in rural areas fared better on that schedule than students in “non-rural” areas.

Researchers studied the scores that students in grades 3-8 earned on an assessment called the Measures of Academic Progress Growth, administered each fall and spring to gauge how much kids learned over the course of the school year. The analysis uses 11 years of test score data in reading and math, collected from the 2008-09 to the 2018-19 academic year.

Researchers found that students who went to school four days a week, as a whole, made smaller gains in reading during the academic year than students who went five days a week. They also earned lower scores in reading on the spring assessment, on average.

When researchers looked at the data more closely, however, they found differences between students attending rural schools and students attending schools located in towns and suburbs — communities the researchers dubbed “non-rural.”

Although adopting a four-day schedule had little to no impact on kids at rural schools, student performance fell considerably at schools in non-rural areas. Those children, as a whole, made less progress in reading and math during the academic year than children attending non-rural schools that operated five days a week. They also earned lower scores in both reading and math on the spring exam.

“The estimated effects on math and reading achievement in non-rural four-day week schools are ‘medium’ and meaningful,” the researchers write, adding that the difference is roughly equivalent to a quarter of a school year worth of learning in the fifth grade.

Researchers also discovered that student performance at schools with four-day schedules varied by gender and race. At schools using a four-day-a-week schedule, girls made smaller gains in reading and math than boys, on average. Hispanic students made less progress in math than white students, who made less progress in math than Native American students.

“The estimated effects on math and reading gains during the school year are not ‘large’ by the developing standards used to interpret effect sizes of education interventions, but they are also not trivial,” the researchers write. “For the many districts and communities who have become very fond of the schedule, the evidence presented in this study suggests that how the four-day school week is implemented may be an important factor in its effects on students.”

Impacts of the Four-Day School Week on Early Elementary Achievement
Paul N. Thompson; et al. Early Childhood Research Quarterly, 2nd Quarter 2023.

Summary: This study is the first to examine the four-day school week’s impact on elementary schools’ youngest students. Researchers looked at how children in Oregon who went to school four days a week in kindergarten later performed in math and English Language Arts when they reached the third grade. What they found: Overall, there were “minimal and non-significant differences” in the test scores of third-graders who attended kindergarten on a four-day schedule between 2014 and 2016 and third-graders who went to kindergarten on a five-day schedule during the same period.

When the researchers studied individual groups of students, though, they noticed small differences. For example, when they looked only at children who had scored highest on their pre-kindergarten assessments of letter sounds, letter names and early math skills, they learned that kids who went to kindergarten four days a week scored a little lower on third-grade tests than those who had gone to kindergarten five days a week.

The researchers write that they find no statistically significant evidence of detrimental four-day school week achievement impacts, and even some positive impacts” for minority students, lower-income students,  special education students, students enrolled in English as a Second Language programs and students who scored in the lower half on pre-kindergarten assessments.

There are multiple reasons why lower-achieving students might be less affected by school schedules than high achievers, the researchers point out. For example, higher-achieving students “may miss out on specialized instruction — such as gifted and enrichment activities — that they would have had time to receive under a five-day school schedule,” they write.

Effects of 4-Day School Weeks on Older Adolescents: Examining Impacts of the Schedule on Academic Achievement, Attendance, and Behavior in High School
Emily Morton. Educational Evaluation and Policy Analysis, June 2022.

Summary: Oklahoma high schools saw less fighting and bullying among students after switching from a five-day-a-week schedule to a four-day schedule, this study finds. Fighting declined by 0.79 incidents per 100 students and bullying dropped by 0.65 incidents per 100 students.

The other types of student discipline problems examined, including weapons possession, vandalism and truancy, did not change, according to the analysis, based on a variety of student and school data collected through 2019 from the Oklahoma State Department of Education and National Center for Education Statistics.

“Results indicate that 4-day school weeks decrease per-pupil bullying incidents by approximately 39% and per-pupil fighting incidents by approximately 31%,” writes the author, Emily Morton, a research scientist at NWEA, a nonprofit research organization formerly known as the Northwest Evaluation Association.

Morton did not investigate what caused the reduction in bullying and fighting. She did find that moving to a four-day schedule had “no detectable effect” on high school attendance or student scores on the ACT college-entrance exam.

Only a Matter of Time? The Role of Time in School on Four-Day School Week Achievement Impacts
Paul N. Thompson and Jason Ward. Economics of Education Review, February 2022.

Summary: Student test scores in math and language arts dipped at some schools that adopted a four-day schedule but did not change at others, according to this analysis of school schedule switches in 12 states.

Researchers discovered “small reductions” in test scores for students in grades 3 through 8 at schools offering what the researchers call “low time in school.” These schools operate an average of 29.95 hours during the four-day week. The decline in test scores is described in terms of standard deviation, not units of measurement such as points or percentages.

At schools offering “middle time in school” — an average of 31.03 hours over four days — test scores among kids in grades 3 through 8 did not change, write the researchers, Paul N. Thompson, an associate professor of economics at Oregon State University, and Jason Ward, an associate economist at the RAND Corp., a nonprofit research organization.

Scores also did not change at schools providing “high time in school,” or 32.14 hours over a four-day school week, on average.

When describing this paper’s findings, it’s inaccurate to say researchers found that test scores dropped as a result of schools adopting a four-day schedule. It is correct to say test scores dropped, on average, across the schools the researchers studied. But it’s worth noting the relationship between test scores and the four-day school week differs according to the average number of hours those schools operate each week.

For this analysis, researchers examined school districts in states that allowed four-day school weeks during the 2008-2009 academic year through the 2017-2018 academic years. They chose to focus on the 12 states where four-day school weeks were most common. The data they used came from the Stanford Educational Data Archive and “a proprietary, longitudinal, national database” that tracked the use of four-day school weeks from 2009 to 2018.

The researchers write that their findings “suggest that four-day school weeks that operate with adequate levels of time in school have no clear negative effect on achievement and, instead, that it is operating four-day school weeks in a low-time-in-school environment that should be cautioned against.”

Three Midwest Rural School Districts’ First Year Transition to the Four Day School Week
Jon Turner, Kim Finch and Ximena Uribe-Zarain. The Rural Educator, 2019.

Abstract: “The four-day school week is a concept that has been utilized in rural schools for decades to respond to budgetary shortfalls. There has been little peer-reviewed research on the four-day school week that has focused on the perception of parents who live in school districts that have recently switched to the four-day model. This study collects data from 584 parents in three rural Missouri school districts that have transitioned to the four-day school week within the last year. Quantitative statistical analysis identifies significant differences in the perceptions of parents classified by the age of children, special education identification, and free and reduced lunch status. Strong parental support for the four-day school week was identified in all demographic areas investigated; however, families with only elementary aged children and families with students receiving special education services were less supportive than other groups.”

Juvenile Crime and the Four-Day School Week
Stefanie Fischer and Daniel Argyle. Economics of Education Review, 2018.

Abstract: “We leverage the adoption of a four-day school week across schools within the jurisdiction of rural law enforcement agencies in Colorado to examine the causal link between school attendance and youth crime. Those affected by the policy attend school for the same number of hours each week as students on a typical five-day week; however, treated students do not attend school on Friday. This policy allows us to learn about two aspects of the school-crime relationship that have previously been unstudied: one, the effects of a frequent and permanent schedule change on short-term crime, and two, the impact that school attendance has on youth crime in rural areas. Our difference-in-difference estimates show that following policy adoption, agencies containing students on a four-day week experience about a 20 percent increase in juvenile criminal offenses, where the strongest effect is observed for property crime.”

Staff Perspectives of the Four-Day School Week: A New Analysis of Compressed School Schedules
Jon Turner, Kim Finch and Ximena Uribe–Zarian. Journal of Education and Training Studies, 2018.

Abstract: “The four-day school week is a concept that has been utilized in rural schools for decades to respond to budgetary shortfalls. There has been little peer-reviewed research on the four-day school week that has focused on the perception of staff that work in school districts that have recently switched to the four-day model. This study collects data from 136 faculty and staff members in three rural Missouri school districts that have transitioned to the four-day school week within the last year. Quantitative statistical analysis identifies strong support of the four-day school week model from both certified educational staff and classified support staff perspectives. All staff responded that the calendar change had improved staff morale, and certified staff responded that the four-day week had a positive impact on what is taught in classrooms and had increased academic quality. Qualitative analysis identifies staff suggestions for schools implementing the four-day school week including the importance of community outreach prior to implementation. No significant differences were identified between certified and classified staff perspectives. Strong staff support for the four-day school week was identified in all demographic areas investigated. Findings support conclusions made in research in business and government sectors that identify strong employee support of a compressed workweek across all work categories.”

The Economics of a Four-Day School Week: Community and Business Leaders’ Perspectives
Jon Turner, Kim Finch and Ximena Uribe–Zarian. Journal of Education and Training Studies, 2018.

Abstract: “The four-day school week is a concept that has been utilized in rural schools in the United States for decades and the number of schools moving to the four-day school week is growing. In many rural communities, the school district is the largest regional employer which provides a region with permanent, high paying jobs that support the local economy. This study collects data from 71 community and business leaders in three rural school districts that have transitioned to the four-day school week within the last year. Quantitative statistical analysis is used to investigate the perceptions of community and business leaders related to the economic impact upon their businesses and the community and the impact the four-day school week has had upon perception of quality of the school district. Significant differences were identified between community/business leaders that currently have no children in school as compared to community/business leaders with children currently enrolled in four-day school week schools. Overall, community/business leaders were evenly divided concerning the economic impact on their businesses and the community. Community/business leaders’ perceptions of the impact the four-day school week was also evenly divided concerning the impact on the quality of the school district. Slightly more negative opinions were identified related to the economic impact on the profitability of their personal businesses which may impact considerations by school leaders. Overall, community/business leaders were evenly divided when asked if they would prefer their school district return to the traditional five-day week school calendar.”

Impact of a 4-Day School Week on Student Academic Performance, Food Insecurity, and Youth Crime
Report from the Oklahoma State Department of Health’s Office of Partner Engagement, 2017.

Summary: “A Health Impact Assessment (HIA) utilizes a variety of data sources and analytic methods to evaluate the consequences of proposed or implemented policy on health. A rapid (HIA) was chosen to research the impact of the four-day school week on youth. The shift to a four-day school week was a strategy employed by many school districts in Oklahoma to address an $878 million budget shortfall, subsequent budget cuts, and teacher shortages. The HIA aimed to assess the impact of the four-day school week on student academic performance, food insecurity, and juvenile crime … An extensive review of literature and stakeholder engagement on these topic areas was mostly inconclusive or did not reveal any clear-cut evidence to identify effects of the four-day school week on student outcomes — academic performance, food insecurity or juvenile crime. Moreover, there are many published articles about the pros and cons of the four-day school week, but a lack of comprehensive research is available on the practice.”

Does Shortening the School Week Impact Student Performance? Evidence from the Four-Day School Week
D. Mark Anderson and Mary Beth Walker. Education Finance and Policy, 2015.

Abstract: “School districts use a variety of policies to close budget gaps and stave off teacher layoffs and furloughs. More schools are implementing four-day school weeks to reduce overhead and transportation costs. The four-day week requires substantial schedule changes as schools must increase the length of their school day to meet minimum instructional hour requirements. Although some schools have indicated this policy eases financial pressures, it is unknown whether there is an impact on student outcomes. We use school-level data from Colorado to investigate the relationship between the four-day week and academic performance among elementary school students. Our results generally indicate a positive relationship between the four-day week and performance in reading and mathematics. These findings suggest there is little evidence that moving to a four-day week compromises student academic achievement. This research has policy relevance to the current U.S. education system, where many school districts must cut costs.”

Other resources

• The Education Commission of the States offers a 50-state comparison of public school students’ instructional time requirements. For example, students in Colorado are required to be in school for a minimum of 160 days each academic year while in Vermont, the minimum is 175 days and in North Carolina, it’s 185.
• The State of the American Teacher project offers insights into how teachers feel about their jobs and the education field as a whole. In early 2022, RAND Corp. surveyed a nationally representative sample of teachers, asking questions on topics such as job-related stress, school safety, COVID-19 mitigation policies and career plans. Survey results show that 56% of teachers who answered a question about their attitude toward their job “strongly” or “somewhat” agreed with the statement, “The stress and disappointments involved in teaching aren’t really worth it.” Meanwhile, 78% “strongly” or “somewhat” agreed with the statement, “I don’t seem to have as much enthusiasm now as I did when I began teaching.”
• Opinions about the four-day school week vary among school board members, district-level administrators, school principals and teachers. These organizations can provide insights: the Schools Superintendents Association, National School Boards Association, National Association of Elementary School Principals and National Association of Secondary School Principals.

Looking for more research on public schools? Check out our other collections of research on student lunches, school uniforms, teacher salaries and teacher misconduct.

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Journalists can’t report accurately on research involving human subjects without knowing certain details about the sample of people researchers studied. It’s important to know, for example, whether researchers used a nationally representative sample.

That’s important whether a journalist is covering an opinion poll that asks American voters which presidential candidate they prefer, an academic article that examines absenteeism among U.S. public school students or a clinical trial of a new drug designed to treat Alzheimer’s disease.

When researchers design a study, they start by defining their target population, or the group of people they want to know more about. They then create a sample meant to represent this larger group. If researchers want to study a group of people across an entire country, they aim for a nationally representative sample — one that resembles the target population in key characteristics such as gender, age, political party affiliation and household income.

Earlier this year, when the Pew Research Center wanted to know how Americans feel about a new class of weight-loss drugs, it asked a sample of 10,133 U.S. adults questions about obesity and the effects of Ozempic, Wegovy and similar drugs. Pew designed the survey so that the answers those 10,133 people gave likely reflected the attitudes of all U.S. adults across various demographics.

If Pew researchers had simply interviewed 10,133 people they encountered at shopping malls in the southeastern U.S., their responses would not have been nationally representative. Not only would their answers reflect attitudes in just one region of the country, the individuals interviewed would not represent adults nationwide.

A nationally representative sample is one of several types of samples used in research. It’s commonly used in research that examines numerical data in public policy fields such as public health, criminal justice, education, immigration, politics and economics.

To accurately report on research, journalists must pay close attention to who is and isn’t included in research samples. Here’s why that information is critical:

1. If researchers did not use a sample designed to represent people from across the nation, it would be inaccurate to report or imply that their results apply nationwide.

A mistake journalists make when covering research is overgeneralizing the results, or reporting that the results apply to a larger group of people than they actually do. Depending on who is included in the sample, a study’s findings might only apply to the people in the sample. Many times, findings apply only to a narrow group of people at the national level who share the same characteristics as the people in the sample — for example, individuals who retired from the U.S. military after 2015 or Hispanic teenagers with food allergies.

To determine who a study is designed to represent, look at how the researchers have defined this target population, including location, demographics and other characteristics.

“Consider who that research is meant to be applicable to,” says Ameeta Retzer, a research fellow at the University of Birmingham’s Department of Applied Health Sciences.

2. When researchers use a nationally representative sample, their analyses often focus on what’s happening at a national level, on average. Because of this, it’s never safe to assume that national-level findings also apply to people at the local level.

“As a word of caution, if you’re using a nationally representative sample, you can’t say, ‘Well, that means in California …,” warns Michael Gottfried, an applied economist and professor at the University of Pennsylvania’s Graduate School of Education.

When researchers create a nationally representative sample of U.S. grade school students, their aim is to gain a better understanding of some aspect of the nation’s student population, Gottfried says. What they learn will represent an average across all students nationwide.

“On average, this is what kids are doing, this is how kids are doing, this is the average experience of kids in the United States,” he explains. “The conclusion has to stay at the national level. It means you cannot go back and say kids in Philadelphia are doing that. You can’t take this information and say, ‘In my city, this is happening.’ It’s probably happening in your city, but cities are all different.”

3. There’s no universally accepted standard for representativeness.

If you read a lot of research, you’ve likely noticed that what constitutes a nationally representative sample varies. Researchers investigating the spending habits of Americans aged 20 to 30 years might create a sample that represents this age group in terms of gender and race. Meanwhile, a similar study might use a sample that represents this age group across multiple dimensions — gender, race and ethnicity along with education level, household size, household income and the language spoken at home.

“In research, there’s no consensus on which characteristics we include when we think about representativeness,” Retzer notes.

Researchers determine whether their sample adequately represents the population they want to study, she says. Sometimes, researchers call a sample “nationally representative” even though it’s not all that representative.

Courtney Kennedy, vice president of methods and innovation at Pew Research Center, has questioned the accuracy of election research conducted with samples that only represent U.S. voters by age, race and sex. It’s increasingly important for opinion poll samples to also align with voters’ education levels, Kennedy writes in an August 2020 report.

“The need for battleground state polls to adjust for education was among the most important takeaways from the polling misses in 2016,” Kennedy writes, referring to the U.S. presidential election that year.

4. When studying a nationwide group of people, the representativeness of a sample is more important than its size.

Journalists often assume larger samples provide more accurate results than smaller ones. But that’s not necessarily true. Actually, what matters more when studying a population is having a sample that closely resembles it, Michaela Mora explains on the website of her research firm, Relevant Insights.

“The sheer size of a sample is not a guarantee of its ability to accurately represent a target population,” writes Mora, a market researcher and former columnist for the Dallas Business Journal. “Large unrepresentative samples can perform as badly as small unrepresentative samples.”

If a sample is representative, larger samples are more helpful than smaller ones. Larger samples allow researchers to investigate differences among sub-groups of the target population. Having a larger sample also improves the reliability of the results.

5. When creating samples for health and medical research, prioritizing certain demographic groups or failing to represent others can have long-term impacts on public health and safety.

Retzer says that too often, the people most likely to benefit from a new drug, vaccine or health intervention are not well represented in research. She notes, for example, that even though people of South Asian descent are more likely to have diabetes than people from other ethnic backgrounds, they are vastly underrepresented in research about diabetes.

“You can have the most beautiful, really lovely diabetes drug,” she says. “But if it doesn’t work for the majority of the population that needs it, how useful is it?”

Women remain underrepresented in some areas of health and medical research. It wasn’t until 1993 that the National Institutes of Health began requiring that women and racial and ethnic minorities be included in research funded by the federal agency. Before that, “it was both normal and acceptable for drugs and vaccines to be tested only on men — or to exclude women who could become pregnant,” Nature magazine points out in a May 2023 editorial.

In 2022, the U.S. Food and Drug Administration issued guidance on developing plans to enroll more racial and ethnic minorities in clinical trials for all medical products.

When journalists cover research, Retzer says it’s crucial they ask researchers to explain the choices they made while creating their samples. Journalists should also ask researchers how well their nationally representative samples represent historically marginalized groups, including racial minorities, sexual minorities, people from low-income households and people who don’t speak English.

“Journalists could say, ‘This seems like a really good finding, but who is it applicable to?’” she says.

The Journalist’s Resource thanks Chase Harrison, associate director of the Harvard University Program on Survey Research, for his help with this tip sheet.  

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Threats against poll workers made national news following false claims from former President Donald Trump and supporters that Joe Biden had fraudulently won the 2020 presidential election.

For example, in Georgia “two local election workers, Ruby Freeman and Wandrea Moss were pressured to make false claims of voter fraud in the 2020 presidential election,” write the authors of a 2022 essay on local political violence, published in the State and Local Government Review. “After refusing to lie, a far-right media outlet spread conspiracies about the two women that resulted in a mob surrounding their house.”

In April 2024, a federal judge upheld a $148 million judgment for Freeman and Moss from a civil case against former Trump lawyer Rudy Giuliani, who admitted to making false claims about the poll workers.

Poll workers perform fundamental tasks in democratic societies, ensuring citizens can safely and freely cast their ballots for measures and candidates, often working long hours on Election Day for low pay.

More than 900,000 poll workers staffed early voting sites and Election Day polling places during the 2016 national elections in the U.S., according to the federal Election Assistance Commission. That number dipped to about 775,000 for 2020, when the COVID-19 pandemic curtailed in-person voting.    

Poll workers are often temporary government employees hired to help on Election Day, though they almost always undergo training beforehand. They greet voters, remind them of their voting district, verify their eligibility, help them use voting equipment, assist voters with disabilities and register voters in states that allow same-day registration, among other tasks.

While poll worker job titles vary by election district, districts may hire a clerk in charge of overall operations on Election Day along with assistant clerks, equipment operators, inspectors who verify that voters are registered, and deputies who greet voters.

Pay varies by election administration jurisdictions, which usually align with county boundaries. In Miami-Dade County, for example, poll workers are paid between $200 and $346 including training, pre-election setup and Election Day duties.

Most poll workers in New York City get $250 for Election Day and are expected to work from 5 a.m. to after 9 p.m., when polls close. In rural Coffee County, Alabama, Election Day pay maxes out at $185.

Election officials, by contrast, are government employees who work on Election Day but also during the rest of the year to prepare for and administer elections.

Journalists can reach out to election officials or visit election office websites to find poll worker duties and job titles. The nonpartisan U.S. Vote Foundation offers this election official directory by state.

Poll worker intimidation and threats

Poll workers are often motivated by civic duty, according to research and reporting featured in the tipsheet below. Despite their commitment to democracy, poll workers have recently been increasingly concerned about threats and violence while doing their jobs.

More than one-third of election officials — 38% — have experienced “threats, harassment, or abuse” specifically because of their job, finds a 2024 survey of 928 local election officials conducted by the Brennan Center for Justice at New York University.

That’s up from 30% who reported the same the year prior. More than half of the officials surveyed in 2024 by the Brennan Center said they are worried about the safety of their staff in future elections and 92% have enacted measures to protect voters and poll workers since 2020.

Some 28% indicated they were “very” or “somewhat” concerned about harassment or threats aimed at their family or loved ones while 27% were “very” or “somewhat” concerned about being assaulted at home or work.

Looking to November

The 2024 presidential race is poised to be a rematch between Trump and Biden.

The ongoing potential for threats to poll workers and election officials is real enough that the U.S. Department of Justice has launched a task force to address those threats.

But some election officials don’t think the task force is doing enough. National Association of State Election Directors Executive Director Amy Cohen in June told reporter Zachary Roth with the nonprofit Oregon Capital Chronicle that it is “very clear that we are not seeing a deterrent effect.”

At the same time, threats do not always come to the attention of police — 45% of local election officials surveyed by the Brennan Center who reported being threatened did not file a report to law enforcement.

We put together this tipsheet, mostly based on recent academic research, to bolster your coverage of threats and violence against election workers in advance of Election Day 2024.

1. Understand the social forces that tend to lead to political violence.

Rachel Kleinfeld, a senior fellow with the nonpartisan think tank Carnegie Endowment for International Peace, identifies four risk factors for political violence in an October 2021 paper in the Journal of Democracy. Kleinfeld defines political violence broadly as “physical harm or intimidation that affects who benefits from or can participate fully in political, economic, or sociocultural life.”

To identify social and political situations that increase the risk for political violence, she draws from examples of political violence abroad, such as anti-Muslim attacks during the political rise of Indian Prime Minister Narendra Modi in the early 2000s.

The risk factors, according to Kleinfeld, are:

• A contested election with high stakes for the balance of power. “For much of U.S. history, one party held legislative power for decades,” Kleinfeld writes. “Yet since 1980, a shift in control of at least one house of Congress was possible — and since 2010, elections have seen a level of competition not seen since Reconstruction.”
• Partisanship based on broad groups. “Up to the 1990s, many Americans belonged to multiple identity groups –for example, a union member might have been a conservative, religious, Southern man who nevertheless voted Democratic,” Kleinfeld writes. “Today, Americans have sorted themselves into two broad identity groups: Democrats tend to live in cities, are more likely to be minorities, women, and religiously unaffiliated, and are trending liberal. Republicans generally live in rural areas or exurbs and are more likely to be white, male, Christian, and conservative.”
• Election rules, such as winner-take-all, that let candidates exploit partisanship. “Winner-take-all elections are particularly prone to violence, possibly because small numbers of voters can shift outcomes,” Kleinfeld writes. “Two-party systems are also more correlated with violence than are multiparty systems, perhaps because they create us-them dynamics that deepen polarization.”
• A lack of institutional checks on political violence. “The United States suffers from three particularly concerning institutional weaknesses today — the challenge of adjudicating disputes between the executive and legislative branches inherent in presidential majoritarian systems, recent legal decisions enhancing the electoral power of state legislatures, and the politicization of law enforcement and the courts,” Kleinfeld writes.

Kleinfeld concludes: “Although political violence in the United States is on the rise, it is still lower than in many other countries. Once violence begins, however, it fuels itself. Far from making people turn away in horror, political violence in the present is the greatest factor normalizing it for the future.”

2. Know that a small but notable segment of the U.S. population thinks political violence is sometimes justified.

To capture a snapshot of Americans’ views of political violence, nine scholars affiliated with the Violence Prevention Research Program at the University of California, Davis, conducted a nationally representative survey with 8,620 participants during the summer of 2022. Results were published in September 2023 in the journal Injury Epidemiology.  

Nearly 20% of those surveyed strongly or very strongly agreed that having a “strong leader for America is more important than having a democracy.” About 14% strongly or very strongly agreed that “in the next few years, there will be civil war in the United States.” And nearly 8% reported that in the future they would be very or extremely likely to be “armed with a gun” in a situation where political violence is justified.

The researchers define political violence as “the use of physical force or violence to advance political objectives.” When they asked participants to imagine a scenario in which they believed political violence was justified “to advance an important political objective,” nearly 22% responded that political violence is never justified.

But, given the same scenario, 4.5% responded that they would be sometimes, very or completely willing to use violence against a poll worker and 6.1% reported the same for using force or violence against an elected local official.

The authors estimate 8 million adults in the U.S. think violence in general can be justified to make political gains, though they emphasize caution since their survey is small compared with the overall population. 

“Our extrapolations also suggest that millions of Americans would be very or completely willing to engage in violence themselves to advance a political objective that they support; between 5 and 6 million people would threaten or intimidate someone, injure them, or kill them,” the authors write.

3. Remind audiences of the long history of electoral violence in the U.S.

While recent violence and threats toward poll workers may seem startling to audiences, they should be made aware of the long history of electoral violence in the U.S.

For example, Black politicians faced violent attacks from white individuals and mobs following the Civil War. This violence formed the foundation for Jim Crow laws that segregated public facilities for white and Black Americans and sharply curtailed Black voting rights for generations.

“The pursuit of legalized voter suppression by Southern Democrats only became possible once violence had been successful enough to put Democrats back in power, Southern state governments (re)developed electoral institutions, and national Republicans abandoned black voters,” write the authors of a March 2019 paper in Perspectives on Politics.

Before and after the civil rights legislation of the 1960s outlawed Jim Crow era segregation, Black voters attempting to register in the south faced physical threats and violence, including from white individuals, mobs and law enforcement.

“Sporadic violence to discourage black political participation persisted as late as the 1960s and lynching continued to be a tool to limit black civil rights, repress black labor, reinforce white racial solidarity, and punish blacks for alleged crimes for many years,” write the authors of the Perspectives on Politics paper.

4. Interview poll workers about what motivates them.

Despite sometimes facing threats to their safety, many poll workers remain resilient in their commitment to facilitating free and fair elections in the U.S. In reviewing recent research, the authors of a chapter in a 2024 book on lessons learned from the 2020 presidential race, published by academic press Springer Link, relay that civic duty and social engagement are top motivators for poll workers.

The authors also conduct their own survey on what motivates poll workers — specifically, 1,729 poll workers in Miami-Dade County during early 2021. Those surveyed were most motivated by being part of the democratic process, performing their civic duty or wanting “to make a difference.”

They were least motivated by financial considerations, such as making some extra money, a finding that tracks with a quarter of participants being retired and despite large job losses at the time stemming from COVID-19 business closures.

But, the authors note, returning poll workers were more interested in pay than first-time poll workers, suggesting that “financial motivations may be less important for recruitment of new poll workers but may become increasingly important for retaining poll workers from election to election.”

The poll workers in Miami motivated by a sense of civic duty are not alone. For example, a poll worker near Seattle received an envelope of white powder while counting mail-in ballots during November 2023. But the elected official in charge told Stateline reporter Matt Vasilogambros that after the fire department arrived, “everybody marched right into that building, and said, ‘Oh, heck no, you are not disrupting the democratic process.’”

5. Understand how election officials try to manage the emotional burden of intimidation, for themselves and their staff.

Poll workers are often steadfast in their commitment to the democratic process, but intimidation and violence can take an emotional toll on them.

Experts and journalists who have researched and worked with trauma survivors say trauma-informed journalism is a good way to tell better, more accurate stories and help protect survivors from further harm.

“Most election workers come to the job with a strong sense of patriotism and pride in their work,” write the authors of a November 2022 article in the journal Administration and Society. “The enthusiasm election workers have for their job is crucial to maintaining trust in the system and creating a connection with the citizen-customer.”

For many citizens, the voting experience and interactions with poll workers “can shape voter perceptions of the government in a broader sense,” the authors write. For poll workers, greeting citizens in a friendly way and doing their best to ensure a smooth voting experience is part of what the authors call “emotional labor,” borrowing a phrase from past research.

For example, the burden of emotional labor might be high for a poll worker who is tired at the end of a long Election Day but is still expected to be helpful and courteous to voters.

The authors of the Administration and Society article identify three ways election administrators have recently tried to relieve or limit the emotional labor of poll workers in the face of violence or violent threats. Some are leaning into more public outreach, while others are making their election offices and workers less accessible to the public.

• Administrative strategies “focus on changes to the way the job is done to avoid burnout from emotional labor,” the authors write. This may include administrators investing in public education campaigns and offering tours of poll sites to build trust with voters they serve. Strategies may also include establishing election associations for officials to share best practices for combating misinformation and ensuring poll worker safety.
• Security strategies “may encompass tactics to protect and manage any direct and indirect attack or threat,” the authors write. Some election officials have put bulletproof glass in their offices and have decreased public outreach. Training for some poll workers now includes “deeper security instructions and quick ways to contact the main election office in the case of incidents.”
• Personal protective strategies, such as those used by the city clerk of Detroit, who “took firearms training and now carries a concealed weapon after receiving threats, including one outside of her home,” the authors write. Other officials, such as Georgia Secretary of State Brad Raffensperger, have requested more police presence at polling places and election offices following threats.

6. Note the difference between poll watchers and poll workers.

Poll workers and poll watchers sound similar but they’re very different. While poll workers are employed by election administration offices, poll watchers, sometimes called “election observers,” are members of the public or partisan groups interested in observing parts of the Election Day process.

States have different rules for people interested in observing voting. In certain jurisdictions they may be able to arrive early to polling sites and verify that voting machines are empty of ballots, watch election officials testing voting machines and other routine but important parts of setting up on Election Day.

Poll watchers are often members of partisan groups or political parties that may favor or oppose certain candidates or ballot measures. Election administration agencies may offer guides detailing poll watcher rights and rules.

They generally are allowed only to ensure that the voting process appears fair. No one watching an election may disrupt the process. States also restrict electioneering — trying to influence voters by handing out pamphlets or partisan apparel, for example — near polling sites.

But poll watchers too have a fraught history. During Reconstruction and again during the 1950s and 1960s, poll watchers intimated racial minorities attempting to exercise their right to register and vote. More recently, before the 2020 presidential election, Trump called on supporters to volunteer as poll watchers and “watch all the thieving and stealing and robbing they do,” none of which happened.

Other resources

Academic

Georgetown University Law Center | What to do if armed groups are near polling or registration places

MIT Election Data + Science Lab | Opting Out? Recent Challenges in Recruiting and Retaining Poll Workers

Election Law Journal | What Do We Actually Know About Poll Worker Recruitment in the United States?

Federal government

U.S. Department of Justice | Public Integrity Section annual reports

U.S. Election Assistance Commission | Election Administration and Voting Survey reports | Election Official Security

Nonprofit

Brookings Institution | The Americans on the front lines of elections

U.S. Vote Foundation | Election Official Directory

National Association of State Election Directors | State voter information

National Association of Election Officials | Board of Directors

News coverage

NBC News | Election worker turnover has reached historic highs ahead of the 2024 vote, new data shows

Oregon Capital Chronicle | Election workers worry that federal threats task force isn’t enough to keep them safe

Stateline | In face of threats, election workers vow: ‘You are not disrupting the democratic process’

The New York Times | Election Workers Face Flood of Threats, but Charges Are Few

The post Reporting on violence and threats against US election workers: 6 things to know appeared first on The Journalist's Resource.

This piece was updated on June 13, 2024 to reflect the recent Supreme Court decision about access to mifepristone, and to highlight new research on medication abortion. It was originally published in November 2023, shortly after the interviews with Ruvani Jayaweera and Carrie Baker took place.

On June 13, the Supreme Court justices in a unanimous decision preserved access to mifepristone, a medication that’s used for the safe termination of early pregnancy, writing that “federal courts are the wrong forum for addressing the plaintiffs’ concerns about FDA’s actions.”

The legal future of mifepristone had hung in the balance for several months.

In August 2023, the 5th U.S. Circuit Court of Appeals ruled that mifepristone should not be prescribed past the seventh week of pregnancy, prescribed via telemedicine, or shipped to patients through the mail. In September, the Justice Department asked the Supreme Court to consider a challenge to that ruling.

On Dec. 13, 2023, the Supreme Court justices announced that they would take up the case on the availability of mifepristone. The American College of Obstetricians and Gynecologists issued a statement on the same day urging the court to rule in favor of keeping the pill on the market and available to patients. The justices heard oral arguments on March 26, 2024 before issuing the June 13 ruling.

Meanwhile, abortion is on the ballot in four states this year so far. Measures have also been proposed in several other states, with initiatives that aim to ban, restrict, or expand abortion rights. (State laws that ban abortion apply to both abortion medications and surgical procedures.)

It’s important for journalists covering abortion to have a good understanding of medication abortion so that they can better inform their audiences. Below, we explain what medication abortion is, how individuals access it, and what research shows about its safety and effectiveness.

Medication abortion

Medication abortion is also known as abortion with pills or medical abortion. The Food and Drug Administration has approved medication abortion for up to 10 weeks of pregnancy and the World Health Organization authorizes its use for up to 12 weeks. It is endorsed by several organizations, including the American College of Obstetricians & Gynecologists and the American Medical Association. Medication abortion can also be used beyond 12 weeks of pregnancy, according to several organizations including the World Health Organization and the International Federation of Gynecology and Obstetrics.

Medication abortions accounted for 51% of all abortions in the U.S. in 2020, according to a 2022 CDC report. Use of medication abortion has been on the rise in recent years, increasing by 154% from 2011 to 2020, and by 22% from 2019 to 2020.

In many parts of the world, including the U.S., a two-medication protocol is used for medication abortion: mifepristone followed by misoprostol. Mifepristone blocks the hormone that is required for the continuation of pregnancy, and misoprostol causes the uterus to cramp and expel the pregnancy tissue.

The current approved regimen for medication abortion is 200 mg of mifepristone, followed by 800 mcg of misoprostol within 24 to 48 hours. Individuals are advised to follow up with a health care provider seven to 14 days after taking mifepristone, according to the FDA.

Studies have shown that both drugs are safe and effective. In consultation with medical experts, The New York Times has curated and reviewed a collection of 101 studies on medication abortion, all of which conclude that the pills are safe.

History of mifepristone

Mifepristone, or RU-486, is a drug that blocks progesterone, a hormone that’s needed for a pregnancy to continue.

Developed by the now-defunct French pharmaceutical firm Roussel-Uclaf, the pill was first approved in France and China in 1988. As of May this year, 96 countries have approved it for medication abortion, according to the Guttmacher Institute, a sexual and reproductive health research and policy organization that supports abortion rights.

The FDA approved mifepristone for medical termination of pregnancy in September 2000. Some 5.9 million women in the U.S. used mifepristone between September 2000 and December 2022, 32 of whom died, according to the FDA, which notes in its report that “the fatal cases are included regardless of causal attribution to mifepristone.” Causes of death included infection, homicide, ruptured ectopic pregnancy, drug overdose, and suicide.

Danco Laboratories manufactures Mifeprex, the brand name for mifepristone. In 2019, the FDA approved a generic version of the drug, which is manufactured by GenBioPro. The drug is also manufactured by other companies around the globe.

When the FDA first approved the pill in 2000, the recommended dosage of mifepristone was higher, 600 mg, compared with the current 200 mg. Studies over time showed the lower dose is effective.

Initially, the FDA also required three doctor office visits, on days one, three, and 14 after taking the pill. Prescribers had to be licensed physicians and the drug had to be dispensed in person at a medical facility. The pill was approved to be prescribed within 49 days of gestation, or seven weeks.

By 2016, after evaluating safety data, the FDA modified prescribing requirements, extending the prescription period to up to 70 days of pregnancy, or 10 weeks. It reduced the number of required office visits to one, between seven and 14 days of taking the pill, and the prescriber no longer had to be a physician. Still, mifepristone was not available at brick-and-mortar pharmacies for patients who had a prescription, nor was it available via telemedicine.

But the onset of the COVID-19 pandemic in 2020, which closed many practices and limited in-office doctor visits, changed that.

Mifepristone prescription after COVID-19 and overturn of Roe v. Wade

In December 2021, the FDA reviewed mifepristone’s long-standing safety data and decided to remove the in-person dispensing requirements, expanding access to telehealth visits in states where abortion isn’t banned. The pill can also be mailed to patients since providers no longer have to dispense the pills in person.

It also allowed brick-and-mortar pharmacies that obtain certification from manufacturers to dispense the drug to people in person or through mail with a prescription.

So far, 18 independent brick-and-mortar pharmacies are dispensing mifepristone, and larger drugstore chains may soon join their ranks.

It’s important to note that since approving mifepristone, the FDA has required prescribers to be certified — which means they have to register with the drugmaker. Pharmacies too need to be certified. Advocates say this requirement further limits who can distribute the drug.

In June 2022, the U.S. Supreme Court overturned Roe v. Wade, striking down the constitutional right to abortion and allowing individual states to decide on access to abortion. Since the decision, 14 states have banned abortion altogether. Those bans apply to both surgical and medication abortions.

Misoprostol and misoprostol-only abortions

The second pill used in the two-pill regimen for medication abortion is misoprostol. The pill is approved by the FDA to prevent stomach ulcers in people at high risk of developing them. It was first approved in 1988.

Even though the FDA hasn’t approved it for medication abortion, misoprostol is used off-label as part of the approved two-pill regimen for medication abortion.

Off-label use means health care providers prescribe a drug for diseases or conditions for which it’s not approved by regulatory bodies such as the FDA. They do so when they deem its use is medically appropriate for the patient.

It is also used worldwide for medication abortion, medical management of miscarriage, induction of labor, and treatment of postpartum bleeding. The drug causes the uterus to cramp and expel pregnancy tissue.

The pill can be used alone for medication abortion.

The World Health Organization has endorsed the use of misoprostol-only for ending a pregnancy in parts of the world where mifepristone is not available. Studies have shown the regimen is safe and effective, although it may have more side effects compared with the two-medication regimen.

A study published in JAMA Network Open in October 2023 finds that misoprostol alone is highly effective in self-managed medication abortions.

Abortion with misoprostol alone is rare in the U.S. but the a legal ban on mifepristone could have made it it the only option for some individuals, she says.

“What our study adds is that under the worst-case scenario in which mifepristone is removed, it doesn’t mean that there’s a ban on medication abortion,” says Ruvani Jayaweera, an epidemiologist and research scientist at Ibis Reproductive Health, a nonprofit organization that conducts social science research primarily on access to abortion and contraception around the world. “Our hope is that this study provides assurance to providers and people who are using misoprostol alone, whether it’s in a clinic-based setting or a telehealth setting or a self-managed setting, about the effectiveness of this method.”

Accessing abortion pills

Abortion pills are prescription medications in the U.S. Individuals in states where abortion is still legal can obtain them from licensed providers in person or via telehealth.

Abortion is currently banned in 14 states. Eleven states have laws limiting abortion between six and 22 weeks. Twelve of the 36 states where abortion is available have restrictions on prescribing medication abortion via telehealth, according to the Kaiser Family Foundation.

In response, activists have created networks of support to help individuals access abortion pills, explains Carrie N. Baker, a contributing editor to Ms. Magazine and professor at Smith College who studies and teaches courses on gender, law and public policy.

“The mainstream press is not adequately paying attention to what’s happening in the United States with regard to the underground network of abortion pill access,” says Baker, who has a forthcoming book on the history and politics of abortion pills in the United States.

These networks have also existed to help individuals around the world.

Europe-based Aid Access mails the medication abortion regimen — mifepristone and misoprostol — to all 50 states, regardless of abortion restrictions. There are other U.S.-based services, including Plan C, which provides people with available options to get abortion pills based on the state they live in.

In a November 2022 research letter published in JAMA, Aid Access reported that after the U.S. Supreme Court overturned Roe v. Wade, the average daily requests for telemedicine services for medication abortion increased from 82.6 to 231.7.

In the U.S., prescribing abortion medications via telehealth is nuanced based on state abortion laws.

For instance, U.S.-based virtual reproductive and sexual health clinic Hey Jane and online pharmacies like Honeybee can provide care and ship the pills to people in states where abortion is not banned. In all states, people may obtain medication abortion from alternative telemedicine services, online websites, or community networks, though the legal risk of each of these options may differ depending on the state. Services like ReproLegal Helpline help guide individuals on laws in their state, Jayaweera says.

Also, physicians in states that have passed shield laws can also prescribe medications via telemedicine to people in states where abortion is banned. So far, several states including Washington, Colorado, Massachusetts, Vermont, New York and California have passed telemedicine shield laws for health providers.

Abortion shield laws “seek to protect abortion providers, helpers, and seekers in states where abortion remains legal from legal attacks taken by antiabortion state actors,” according to a review article published in The New England Journal of Medicine in March 2023. Seven states so far have enacted a shield law since the overturn of Roe v. Wade.

But it’s important to know and note that those laws don’t protect individuals, Jayaweera says.

“One of the things to be especially sensitive to is with telemedicine or online models is that even if the risk is very much minimized for the provider, the legal risk falls on the individual in restricted states,” she says, underscoring the importance of educating individuals about those risks during counseling.

Self-managed abortion

Self-managed abortion is when individuals use medication abortion without medical supervision, ordering pills via telehealth, online pharmacies, mail or in-person.

Worldwide, most medication abortions are self-managed, Jayaweera says.

As a reminder, although the drugs are shown to be safe and effective, the individuals who use self-managed abortion may face legal risks, explain Drs. Daniel Grossman and Nisha Verma in a viewpoint published in JAMA in November 2022.

“Resources like the If/When/How legal helpline may be useful for patients and clinicians who are trying to understand their legal risks related to self-managed abortion. Patients requesting emotional support could be connected with resources that provide free confidential talk lines,” the authors write.

Worldwide, 22 countries ban abortion altogether, according to the Center for Reproductive Health, a global advocacy organization, and many others restrict it. This has given rise to safe abortion hotlines and “accompaniment groups” of people who have training in abortion counseling for individuals who are using medication abortion.

They also “provide a lot of empathetic counseling throughout the process and provide people with additional assurance and support and to help them understand if what they are experiencing is normal, or if they need to seek care,’” says Jayaweera.

She was part of a research team that found the outcomes of self-managed abortions were comparable to the ones performed under clinical supervision. The study, among others, contributed to the World Health Organization revising its guidelines last year to add self-managed abortion in early pregnancy to its abortion guidelines.

National organizations including the American Medical Association and the American College of Obstetricians and Gynecologists oppose the criminalization of self-managed abortion because it deters patients from seeking care when complications occur, write Dr. Lisa H. Harris and Daniel Grossman in a review article published in the New England Journal of Medicine in March 2020.

“Given the safety of the combination of mifepristone and misoprostol for self-managed abortion, the biggest danger to patients may be legal prosecution,” the study authors add. “Doctors and health care institutions must develop strategies that favor effective, compassionate clinical care over legal investigation of patients.”

A note on abortion ‘reversal’ pills

On Oct. 30, a judge in Kansas blocked a state law that requires health care providers to tell patients that medication abortion can be reversed, despite a lack of scientific evidence. A few days earlier, in Colorado, a federal judge ruled that a Catholic medical center can’t be stopped from offering medication abortion “reversal” treatment.

So-called abortion medication “reversal” treatment involves taking a dose of the hormone progesterone in an attempt to stop the effects of mifepristone, but it’s important for journalists to inform their audiences that “reversal” of medication abortion is not supported by science. (The Associated Press recommends using quotation marks in order to stress the lack of scientific evidence.) The American College of Obstetricians and Gynecologists has publicly stated that it does not support the treatment.

“Despite this, in states across the country, politicians are advancing legislation to require physicians to recite a script that a medication abortion can be ‘reversed’ with doses of progesterone, to cause confusion and perpetuate stigma, and to steer women to this unproven medical approach,” reads a statement on ACOG’s website. “Unfounded legislative mandates like this one represent dangerous political interference and compromise patient care and safety.”

Between 2012 and 2021, 14 states had enacted abortion “reversal” laws, according to a February article in the American Journal of Public Health.

“States largely use explicit language to describe reversal, require patients receive information during preabortion counseling, require physicians or physicians’ agents to inform patients, instruct patients to contact a health care provider or visit abortion pill reversal resources for more information, and require reversal information be posted on state-managed Web sites,” the authors write. “Reversal laws continue a dangerous precedent of using unsound science to justify laws regulating abortion access, intrude upon the patient‒provider relationship, and may negatively affect the emotional and physical health of patients seeking [a medication abortion].”

A 2020 randomized controlled study of medication abortion reversal, involving 40 patients, ended early because of safety concerns for 12 participants. Some of the women in the study received 400 mg of progesterone after taking mifepristone to “reverse” the abortion. Others were given a placebo after taking mifepristone. Three patients – one had taken progesterone and two had received placebo – had severe hemorrhage and required ambulance transport to the hospital, the authors write.

“We could not estimate the efficacy of progesterone for mifepristone antagonization due to safety concerns when mifepristone is administered without subsequent prostaglandin analogue treatment. Patients in early pregnancy who use only mifepristone may be at high risk of significant hemorrhage,” they write in the study.

A March 2023 systematic review of four studies finds, “based mostly on poor-quality data, it appears the ongoing pregnancy rate in individuals treated with progesterone after mifepristone is not significantly higher compared to that of individuals receiving mifepristone alone.”

A 2015 systematic review of 11 studies on medication abortion reversal during the first trimester of pregnancy finds “evidence is insufficient to determine whether treatment with progesterone after mifepristone results in a higher proportion of continuing pregnancies compared to expectant management.”

Research roundup

The following roundup of systematic reviews examines the safety and effectiveness of medication abortion. They are listed by publication date. The list is followed by additional research and reporting resources.

Effectiveness and Safety of Misoprostol-Only for First-Trimester Medication Abortion: An Updated Systematic Review and Meta-Analysis
Elizabeth G. Raymond, Mark A. Weaver, and Tara Shochet. Contraception, November 2023.

A review of 49 published studies, including a total of 16,354 patients, finds misoprostol-only is effective and safe for the termination of first-trimester pregnancy, especially when mifepristone is not available.

“Technically An Abortion”: Understanding Perceptions and Definitions of Abortion in the United States
Alicia J. VandeVusse, et al. Social Science & Medicine, October 2023.

The study is based on in-depth interviews of 64 cisgender women and 2009 participants in an online survey. Individuals were asked about their understanding of pregnancy outcomes including abortion and miscarriage. “The blurred boundaries between different types of pregnancies and their outcomes emphasize the differences in people’s notions of what constitutes an abortion,” the authors write. “It shapes how abortion stigma can arise across different pregnancy outcomes, as well as people’s own perceptions of the care they have sought, the legality of this care, and their experience in accessing it. Understanding how people construct boundaries around abortion allows for more effective healthcare messaging and advocacy, which is increasingly relevant as legal restrictions on abortion mount while telemedicine and medication abortion become more widely available to some.”

Requests for Self-managed Medication Abortion Provided Using Online Telemedicine in 30 US States Before and After the Dobbs v Jackson Women’s Health Organization Decision
Abigail R. A. Aiken, et al. JAMA, November 2022.

The authors analyze anonymized requests for abortion pills to Aid Access, a Europe-based abortion pill provider. They analyzed the requests before Roe v. Wade was overturned, after the decision was leaked, and after the decision was announced. They find that each of the 30 states from which requests came, regardless of abortion policy, showed a higher request rate after the leak and announcement compared to before. The largest increases were in states that enacted total bans on abortion.

Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries
Ian Ferguson and Heather Scott. Journal of Obstetrics and Gynaecology Canada. April 2020.

A review of 36 studies, including a total of 25,385 medical abortions, finds the combination of mifepristone and misoprostol is “highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.” Among a group of 17,381 women, 0.8% required hospitalization.

Telemedicine for Medical Abortion: A Systematic Review
M. Endler, et al. British Journal of Obstetrics and Gynaecology, March 2019.

A review of 13 studies, mostly based on self-reported data, finds the rates of complete abortion, hospitalization, and blood transfusion after abortion through 10 weeks of pregnancy were at similar levels to those reported after in-person abortion care in the published studies.

First-Trimester Medical Abortion with Mifepristone 200 mg and Misoprostol: A Systematic Review
Elizabeth G. Raymond, Caitlin Shannon, Mark Weaver, and Beverly Winikoff. Contraception, January 2013.

A review of 87 studies, including a total of 47,283 women, finds medical abortion in early pregnancy with 200 mg mifepristone followed by misoprostol is highly effective and safe.

Additional research

Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening
Daniel Grossman, et al. JAMA Internal Medicine, May 2024.

Pharmacists’ Experiences Dispensing Misoprostol and Readiness to Dispense Mifepristone
Meron Ferketa, et al. Journal of the American Pharmacists Association, October 2023.

Medication Abortion Safety and Effectiveness With Misoprostol Alone
Ruvani Jayaweera, et al. JAMA Network Open, October 2023.

Prior Cesarean Birth and Risk of Uterine Rupture in Second-Trimester Medication Abortions Using Mifepristone and Misoprostol: A Systematic Review and Meta-analysis
Andrea Henkel, et al. Obstetrics & Gynecology, October 2023.

Changes in Induced Medical and Procedural Abortion Rates in a Commercially Insured Population, 2018 to 2022
Catherine S. Hwang, et al. Annals of Internal Medicine, October 2023.

Explaining the Fifth Circuit Court of Appeals Ruling on Mifepristone Access
Molly A. Meegan, JAMA, October 2023.

Effectiveness of Self-Managed Medication Abortion Between 9 and 16 Weeks of Gestation
Heidi Moseson, et al. Obstetrics & Gynecology, August 2023.

Comparison of Mifepristone Plus Misoprostol with Misoprostol Alone for First Trimester Medical Abortion: A Systematic Review and Meta-Analysis
Tariku Shimels, Melsew Getnet, Mensur Shafie, and Lemi Belay. Frontiers in Global Women’s Health, March 2023.

Experiences Seeking, Sourcing, and Using Abortion Pills at Home in the United States Through an Online Telemedicine Service
Melissa Madera, et al. Social Science & Medicine: Qualitative Research in Health. December 2022.

Abortion Surveillance — United States, 2020
Katherine Kortsmith, et al. Morbidity and Mortality Weekly Report, November 2022.

Mifepristone: A Safe Method of Medical Abortion and Self-Medical Abortion in the Post-Roe Era
Elizabeth O. Schmidt, Adi Katz, and Richard A. Stein. American Journal of Therapeutics, October 2022.

Effectiveness of Self-Managed Abortion During the COVID-19 Pandemic: Results From a Pooled Analysis of Two Prospective, Observational Cohort Studies in Nigeria
Ijeoma Egwuatu, et al. PLOS Global Public Health, October 2022.

Increasing Access to Abortion
American College of Obstetricians & Gynecologists, December 2020.

Abortion Pill “Reversal”: Where’s the Evidence
Advancing New Standards In Reproductive Health, July 2020.

A Qualitative Exploration of How the COVID-19 Pandemic Shaped Experiences of Self-Managed Medication Abortion with Accompaniment Group Support in Argentina, Indonesia, Nigeria, and Venezuela
Chiara Bercu, et al. Sexual and Reproductive Health Matters, June 2022.

Medical Abortion in the Late First Trimester: A Systematic Review
Nathalie Kapp, Elisabeth Eckersberger, Antonella Lavelanet, Maria Isabel Rodriguez. Contraception, February 2019.

Continuing Pregnancy After Mifepristone and “Reversal” of First-Trimester Medical Abortion: A Systematic Review
Daniel Grossman, et al. Contraception, September 2015.

Medical Compared With Surgical Abortion for Effective Pregnancy Termination in the First Trimester
Luu Doan Ireland, Mary Gatter, Angela Y. Chen. Obstetrics & Gynecology, July 2015.

Resources

What to Know About Fetal Viability — And Why Some Advocates Want It Out of Abortion Law
Mary Chris Jaklevic. Association of Health Care Journalists’ Covering Health blog, October 2023.

#WeCount: A series of reports by the Society of Family Planning aiming to capture the shifts in abortion volume by state and month following the Supreme Court decision to overturn Roe.

History and Politics of Medication Abortion in the United States and the Rise of Telemedicine and Self-Managed Abortion
Carrie N. Baker. Journal of Health Politics, Policy and Law, August 2023.

Mifepristone U.S. Post-Marketing Adverse Events Summary through 12/31/2022
Food and Drug Administration

Questions and Answers on Mifepristone for Medical Termination of Pregnancy Through Ten Weeks Gestation
Food and Drug Administration

Key Facts on Abortion in the United States
Usha Ranji, Karen Diep and Alina Salganicoff. Kaiser Family Foundation, August 2023.

The Availability and Use of Medication Abortion
Kaiser Family Foundation, June 2023.

A Review of Exceptions in State Abortions Bans: Implications for the Provision of Abortion Services
Kaiser Family Foundation, May 2023.

State Requirements for the Provision of Medication Abortion
Kaiser Family Foundation, April 2023.

Are Abortion Pills Safe? Here’s the Evidence.
Amy Schoenfeld Walker, Jonathan Corum, Malika Khurana, and Ashley Wu. The New York Times, April 2023.

Abortion Care Guideline
World Health Organization, March 2022.

Center for Reproductive Rights provides a global view of abortion.

Abortion Facility Database by Advancing New Standards in Reproductive Health, based at the University of California San Francisco, is a research program that informs the most pressing debates on abortion and reproductive health.

The post Abortion pill mifepristone: An explainer and research roundup about its history, safety and future appeared first on The Journalist's Resource.

As artificial intelligence infiltrates virtually every aspect of life, more states in the U.S. are seeking to regulate (or at least monitor) its use. Many are passing legislation, issuing policy rules or forming committees to inform those decisions. In some cases, that includes health insurance, where AI holds great promise to speed and improve administration but also brings potential for peril, including racial bias and omissions inherent in formulas used to determine coverage approvals.

Meanwhile, major health insurers Humana, Cigna, and UnitedHealth all face lawsuits alleging  that the companies improperly developed algorithms that guided AI programs to deny health care. The suit against Cigna followed a ProPublica story revealing “how Cigna doctors reject patients’ claims without opening their files.” The class action suits against United Health and Humana followed an investigative series by STAT, in which reporters revealed that multiple major health insurers had used secret internal rules and flawed algorithms to deny care.

Journalists should pay attention to guardrails governments are seeking to erect to prevent problematic use of AI — and whether they’ll ultimately succeed as intended. Both federal and state governments report they are working to prevent discrimination, a broad concern as AI systems become more sophisticated and help administrators make decisions, including what’s covered by a policy. Proposed state legislation and regulatory guidelines aim to require health insurance companies to be more transparent about how their systems were created, what specific data sets are fed into those systems and how the algorithms that instruct a program’s decision-making are created.

We’ve created this guide to help journalists understand the nascent regulatory landscape, including proposed state laws; which regulators are compiling and issuing guidelines; and what researchers have learned so far.                                       

Government efforts to regulate AI use among health insurers

Who regulates health insurers, and how, depends largely on the type of health insurance itself. Congress and the Biden administration are stepping up efforts to form a blueprint for AI use, including in health insurance.

State-level resolutions and legislation

For local journalists, this complex landscape provides an avenue rich with potential reporting opportunities.

According to the National Conference of State Legislatures, at least 40 states introduced or passed legislation aimed at regulating AI in the 2024 legislative session through March 17, with at least half a dozen of these actions tied to health care. Six states, Puerto Rico and the Virgin Islands adopted resolutions or enacted new laws.

That’s on top of 18 states and Puerto Rico’s adoption of resolutions or legislation tied to AI in 2023, according to data from the NCSL. Many states are modeling regulations to include guidance from the National Association of Insurance Commissioners (NAIC) issued in December 2023.

The Colorado Division of Insurance, for example, is mulling how to apply new rules adopted by the state legislature in 2021, which are designed to be a check for consumers on AI-generated decisions. It was the first state to target AI use in insurance, according to Bloomberg.

Colorado’s insurance commissioners have so far issued guidance for auto and life insurers under the statute. In recent months, commissioners held hearings and called for written comments to help form its approach to applying the new rules to health insurers, according to materials on the agency’s website.

Colorado’s legislation seeks to hold “insurers accountable for testing their big data systems – including external consumer data and information sources, algorithms, and predictive models — to ensure they are not unfairly discriminating against consumers on the basis of a protected class.”  In Colorado, protected class includes race, color, religion, national origin/ancestry, sex, pregnancy, disability, sexual orientation including transgender status, age, marital status and familial status, according to the state’s Civil Rights Division.

There isn’t yet a firm timeline for finalizing these rules for health insurance because the agency is still early in the process as it also works on life insurance, Vincent Plymell, the assistant commissioner for communications and outreach at the Colorado Division of Insurance, told The Journalist’s Resource.

In California, one bill sponsored by the California Medical Association would “require algorithms, artificial intelligence, and other software tools used for utilization review or utilization management decisions” be “fairly and equitably applied.” Earlier language that would have mandated a licensed physician supervise AI use for decisions to “approve, modify, or deny requests by providers” was struck from the bill.

In Georgia, a bill would require coverage decisions using AI be “meaningfully reviewed” by someone with authority to override them. Illinois,  New York,  Pennsylvania, and Oklahoma are also among states that introduced legislation tied to health care, AI and insurance.

Several states including Maryland, New York, Vermont and Washington state have issued guidance bulletins for insurers modeled after language crafted by the NAIC. The model bulletin, issued in December 2023, aims to set “clear expectations” for insurers when it comes to AI. The bulletin also has standard definitions for AI-related terms, like machine learning and large language models.

A group of NAIC members is also developing  a survey of health insurers on the issue.      

One concern insurers have is that rules may be different across states, Avi Gesser, a data security partner at the law firm Debevoise & Plimpton LLP, told Bloomberg Law.

“It would be a problem for some insurers if they had to do different testing for their algorithm state-by-state,” Gesser said in a November 2023 article. “Some insurers may say, ‘Well, maybe it’s not worth it—maybe we won’t use external data, or maybe we won’t use AI.’”

It’s useful for journalists to read published research to learn more about how artificial intelligence, insurers and health experts are approaching the issue technically, politically and legally. To help, we’ve curated and summarized several studies and scholarly articles on the topic.      

Research Roundup:    

Responsible Artificial Intelligence in Healthcare: Predicting and Preventing Insurance Claim Denials for Economic and Social Wellbeing
Marina Johnson, Abdullah Albizri and Antoine Harfouche. Information Systems Frontiers, April 2021.

The study: The authors examine AI models to help hospitals identify and prevent denials of patient insurance claims, aiming to cut the costs of appeals and reduce patient emotional distress. They examine six different kinds of algorithms to recommend the best model for predicting claim rejections and test it in a hospital. The authors use “white box” and “glass box” models, which reveal more data and mechanisms in an AI program than “black box” models, to develop what they label a Responsible Artificial Intelligence recommendation for an AI product to solve this problem.

In developing the proposed solution, the authors take into account five principles: transparency, justice, a no-harm approach, accountability and privacy.

To develop their proposal, the researchers used a dataset of 57,458 claims from a single hospital submitted to various insurance companies. They caution that their experiment involved using data from a single hospital.

The findings      
The solution the authors propose seeks to identify, in part, errors in coding and billing, medical needs, and mismatched codes for services and procedures to a patient’s diagnosis. Once flagged by the system the error can be fixed before submitting to an insurance company. That may spare the insured patient from going through the appeals process. The technical solution proposed by the authors “delivers a high accuracy rate” at about 83%, they write.

They recommend future research use data from insurance companies in which “many providers submit claims, providing more generalizable results.”

The authors write: “Insured patients suffering from a medical condition are overburdened if they have to deal with an appeal process for a denied claim. An AI solution similar to the one proposed in this study can prevent patients from dealing with the appeal process.”

Fair Regression for Health Care Spending
Anna Zink and Sherri Rose. Biometrics, September 2020.

The study: In this study, the authors examine and suggest alternative methods to predict spending in health insurance markets so insurers can provide fair benefits for enrollees in a plan, while more accurately gauging their financial risk. The authors examine “undercompensated” groups, people who are often underpaid by health insurance formulas, including people with mental illness or substance abuse disorders. They then suggest new tools and formulas for including these groups in regression analysis used to calculate fair benefits for enrollees. Regression analysis is a way of parsing variables in data to glean the most important factors in determining risk, what the impact is and how robust those factors are in calculations used to predict fair benefits and coverage.   

The findings: In their analysis, the authors use a random sample of 100,000 enrollees from the IBM MarketScan Research database in 2015 to predict total annual expenditures for 2016. Almost 14% of the sample were coded with a diagnosis of mental health and substance abuse disorder. When insurance companies “underpredict” spending for groups like these, “there is evidence that insurers adjust the prescription drugs, services, and providers they cover” and alter a plans’ benefit design “to make health plans less attractive for enrollees in undercompensated groups.”

The authors propose technical changes to formulas used to calculate these risks to produce what they find are more inclusive results for underrepresented groups, in this case those categorized as having mental health and substance use disorders. One of their suggested changes meant a 98% reduction in risk that insurers would be undercompensated, likely leading to an improvement in coverage for that group. It only increased insurer risk tied to predicting cost for enrollees without mental health and substance use disorders by about 4%, or 0.5 percentage points. The results could lead to “massive improvements in group fairness.”

The authors write: “For many estimators, particularly in our data analysis, improvements in fairness were larger than the subsequent decreases in overall fit. This suggests that if we allow for a slight drop in overall fit, we could greatly increase compensation for mental health and substance use disorders. Policymakers need to consider whether they are willing to sacrifice small reductions in global fit for large improvements in fairness.”

Additional reading: The authors outline this and two other studies tied to the topic in a November 2022 policy brief for the Stanford University Human Centered Artificial Intelligence group.

The Imperative for Regulatory Oversight of Large Language Models (or Generative AI) in Healthcare
Bertalan Meskó and Eric J. Topol. NPJ Digital Medicine, July 2023.

The article: In this article, the authors argue a new regulatory category should be created specifically for large language models in health care because they are different from previous artificial intelligence mechanisms in scale, capabilities and impact. LLMs can also adapt their responses in real-time, they note. The authors outline categories regulators could create to harness — and help control — LLMs.

By creating specific prescriptions for managing LLMs, regulators can help gain the trust of patients, physicians and administrators, they argue.

The findings: The authors write that safeguards should include ensuring:
• Patient data used for training LLMs are “fully anonymized and protected” from breaches, a “significant regulatory challenge” because violations could run afoul of privacy laws like the Health Insurance Portability and Accountability Act (HIPAA.)
• Interpretability and transparency for AI-made decisions, a “particularly challenging” task for “black box” models that use hidden and complex algorithms.
• Fairness and safeguards against biases. Biases can find their way into LLMs like Chat GPT-4 during model training that uses patient data, leading to “disparities in healthcare outcomes.”
• Establishing data ownership, something that’s hard to define and regulate.
• Users don’t become over-reliant on AI models, as some AI models can “hallucinate” and yield errors.

The authors write: “LLMs offer tremendous promise for the future of healthcare, but their use also entails risks and ethical challenges. By taking a proactive approach to regulation, it is possible to harness the potential of AI-driven technologies like LLMs while minimizing potential harm and preserving the trust of patients and healthcare providers alike.”

Denial—Artificial Intelligence Tools and Health Insurance Coverage Decisions
Michelle M. Mello and Sherri Rose, JAMA Health Forum, March 7, 2024

The article: In this Forum article, the authors, both professors of health policy,   call for national policy guardrails for AI and algorithmic use by health insurers. They note investigative journalism helped bring incidents to light in cases tied to Medicare Advantage as well as congressional hearings and class-action lawsuits against major health insurance companies.

The authors highlight and describe class-action suits against UnitedHealthcare and Humana that allege the companies pressured managers to discharge patients prematurely based on results from an AI algorithm. They also note Cigna, another insurance firm, is facing a class action suit alleging it used another kind of algorithm to deny claims at an average of 1.2 seconds each.
Algorithms can now be trained “at an unprecedented scale” using datasets such as Epic’s Cosmos, which represents some 238 million patients, the authors note.  But even developers may not know the mechanics behind — or why — an AI algorithm makes a recommendation.

The authors write: “The increased transparency that the CMS, journalists, and litigators have driven about how insurers use algorithms may help improve practices and attenuate biases. Transparency should also inspire recognition that although some uses of algorithms by insurers may be ethically unacceptable, others might be ethically obligatory. For example, eliminating the use of (imperfect) algorithms in health plan payment risk adjustment would undermine equity because adjusting payments for health status diminishes insurers’ incentive to avoid sicker enrollees. As the national conversation about algorithmic governance and health intensifies, insurance-related issues and concerns should remain in the foreground.”

Additional resources for journalists

• This research review and tip sheet from The Journalist’s Resource offers a primer, definitions and foundational research on racial bias in AI in health care. 

• The Association of Health Care Journalists  on its website features a guide to how health insurance works in each state. Created by Georgetown University’s Center on Health Insurance Reforms and supported by the Robert Wood Johnson Foundation, the guide provides useful statistics and resources that give journalists an overview of how health insurance works in each state. That includes a breakdown of different kinds of insurance that serve the population in each place, including how many people are covered by Medicare, Medicaid and employer-backed insurance. The guide can help inform journalist’s questions about the health insurance landscape locally, says      Joe Burns, the beat leader for health policy (including insurance) at AHCJ.

• The National Association of Insurance Commissioners has a map of which states adopt its model bulletin as well as a page documenting the work of its Big Data and Artificial Intelligence working group.

• Congress.gov features a clickable map of state legislature websites.

•The National Conference of State Legislatures tracks bills on AI for legislative sessions in each state. This list is current as of March 2024.

• The National Center for State Courts links to the websites of state-level courts.

• Here’s the Office of the National Coordinator for Health Information Technology’s final rule and fact sheets under the 21st Century Cures Act.

• Here’s a video and transcripts of testimony from a Feb. 8 U.S. Senate Finance hearing titled “Artificial Intelligence and Health Care: Promises and Pitfalls.”    

• KFF, formerly called the Kaiser Family Foundation, maintains a map showing what percentage of each state’s population is covered by health insurance.

The post The possibilities and perils of AI in the health insurance industry: An explainer and research roundup appeared first on The Journalist's Resource.

School board elections have grown increasingly politicized in recent years as conservative politicians and advocacy organizations push to restrict how public schools address issues related to race, gender and sexuality.

But the job of school board members, many of whom are unpaid volunteers, isn’t just setting education policy. In fact, they oversee and make decisions about a range of programs and projects, including the school district’s annual budget, which, in the largest cities, can total tens of billions of dollars.

Their primary responsibility: Being a watchdog for their communities to ensure public money is well spent, schools and buses are safe, and students receive a high-quality education.

Nationwide, more than 82,000 people served on school boards in more than 13,000 public school districts during the 2022-23 academic year, according to Ballotpedia, a nonpartisan online political encyclopedia. Texas alone has 1,022 school districts.

The vast majority of board members are elected to office. And this fall, counties, cities and towns in many states will hold school board elections.

These races tend to be decided by a small number of people, however. A “discouragingly low” number of voters participate in school board elections — often 5% to 10%, according to the National School Boards Association. Even when voters show up at the polls, many skip school board races because they tend to appear at the bottom or on the back of their ballots.

Nonprofit groups such as Campaign for Our Shared Future and the XQ Institute are trying to change that by calling attention to the importance of school board elections.

Meanwhile, Moms for Liberty, a conservative political organization, and Run for Something, a progressive political organization, are vying to get their candidates seated on local school boards.

Moms for Liberty, founded in 2021 by two former school board members in Florida, has grown to 130,000 members and 300 chapters in 48 states, according to its X account. Of the 166 school board candidates it publicly endorsed in 2023, 54 won their elections, according to a recent analysis from the nonprofit think tank the Brookings Institution.

Last year, Run for Something endorsed 416 candidates running for various local offices across the U.S. and 226 won, according to the group’s 2024 Strategic Plan. Late last year, Run for Something announced its 50 State School Board Strategy to “fight back and recruit and train young, diverse progressive candidates for school board.”

Guidance for journalists

To help journalists cover school board elections, we’ve gathered and summarized six academic studies that look at how school board members are chosen and the impact they can have on school funding and student achievement.

Journalists need to keep in mind that while school boards make decisions on such things as book bans and which bathrooms transgender children use, their overarching goal is ensuring nearly 50 million students in pre-kindergarten through 12^th grade develop the skills necessary to get jobs, go to college or otherwise become responsible adults.

The most recent research suggests:

• Most people who vote in school board elections in California, Illinois, Ohio and Oklahoma are white and likely don’t have children in local public schools. Estimates further suggest that in at least two-thirds of school districts where the majority of students are racial and ethnic minorities, the majority of voters are white.
• Teacher unions maintain a strong influence over school board elections in Florida and California, where most candidates endorsed by teacher unions prevail.
• In North Carolina, public schools become less racially segregated when Democrats join school boards than when someone affiliated with another political party or someone with no party affiliation joins.
• Student test scores rise and schools serving large percentages of Hispanic students receive more funding in California when a white school board member is replaced by someone who is not white.

Although much of the most recent research on U.S. school board elections focuses on a small group of states, these studies provide insights on issues affecting school boards nationwide.

We elaborate on these studies below. But first, we’d like to spotlight three important pieces of context journalists should consider including in news stories about school board elections.

• Voter turnout in school board races is notoriously low in some parts of the U.S. In Newark, New Jersey, for example, about 3% to 4% of voters typically participate in school board elections, according to Chalkbeat Newark. Only a few hundred people voted in the school board election held in April in Oklahoma City, home to more than 700,000 people, the Oklahoma State Election Board reports.
• In many communities, most school board members are white men. Ballotpedia examined the demographics of more than 82,000 people who served on school schools during the 2022-2023 academic year and found that 52% were male and 43% were female. In Arkansas, Missouri, Nebraska, Oklahoma, Tennessee and Texas, more than 60% were men. Meanwhile, 78% of school board members who participated in a survey the National School Boards Association conducted in 2017 and 2018 identified as white.
• School board elections are generally nonpartisan, but that may be changing. In nonpartisan races, candidates’ political party affiliation, if they have one, is not listed on the ballot. In November, Florida voters will decide whether to amend the state constitution to allow school board elections there to be partisan. In recent months, legislators in Arizona, Indiana, Kentucky and New Hampshire have introduced bills to make school board elections partisan in those states. In North Carolina, where counties can decide whether their school board races are partisan, a growing number of boards have made the change.

No organization tracks school board elections in all 50 states and the District of Columbia. However, Ballotpedia provides information on elections in 475 of the largest school districts, including the 100 most populous cities.

Research roundup

The Democratic Deficit in U.S. Education Governance
Vladimir Kogan, Stéphane Lavertu and Zachary Peskowitz. American Political Science Review, March 2021.

The study: Researchers looked at how the demographics of people who vote in school board elections in the U.S. differ from the demographics of students attending local public schools. They examined a variety of data on voters who participated in school board elections between 2008 and 2016 and students who attended public schools during that period. The researchers focused on four states — California, Illinois, Ohio and Oklahoma — because they are large states with numerous school districts and higher percentages of students who are racial and ethnic minorities.

Because votes are confidential, the researchers predicted the race or ethnicity of each voter by combining census surname distributions with demographic information from the Census block where each voter lived. This is a common procedure for this type of research and has a 90% accuracy rate, the researchers note.

The findings: The study documents a “demographic disconnect.” Most people who voted in school board elections in these four states during this period likely didn’t have children enrolled in local public schools. The authors also note that voters and students differed in terms of race and ethnicity. In at least two-thirds of school districts where the majority of students were racial and ethnic minorities, the majority of voters were white, according to the researchers’ analysis.

The researchers also discovered that the gaps in student achievement separating white students and non-white students tended to be “larger in districts where the electorate looks most dissimilar from the student population.”

In the authors’ words: “If elected officials are motivated to respond to voter preferences, our results suggest that school board members face the least political pressure to address persistent racial achievement gaps in precisely the districts where these gaps are largest because minority populations are most politically underrepresented in these jurisdictions.”

School Boards and Student Segregation
Hugh Macartney and John D. Singleton. Journal of Public Economics, August 2018.

The study: To better understand the role school boards play in student segregation, the researchers matched data on school board members in 105 North Carolina school districts with data on student enrollment patterns in those districts from 2008 to 2012. The researchers looked at whether student enrollment at local elementary schools became more racially diverse after a Democrat joined the school board.

Intentionally segregating students by race is illegal in the U.S. In many parts of the country, public schools are racially segregated as the result of residential sorting, school attendance boundaries and other factors.

The researchers measured changes in race-based segregation in North Carolina by calculating what they call the “black dissimilarity index.” During the study period, 26% of students in North Carolina school district were Black, on average. Meanwhile, 63% of students were deemed “economically disadvantaged.”

The findings: When a Democrat was elected to a school board in North Carolina, racial segregation in local public schools fell. The Black dissimilarity index dropped about 8 percentage points across schools within the district, the researchers write, adding that a main way school boards reduce segregation is by adjusting public schools’ attendance boundaries. 

The researchers note this change typically occurs two years after an election, but is likely temporary. “In the long run, much of it may be undone by household re-sorting,” they write. The researchers found that some white students left their public schools when attendance boundaries shifted and moved to private schools or charter schools.

In the authors’ words: “Taken together, our findings underscore the central role that school boards play in allocating students to schools, with likely implications for the production of learning and social inequality more generally. Understanding how school boards may influence human capital accumulation is of key policy interest and an important direction for future work.”

Are School Boards and Educational Quality Related? Results of an International Literature Review
Marlies Honingha, Merel Ruiterband and Sandra van Thiel. Educational Review, 2020.

The study: Researchers reviewed 16 academic studies published between 1996 and 2016 to better understand the relationship between school boards and educational quality in different countries. The 16 studies look at how various aspects of school boards, including their composition and the behavior of school board members, affect student test scores in the public schools they govern. Twelve studies focus on U.S. school boards, two focus on school boards in the United Kingdom and two examine them in the Netherlands.

The findings: Differences in how school boards and school districts operate in different countries and regions make it difficult to draw any conclusions that would apply to school boards globally, the researchers write. Because several studies examine a single school district or rely heavily on anecdotal evidence, their results cannot be broadly applied. The researchers write that, based on the literature they reviewed, it’s unclear whether school board members have an impact on student achievement in their school districts.Whatever affect they do have is indirect, the researchers add.

The researchers stress the need for larger and more rigorous studies on this issue as well as the need to investigate school board impacts beyond student test scores.

In the authors’ words: “This article draws on a systematic literature review to show that there is a lack of solid empirical evidence on the relation between boards and educational quality. This means that we know less than is reflected in policy assumptions about school boards. The ambitions for school boards and the expectations upon them are not evidence-based.”

How Does Minority Political Representation Affect School District Administration and Student Outcomes?
Vladimir Kogan, Stéphane Lavertu and Zachary Peskowitz. American Journal of Political Science, July 2021.

The study: The researchers investigate whether student achievement changes after racial and ethnic minorities are elected to local school boards. The researchers reconstructed the composition of local school boards between 2000 and 2014 using election data obtained from the California Election Data Archive. They collected data on public school districts and student test scores during that period from the California Department of Education.

The findings: After a racial or ethnic minority was elected to a school board in California, test scores rose among students who were racial or ethnic minorities. While the increase did not materialize until several years after the election and then gradually declined in magnitude, it was substantial.

“The largest estimated effect occurs five years after the election, when the estimated effect of a pivotal minority candidate victory is approximately 0.15 standard deviations,” the researchers write, adding that the change is roughly equivalent to an additional 46 days of learning.

The researchers could not determine the effect on white students’ scores. However, they found “no evidence that the improvements in non-white student performance come at the expense of white students.” They suggest gains in minority students’ test scores may have been driven in part by increased operational spending and changes in school administration that happened after the election of the minority school board member.

In the authors’ words: “We find little evidence that minority representation on school boards affects the total number of employees or the racial and ethnic composition of rank-and-file workers. Nor does school board composition appear to have a consistent effect on school-level segregation. We do, however, find evidence that the share of school district principals who are non-white increases when minorities win more school board seats, providing another potential policy lever through which changes in board composition may affect student learning.”

No Spending without Representation: School Boards and the Racial Gap in Education Finance
Brett Fischer. American Economic Journal: Economic Policy, May 2023.

The study: This paper, which also focuses on California school boards, looks at whether replacing a non-Hispanic school board member with a Hispanic board member results in greater spending on Hispanic students. The researcher examined capital spending specifically — how local school boards used grant money that they received from the state’s School Facility Program to fund projects such as campus renovations between 1999 and 2016.

The findings: After a non-Hispanic school board member was replaced with a Hispanic board member, California school boards invested more money in schools where the majority of students were Hispanic. The researcher’s analysis “indicates that a 20 percentage point increase in Hispanic board representation raises [School Facility Program] modernization spending by $93 per student (81 percent) among high-Hispanic schools within the district.” Schools with relatively low Hispanic enrollment received an increase, too, although a smaller one. However, that increase was determined not to be statistically significant.

The analysis also suggests that after a Hispanic person joined a school board, that school district directed more construction funding to schools with a high percentage of students who qualify for free or reduced-price meals at school. There’s also evidence that having a Hispanic school board member is linked to improvements in teacher retention at “high-Hispanic” schools.

In the author’s words: “My analysis confirms that school boards play an integral role in education finance. Using spending data from the [School Facility Program], I find that an additional minority (Hispanic) school board member increases spending on school renovations using state transfer grants. In particular, SFP spending on high-Hispanic and high-poverty schools within the district increases by up to 69 percent, which juxtaposes smaller, insignificant changes among low-Hispanic and relatively affluent schools.”

Teachers’ Unions and School Board Elections: A Reassessment
Michael T. Hartney. Chapter in Groups in U.S. Local Politics, September 2023.

The study: The researcher examines the impact that teacher-union endorsements have on school board elections in California and Florida. The researcher chose to study California because it’s a large, racially diverse state where unions representing government employees are especially powerful, he writes. He chose Florida, another large, racially diverse state, because labor law there has historically been less favorable to teacher unions.

He analyzed union endorsements given to 3,336 school board candidates across 468 school districts in California between 1995 and 2020. He also analyzed endorsements of 361 school board candidates running for office in 36 Florida school districts between 2010 and 2020.

The findings: In both states, school board candidates backed by local teacher unions did “exceptionally well” in most elections. In California, about 90% of union-backed incumbents were reelected and two-thirds of union-backed candidates running against an incumbent won their races. Meanwhile in Florida, about 80% of incumbents endorsed by teacher unions won reelection and more than half of candidates who challenged an incumbent and had union endorsements prevailed.

In the author’s words: “I have shown, quite simply, that union power in school board elections remains both robust and resilient. Irrespective of the very real setbacks that unions have faced in state and national politics, in the local trenches of school board electioneering, the data tell an unambiguous story: teacher-union interest groups remain an important player, they are still the ones to beat.”

Additional resources

• In “Outside money targets school board elections,” we examine research on how wealthy individuals and national advocacy groups have used their money to influence local school board elections.
• The National School Boards Association offers various national reports on school boards. Organizations such as the Illinois Association of School Boards and Texas Association of School Boards provide state-level data and reports.
• We created a tip sheet to help journalists understand and cover teacher unions, including their influence on local school boards.
• This article warns journalists about the dangers of horse race coverage of elections — focusing on who’s in the lead and who’s behind instead of policy issues. It can harm political candidates, the public and news outlets themselves.
• Tammy Patrick, a former federal compliance officer for the Maricopa County Elections Department in Arizona, offers eight tips to help journalists improve their overall coverage of U.S. elections.

The image above was obtained from the Flickr account of Joe Brusky and is being used under a Creative Commons license. No changes were made.

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Sports venue construction in the U.S. tends to happen in waves, roughly every three decades. Sports economists suggest another wave is happening now, with numerous proposed or approved venue construction projects around the country seeking or having secured public dollars, from Tennessee to Wisconsin to Nevada to Florida.  

Professional sports owners often justify asks of hundreds of millions in taxpayer dollars for new or revamped stadiums with estimates of huge economic returns for communities. It’s important that journalists covering these projects understand how public dollars are raised to pay for them and how to interrogate economic impact claims that teams produce.

Across the four biggest sports leagues in the U.S. — Major League Baseball, the National Football League, the National Basketball Association and the National Hockey League — there have been eight new venues built since 2020 at a total construction cost of roughly $3.3 billion, according to a September 2023 paper in the Journal of Policy Analysis and Management. About $750 million in public funds went toward those construction projects, not including bond interest, the paper finds.

Research conducted over decades indicates these investments almost never lead to massive economic gains for host cities. Legislators have since pushed the recent public contribution figure even higher. This includes $500 million to renovate the Milwaukee Brewers ballpark, more than $1 billion in bonds toward a new stadium for the NFL’s Tennessee Titans and $380 million for a new ballpark for the A’s, which are poised to move from Oakland to Las Vegas in 2028.

We recently published two pieces on public financing of sports venues: A research-based primer and research roundup and a short tipsheet for covering the topic.

To give journalists an even stronger foundation for their coverage of sports venue financing, The Journalist’s Resource co-hosted an hourlong webinar May 16 with Econofact, a nonpartisan, online publication out of The Fletcher School at Tufts University.

I co-moderated the panel discussion with Michael Klein, the William L. Clayton Professor of International Economic Affairs at Tufts and founder and executive editor of Econofact. The panelists were:

• Andrew Zimbalist, the Robert A. Woods Professor Emeritus of Economics at Smith College.
• Victor Matheson, a professor of economics and accounting at the College of the Holy Cross who specializes in sports economics.
• Alan Snel, the publisher of LVSportsBiz.com, a news outlet that covers the convergence of sports, business, stadiums and politics.

One takeaway: There are numerous examples of professional sports franchises that built their venues with little or no public investment.

“We have the Golden State Warriors playing in an entirely privately financed stadium in San Francisco,” Matheson said during the webinar. “We have SoFi stadium in [Los Angeles], almost entirely privately financed there, and that’s about a $5 billion stadium. I think one of the most important things to take from this hour is that public financing is not required.”

Here are 7 key tips from the webinar.

1. Ask these three questions about economic impact estimates. If team officials can’t explain their numbers, don’t report them.

Who commissioned the study?

“If it is a study that is paid for by the league or the team, that is not an economic impact study,” Matheson said. “That is a press release.”

Can I see a copy of the study?

While teams or municipalities may or may not release lengthy economic impact reports, public officials and journalists sometimes cite big number estimates from teams without scrutiny of the underlying analysis.

“You would be amazed by how many people say, ‘There is a study that says [the economic impact] is a billion dollars,” Matheson said. “But you can never get your hands on that study.”

What do economists think?

“Call an economist,” Matheson said. “You can find lots of us. Whatever your local jurisdiction is, there’s a sports economist there who teaches in your state or your local region who understands these issues who has a good local feel. Most of us have a good national feel as well.” 

If team representatives can’t justify estimates of economic growth, or show than an independent analysis exists, don’t report those estimates.

“The big problem with these gigantic economic impact numbers is that the methodology is not explained,” said Snel.

He noted that LVSportsBiz will not publish economic impact estimates unless team officials explain how they did their analysis. 

2. Note that when people spend money at a sports venue and nearby businesses, this often means they don’t spend that money elsewhere.

A new or revamped sports venue tends to shift economic activity, not create new spending, economic research shows.

Interview an economist or two to help explain to audiences how this works. The basic idea is that spending shifts within communities, or from one community to another. The underlying reason has to do with household budgeting.

“Most of the money spent at a sports facility is money that is part of people’s leisure budgets, and they have a certain amount of money that they can spend on various kinds of leisure,” Zimbalist said. “When they spend $200 or $500 taking their family to the ballpark, that’s $200 or $500 they don’t have to spend at the local bowling alley, at a local theater, at a local restaurant. That’s money being displaced, from spending in one part of the city to spending in another, and the net impact can be very close to zero.”

3. Ask hotel owners and rental car firms how they incorporate tax rate changes into their pricing. If public money is raised through hotel and rental car taxes, proponents may claim the tax burden will fall on tourists. But local businesses and franchises may bear some of the burden, too.

Tourists do not necessarily pay hotel and rental car taxes. Why? Because of something called tax incidence, which is how the burden of a tax is divided among consumer and producer — essentially, who pays the tax and at what proportion.

“It’s not always the person who buys the product who pays the tax,” Matheson said. “It can also be the person who sells the product.”

When legislators increase a hotel tax or pass a new one, hotel owners typically respond by adjusting their pricing in one of three ways:

• Raise prices and pass on the entire cost of the tax to consumers. That can hurt their ability to compete for convention and tourism business, Matheson said.
• Hold prices steady and pay the tax burden entirely, reducing profits.
• Some combination, where they pass some of the cost of the tax to consumers and eat the rest.

The same goes for rental car taxes, another sales tax commonly used to help finance stadiums. Local economic conditions will determine how the tax burden shakes out. In extremely competitive markets, businesses may be able to pass on the entire cost to consumers. Point is, it’s important to ask hotel owners and rental car firms how they incorporate tax rate changes into their pricing.

While officials may claim visitor taxes are a way to pass the cost to out-of-towners, the authors of the September 2023 paper note that local people also rent cars. And residents with lower incomes are more likely to use extended stay hotels and potentially have to pay the higher taxes.

4. Don’t forget that team owners stand to benefit most from these projects.

Teams seeking public financing naturally focus public statements on their estimates of community benefits, typically in the form of jobs created and consumer spending.

But team owners, by far, have the most to gain.

“The bottom line is, it’s the pro teams that are garnering the benefits of the revenues from the stadiums,” Snel said. He recommended journalists also report on how new or improved stadiums affect team valuations.

He pointed to the National Football League’s Raiders, which moved from Oakland to Las Vegas in 2020. The team was valued at $2.2 billion in 2019. That figure nearly tripled to $6.2 billion by the end of 2023.

There are a variety of reasons for the increase, Snel reports, including TV deals that generate tens of billions of dollars yearly across the NFL, and the sale of the Washington Commanders in 2023 for more than $6 billion, which set the market for premium franchises. But according to Forbes, $1.4 billion of the team’s current value is tied to the stadium itself, which was heavily subsidized with public dollars.

5. Learn about “leakage” and how it can affect economic impact estimates.

When people spend money at local businesses, there is less of what economists call “leakage” than when people spend with mega corporations like sports franchises.

This means every dollar spent at a local café has a better chance of staying within the local economy than money spent at a sporting event, which tends to “leak” out of the economy and into the savings accounts of team owners. The café owner, by contrast, uses revenue to, for example, pay staff, who also live and spend in the community, or for laundry services provided by another local businesses, or any number of other things.

“The proprietor of the local restaurant or bowling alley or theater tends to have a more moderate income and tends to live almost 100% of the year in that town,” Zimbalist said. “When you spend money at the restaurant, it tends to circulate and stay in the town more. When you spend money at a ballpark, it’s going to millionaires and billionaires. They generally don’t live in the town year-round.”

This ties back into those economic impact estimates. They’ll sometimes include a simple multiplier equation, suggesting money spent at sporting events “multiplies,” or circulates within the local economy, just like spending at the local café.

But sporting event spending tends to have less chance of staying in the local economy, compared with other types of entertainment spending.

Zimbalist explained that team owners “generally have much, much higher savings rates, so they take the money and they put it into the world’s money markets and the money doesn’t stay in the town for these and other reasons. So the leakages are much, much greater and, therefore, the multiplier, the sports multiplier, is much lower than a typical entertainment multiplier.”

6. Keep track of lease deals. When they expire, teams may come asking for more public money.

When covering a city that has a major professional sports franchise, or several of them, review lease agreements to figure out when team owners might ask taxpayers for help revamping their venue, or building a new one.

The National Sports Law Institute of Marquette University Law School has obtained dozens of lease agreements for professional baseball and football franchises, most of them from the 1990s and early 2000s.

The institute has summarized these agreements, available here. The summaries detail, among other things, the yearly rent the franchise owes the municipality, which may be set below market rates. They outline how much the public contributed toward sports venue construction and how much came from the team, along with whether the team or municipality is responsible for regular operating expenses and repairs.

“We had this huge wave of stadium construction in 1992,” Matheson said. “Most of those stadiums are associated with a 30-year lease deal. And because of that, these teams are tied to the stadiums for 30 years, which means that they really can’t start asking for a new stadium, start asking for new public subsidies, until those lease deals expire. But as soon as those lease deals expire, all of the bargaining power shifts to the teams and away from the taxpayer.”

7. If you don’t have time to do a deep dive, at least include these two “boilerplate necessities” in your reporting.

Journalists may not have time to do a deep investigation into how public money is being used to finance sports venue construction or renovation — especially broadcast journalists, who might only have a minute or two to cover a lot of ground.

Snel recommends reporters at least include these two “boilerplate necessities” in their coverage.

• Report the principal and interest on debt. If public money is raised through bonds, tell audiences about the interest on the principal that the city, county or state will have to repay. For example, Clark County, Nevada, took on debt of $750 million toward building the Raiders’ stadium. With interest, that number will grow over the next quarter century. The final tally will actually be north of $1.3 billion, Snel recently reported.
• Remind your audience that economic activity related to sporting events by and large goes back to team owners. “The beneficiaries are the teams,” Snel said. “They’re garnering the lion’s share of all the revenues.”

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News articles in recent weeks have documented the spread of misinformation about hormonal birth control methods on popular social media platforms like TikTok, YouTube and X, formerly called Twitter. Influencers with large and small followings are sharing unsubstantiated claims about the side effects of contraceptives, while directly or indirectly encouraging others to stop using them.

This trend has not escaped researchers, who for several years have been investigating what people who can get pregnant are posting on social media platforms about hormonal and non-hormonal birth control methods. Understanding the drivers of these trends is important because they have implications for policy and patient care, according to researchers. Some worry that during the post-Dobbs era, when there are continued strikes against reproductive rights in the U.S., misinformation about birth control on social media could have a negative influence on contraceptive preferences — potentially leading to more unwanted pregnancies.

More than 90% of women of reproductive age have used at least one contraceptive method, according to a 2023 report by the U.S. National Center for Health Statistics. However, the report also finds that the use of male condoms and withdrawal methods increased between 2006 and 2019, while the use of the birth control pill decreased. Non-hormonal contraception methods, including condoms, spermicides, withdrawal and menstrual cycle tracking, are 10% or less effective than hormonal contraceptives. The only exceptions are surgical sterilization and the copper intrauterine device.

To be sure, not all birth control-related content posted on social media platforms is negative, studies show. Health care professionals are sharing educational material with a high rate of engagement and non-health care professional users share their positive experiences with the birth control methods they use.

But as you will see in the studies curated below, researchers also find that social media users, including influencers, share inaccurate information about hormonal contraceptives on various social media platforms, discuss their discontinuation of birth control in favor of non-hormonal methods and engage in unsubstantiated fear-mongering of hormonal contraceptives.

Researchers also have learned that the content posted on social media platforms has changed in tone over time, mirroring the shift in the national political discourse.

In a 2021 study published in the American Journal of Obstetrics & Gynecology, researchers analyzed more than 800,000 English-language tweets mentioning at least one contraceptive method between March 2006, when Twitter was founded, and December 2019. They coded the sentiment of tweets as positive, neutral or negative.

“What we found over time was that the number of neutral tweets went down for each and every one of the birth control methods, and people became more polarized with regards to how they talk on these social media platforms over those 13 years,” says study co-author Dr. Deborah Bartz, an OB-GYN at Brigham and Women’s Hospital with expertise in complex family planning and an associate professor at Harvard Medical School.

In a February 2024 commentary in the Journal of Women’s Health, University of Delaware researchers Emily Pfender and Leah Fowler argue that ongoing dialogue about contraception on social media provides “a glimpse into public sentiment about available options” to people who can get pregnant.

The authors also note that misinformation and disinformation about hormonal contraception may have a larger effect on health disparities, especially among historically marginalized groups who may already mistrust the medical establishment.

“This may contribute to unintended pregnancy and delayed care, further widening health disparities and hindering progress toward equitable reproductive health outcomes,” Pfender and Fowler write.

Side effects

There are known side effects to hormonal birth control methods, including headaches, nausea, sore breasts and spotting. Most are mild and disappear with continued use or with switching to another method. Among hormonal contraceptives, only the Depo-Provera injection has been linked with weight gain, studies show.  

But some social media influencers have spread false claims about the potential side effects of hormonal birth control methods, ranging from infertility to abortion to unattractiveness. Despite these false claims, physicians and professional organizations such as the American College of Obstetricians and Gynecologists find today’s contraceptive options safe and very effective.

“They’re about the most low-risk prescription that I give,” says Dr. Megana Dwarakanath, an adolescent medicine physician in Pittsburgh. “I always joke that if something goes wrong in someone’s life, they’re within the reproductive years, it always gets blamed on birth control.”

Dwarakanath says her young patients are most worried about two side effects: weight gain and mood. “Those are the things that they will almost always attribute to their birth control at a time that their bodies are also changing very rapidly,” she says. “Things like mental health diagnoses or personality disorders also tend to crop up during the time young people have started or have been on birth control.”

Most research on the link between oral contraceptives and cancer risk comes from observational studies, according to the National Cancer Institute. Overall, the studies have consistently shown that the risks of breast and cervical cancer are slightly increased for women who use oral contraceptives, whereas the risk of endometrial, ovarian and colorectal cancers are reduced.

The use of hormonal birth control has also been associated with an increase in the risk of developing blood clots, studies show. But that risk is not universal for everyone who takes hormonal birth control. This risk is higher for women 35 and older, those who smoke, are very overweight or have a history of cardiovascular disease. Overall, 3 to 9 out of 10,000 women who take the pill are at risk of developing blood clots within a given year. The risk for women who don’t take the pill is 1 to 5 out of 10,000.

There is no association between the pill and mood disorders, according to a large body of research, including a 2021 cohort study of nearly 740,000 young women. 

It’s worth noting the dearth of research into women’s reproductive health due to chronic underfunding of women’s health research. An analysis of funding by the U.S. National Institutes of Health finds that in nearly three-quarters of the cases where a disease affects mainly one gender, the institute’s funding pattern favored males. Either the disease affected more women and was underfunded, or the disease affected more men and was overfunded, according to the 2021 study published in the Journal of Women’s Health.

Aside from underfunding, conducting robust research into the long-term effects of birth control is complex.

“Historically, people haven’t felt that it’s ethically OK to randomize people to birth control methods in large part because the outcome of unintended pregnancy is greater,” for people who are given the placebo, Bartz says.

Research on birth control misinformation on social media

Social media use is widespread among young adults. More than 90% of Americans between 18 and 29 reported ever using YouTube, while 78% said they had used Instagram, 62% used TikTok and 42% used Twitter, according to a 2023 survey of 5,733 U.S. adults by Pew Research Center.

These years overlap with the demographic of people who are most likely to use birth control. And because the use of contraceptives is less stigmatized today, people are more likely to talk with one another about their questions and concerns or share that information online.

In addition to investigating the general landscape of social media posts about birth control, researchers are also interested in the type of content influencers, who typically have 20,000 or more followers, post, because of their persuasive power over their audiences.

“When influencers disclose personal experiences and beliefs about various topics, audience members tend to form similar attitudes especially when they feel connected to the influencer,” Pfender and M. Marie Devlin write in a 2023 study published in the journal Health Communication.

Below we have curated several studies published in recent years documenting the spread of birth control misinformation on social media. The roundup is followed by a quick reference guide on female contraceptives and their actual potential side effects.

Contraceptive Content Shared on Social Media: An Analysis of Twitter
Melody Huang, et al. Contraception and Reproductive Medicine, February 2024.

The study: The authors explore how contraceptive information is shared on X and understand how those posts affect women’s decisions. They analyze a random 1% of publicly available English-language tweets about reversible prescription contraceptive methods, from January 2014 and December 2019. The 4,434 analyzed tweets included at least 200 tweets per birth control method — IUDs, implants, the pill, patch and ring.

The findings: 26.7% of tweets about contraceptive methods discussed decision-making and 20.5% discussed side effects, especially the side effects of IUDs and the depot medroxyprogesterone acetate (DMPA or Depo-Provera) shot. Discussions about the pill, patch or ring prompted more discussions on logistics and adherence. About 6% of tweets explicitly requested information. Tweets about IUDs were most popular in terms of likes.

More importantly, 50.6% of the tweets were posted by contraceptive users, while only 6% came from official health or news sources. Tweets from news or journalistic sources were more frequent than tweets from a health care professional or organization.

Some tweets contained misinformation represented as facts, such as the unsubstantiated claim that IUDs can cause fertility issues. Others were outwardly misogynistic, shaming women and claiming that they wouldn’t be able to have kids because of using hormonal birth control.

One takeaway: “While Twitter may provide valuable insight, with more tweets being created by personal contraceptive users than official healthcare sources, the available information may vary in reliability. Asking patients about information from social media can help reaffirm to patients the importance of social networks in contraceptive decision-making while also addressing misconceptions to improve contraceptive counseling,” the authors write.

What Do Social Media Influencers Say About Birth Control? A Content Analysis of YouTube Vlogs About Birth Control
Emily J. Pfender and M. Marie Devlin. Health Communication, January 2023.

The study: To explore what social media influencers shared on YouTube about their experiences with hormonal and non-hormonal methods of birth control, the researchers analyzed 50 vlogs posted between December 2019 and December 2021. Most of the 50 influencers were categorized on YouTube as Lifestyle (72%) and Fitness (16%). They had between 20,000 and 2.2 million subscribers each.

The findings: In total, 74% of the influencers talked about discontinuing hormonal birth control. About 44% said the main reason they were discontinuing birth control was to be more natural, while 32% said they wanted to improve their mental health and 20% were concerned about weight gain.

Forty percent of influencers mentioned using non-hormonal birth control methods such as menstrual cycle tracking, condoms, non-hormonal IUDs and the pull-out method. Twenty percent reported switching from hormonal to non-hormonal methods.

One takeaway: “Our content analysis revealed that discontinuation of hormonal birth control is commonly discussed among [social media influencers] on YouTube and sexual health information from influencers might not provide accurate educational information and tools… this is especially concerning given that social media is young adults’ primary tool for sexual health information. Future research is needed to understand the effects of SMI birth control content on sexual health behaviors,” the authors write.

Hormonal Contraceptive Side Effects and Nonhormonal Alternatives on TikTok: A Content Analysis
Emily J. Pfender, Kate Tsiandoulas, Stephanie R. Morain and Leah R. Fowler. Health Promotion Practice, January 2024.

The study: The authors analyzed the content of 100 TikTok videos that used the hashtags #birthcontrolsideeffects and #nonhormonalcontraception. Their goal was to understand the types of content about side effects of hormonal and non-hormonal contraceptives on TikTok.

The findings: The videos averaged about 1 minute and garnered an average of 27,795 likes, 251 comments and 623 shares. For #birthcontrolsideeffects, 80% of the audience was 18 to 24 years old and videos with that hashtag had 43 million views worldwide as of July 7, 2023.

Thirty-two percent of the videos were by regular users (non-influencers), 26 by clinicians, 13% by health coaches and 2% by companies. Only 3% had a sponsorship disclosure and 6% included a medical disclaimer, that the person was not a doctor or was not providing medical advice.

Most of the 100 videos (71%) mentioned hormonal contraception. Among them 51% discussed unspecific hormonal contraceptives, 31% talked about the pill and 11% about hormonal IUDs. Four of the 71 creators explicitly recommended against using hormonal contraceptives.

Claims about hormonal contraceptives were mostly based on personal experience. About 25% of the creators cited no basis for their claims, 23% included outside evidence, including unspecified studies or information from the FDA insert, and 11% used a combination of personal and outside evidence.

Almost half (49%) mentioned discontinuing their hormonal contraception, with negative side effects cited as the most common reason.

The creators talked about mental health issues, weight gain, headaches, and less common risks of various cancers or chronic illness, change in personality and blood clots. They were less likely to mention the positive aspects of birth control.

About 52% of videos mentioned non-hormonal contraception, including copper IUDs and cycle tracking.

Nine of the 100 creators expressed feeling dismissed, pressured, gaslit or insufficiently informed about contraception by medical providers.

One takeaway: “Our findings support earlier work suggesting social media may fuel ‘hormonophobia,’ or negative framing and scaremongering about hormonal contraception and that this phobia is largely driven by claims of personal experience rather than scientific evidence,” the authors write. “Within these hashtag categories, TikTok creators frame their provider interactions negatively. Many indicate feeling ignored or upset after medical appointments, not sufficiently informed about contraceptive options, and pressured to use hormonal contraceptives. This finding aligns with previous social media research and among the general population, suggesting opportunities for improvements in contraceptive counseling.”

Popular Contraception Videos on TikTok: An Assessment of Content Topics
Rachel E. Stoddard, et al. Contraception, January 2024.

The study: Researchers analyzed 700 English-language TikTok videos related to hormonal contraception, with a total of 1.2 billion views and 1.5 million comments, posted between October 2019 and December 2021. Their aim was to explore the types of contraception content on TikTok and to understand how the platform influences the information patients take into birth control counseling visits.

The findings: More than half of the videos (52%) were about patient experiences and how to use contraceptives. Other common topics included side effects (35%) and pregnancy (39%).

Only 19% of the videos were created by health care professionals, including midwives, physician assistants and medical doctors, although those videos garnered 41% of the total views, indicating higher engagement. While 93% of health care providers shared educational content, 23% of non-health care providers shared educational content.

One takeaway: “Our findings show an exceptional opportunity for education around contraception for young reproductive-aged individuals, given the accessibility and popularity of these videos. This may also extend to other topics around sex education and family planning, including sexually transmitted infection prevention and treatment and procuring abortion care,” the authors write.

TikTok, #IUD, and User Experience With Intrauterine Devices Reported on Social Media
Jenny Wu, Esmé Trahair, Megan Happ and Jonas Swartz. Obstetrics & Gynecology, January 2023.

The study: Researchers used a web-scraping application to collect the top 100 TikTok videos tagged #IUD on April 6, 2022, based on views, comments, likes and shares. Their aim was to understand the perspectives and experiences of people with IUDs shared on TikTok. The videos had a total of 471 million views, 32 million likes and 1 million shares. Their average length was 33 seconds.

The findings: Some 89% of the creators identified as female and nearly 90% were from the United States; 37% were health care professionals; and 78% were 21 years or older.

Video types included patients’ own experiences with IUD removal (32%), educational (30%) and humorous (25%). More videos (38%) had a negative tone compared with 19% with a positive tone. The videos that portrayed negative user experiences emphasized pain and distrust of health care professionals.

Half of the videos were very accurate, while nearly a quarter were inaccurate (the authors did not use the term misinformation).

One takeaway: “The most liked #IUD videos on TikTok portray negative experiences related to pain and informed consent. Awareness of this content can help health care professionals shape education given the high prevalence of TikTok use among patients,” the authors write. “TikTok differs from other platforms because users primarily engage with an algorithmically curated feed individualized to the user’s interests and demographics.”

Types of female birth control

Most female hormonal contraceptives contain the synthetic version of natural female hormones estrogen and progesterone. They affect women’s hormone levels, preventing mature eggs from being released by the ovaries, a process that’s known as ovulation, hence, preventing a possible pregnancy.

Of the two hormones, progesterone (called progestin in synthetic form) is primarily responsible for preventing pregnancy. In addition to playing a role in preventing ovulation, progesterone inhibits sperm from penetrating through the cervix. Estrogen inhibits the development of follicles in the ovaries.

The information below is sourced from the CDC, the National Library of Medicine, the Cleveland Clinic and the Mayo Clinic.

Intrauterine contraception

Also called Long-Acting Reversible Contraception, or LARC, this method works by thickening the cervical mucus so the sperm can’t reach an egg. There are two types of IUDs: hormonal and non-hormonal.

• Levonorgestrel intrauterine system is a T-shaped device that’s placed inside the uterus by a doctor. It releases a small amount of progestin daily to prevent pregnancy. It can stay in place for 3 to 8 years. Its failure rate is 0.1% to 0.4%.
• Copper T intrauterine device is also T-shaped and is placed inside the uterus by a doctor. It does not contain hormones and can stay in place for up to 10 years. Its failure rate is 0.8%.
• Side effects: Copper IUDs may cause more painful and heavy periods, while progestin IUDs may cause irregular bleeding. In the very rare cases of pregnancy while having an IUD, there’s a greater chance of an ectopic pregnancy, which is when a fertilized egg grows outside of the uterus.

Hormonal methods

• The implant is a single, thin rod that’s inserted under the skin of the upper arm. It releases progestin over 3 years. Its failure rate is 0.1%, making it the most effective form of contraception available.
• Side effects: The most common side effect of an implant is irregular bleeding.
• The injection Depo-Provera or “shot” or “Depo” delivers progestin in the buttocks or arms every three months at the doctor’s office. Its failure rate is 4%.
• Side effects: The shot may cause irregular bleeding. The shot is also the only contraceptive that may cause weight gain. It may also be more difficult to predict when fertility returns once the shot is stopped.
• Combined oral contraceptives or “the pill” contain estrogen and progestin. They’re prescribed by a doctor. The pill has to be taken at the same time daily. The pill is not recommended for people who are older than 35 and smoke, have a history of blood clots or breast cancer. Its failure rate is 7%. Among women aged 15 to 44 who use contraception, about 25% use the pill.
• The skin patch is worn on the lower abdomen, buttocks or upper body, releasing progestin and estrogen. It is prescribed by a doctor. A new patch is used once a week for three weeks. No patch is worn for the fourth week. Its failure rate is 7%.
• Hormonal vaginal contraceptive ring releases progestin and estrogen. It’s placed inside the vagina. It is worn for three weeks and taken out on the fourth week. Its typical failure rate is 7%.
• Side effects: Contraceptives with estrogen, including the pill, the patch and the ring, increase the risk of developing blood clots.
• Progestin-only pill or “mini-pill” only has progestin and is prescribed by a doctor. It has to be taken daily at the same time. It may be a good option for women who can’t take estrogen. Its typical failure rate is 7%.
• Opill is the first over-the-counter daily oral contraceptive in the U.S., approved by the Food and Drug Administration in 2023. Opill only has progestin and like other birth control pills, it has to be taken at the same time every day. It should not be used by those who have or have had breast cancer. Its failure rate is 7%.
• Side effects: The most common side effect of progestin-only pills is irregular bleeding, although the bleeding tends to be light.

Non-hormonal birth control methods include using barriers such as a diaphragm or sponge, condoms and spermicides, withdrawal, and menstrual cycle tracking. Emergency contraception, including emergency contraception pills (the morning-after pill), is not a regular method of birth control.

Additional research studies to consider

Population Attitudes Toward Contraceptive Methods Over Time on a Social Media Platform
Allison A. Merz, et al. American Journal of Obstetrics & Gynecology, December 2020.

Social Media and the Intrauterine Device: A YouTube Content Analysis
Brian T. Nguyen and Allison J. Allen. BMJ Sexual and Reproductive Health, November 2017.

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Former Congressman Tip O’Neill famously said “all politics is local.”

The same applies to election administration in the U.S., which is markedly decentralized. On Election Day, county- and city-level poll workers are the people who make sure voters can smoothly cast their ballots for measures and candidates vying for offices spanning all levels of government.

But this fundamental democratic function isn’t free, and election administrators often say they have a lot to do on limited budgets, research shows. State and local governments — not the federal government — are usually responsible for election administration costs.

Some of the biggest ongoing costs are related to statewide voter registration rolls, which can cost millions of dollars a year to build and maintain, according to to a 2022 report by Massachusetts Institute of Technology political scientist Charles Stewart III.

Costs associated with individual elections include staffing, supplies for polling places and postage for mail-in ballots. Local election agencies have to pay for return postage in 19 states, plus Washington, D.C., but the U.S. Postal Service will typically deliver any ballot that lacks enough postage, billing the appropriate election agency later, according to the nonpartisan National Conference of State Legislatures.

Longer-term costs include upgrading equipment such as scanners that process paper ballots.

Nearly 80% of voters used paper-and-scanner technology during the 2020 election. Most of the remaining voters used direct-recording electronic machines. With those devices, voters use touch screens or push buttons to record their votes digitally, which may or may not include a paper trail.

Nationally, equipment costs would run $100 million to $300 million yearly if each scanner were replaced at the end of its useful life, around ten years, according to the MIT report. As of 2022, the voting equipment used in 24 states was over a decade old, according to a report from the Brennan Center for Justice at New York University.

“Election officials are used to ‘making do’ with what they have,” Stewart writes. “They often express pride in pulling off the complicated logistical maneuvers necessary to conduct elections on a shoestring budget.”

Revenue from sales and property taxes are one major source of funding for elections, according to the 2022 MIT report. While federal grants have sporadically been available since 2002, “there is no ongoing federal mechanism for funding the general expenses of administering elections,” according to a September 2023 report from the Congressional Research Service.

The question of who pays to run elections gained national news attention during the early days of the COVID-19 pandemic. There were, for example, sudden additional costs related to widespread mail-in voting and personal protective equipment for election workers and volunteers.

And there’s not solely government money involved.

For the 2020 election cycle, “private individuals funded grant programs for state and local election administration that were particularly notable in their scale and sources,” according to the CRS report.

Philanthropist Priscilla Chan and her husband Mark Zuckerberg, founder and chief executive of Meta, were the leading donors, committing up to $419.5 million for election administration, including for personal protective equipment.

That commitment was roughly 20% of one estimate of the typical cost of administering elections across the U.S. and about half the $825 million Congress appropriated for state and local election administration in 2020. (That federal appropriation was atypically large due to the pandemic-era challenges — by comparison, Congress appropriated nothing for state and local elections during the 2016 cycle, according to the CRS report.)

A raft of misinformation about the Chan-Zuckerberg funding followed President Joe Biden’s November 2020 win over former President Donald Trump. At the same time, Republican state legislators and conservative groups pushed to remove private dollars from election administration.

There are now 28 states that limit, regulate or prohibit private or charitable funding for elections, according to the NCSL. In 2020, the electoral votes from 22 of those states went to Trump while five went to Biden. Nebraska, which allocates its electoral votes differently from nearly every other state and often splits its electoral votes, sent one to Biden and four to Trump in 2020.

All legislation related to private funding of elections has been passed since 2020, according to the NCSL.

With the new legislation and a variety of election financing systems across the country, it can be confusing to know where to begin to help audiences understand how their elections are funded. These research-based tips will give you a solid base for reporting on election administration funding in your coverage area.

1. Get to know state rules on how localities can finance elections.

Start with this list, compiled by the NCSL, of states that have passed laws about private funding of elections. Note whether your state prohibits all private funding, or limits such funding in some cases.

Alabama, for example, prohibits state and local election officials from soliciting or accepting “any donation in the form of money, grants, property, or personal services from an individual or a nongovernmental entity for the purpose of funding election-related expenses or voter education, voter outreach, or voter registration programs.”

But Alabama election officials can accept a donation of physical space for voting provided by private entities, such as a brick-and-mortar business donating its store for use as a polling place. If there is a state public health emergency, election officials in that state can accept “the donation of items for the preservation or protection of the public health.”

In South Carolina, by contrast, state and county election agencies cannot accept “gifts, donations, or funding from private individuals, corporations, partnerships, trusts, or any third party not provided through ordinary state or county appropriations,” without exceptions. And in Texas, local election officials cannot accept financial contributions over $1,000 without written notice from the secretary of state, who must first obtain unanimous approval from key state leaders, including the governor.

2. Ask election officials if they have enough funding. If not, how much do they need and for what?

Legal scholars have described adequate election funding as a fundamental pillar of the right to vote. “Unlike most other rights, the right to vote relies on governments to build, fund, and administer elections systems,” write law professors Joshua Sellers and Justin Weinstein-Tull in a 2021 New York University Law Review article. “This obligation is not ancillary to the right to vote; it is foundational to it.”

Ask local election officials if they have enough funding for 2024. If not, how much do they think they need and what specific outcomes would additional funding help achieve? What tradeoffs would there be — would more funding for elections mean less funding for other needs?

While election administrators will likely say they would gladly take more funding, there is scant research that provides points of comparison to assess outcomes of increased funding — for example, whether election agencies serving similar constituencies do their jobs differently depending on funding levels.

3. Don’t assume localities with high tax revenues spend more on election administration.

Recent research has focused on parsing the local costs of elections. In a 2021 Vanderbilt Law Review article, Sellers and law professor Roger Michalski seek to correct what they call the “shamefully inadequate amount of information about how much our elections cost.”

Sellers and Michalski use a “novel and painstakingly hand-coded dataset,” on election costs at the local and state levels from 2010 to 2017 across four states that make up nearly one-third of the national population: California, Arizona, Texas and Florida. Part of the challenge in analyzing election spending data across and within states is that agencies record their election-related expenses differently. The authors found that some agencies provide detailed expenditures down to the cost of postage, while others more broadly record costs.

They do not find connections between election funding and demographic factors such as race, poverty and educational attainment.

“Election spending in majority-minority communities seems largely indistinguishable from spending in predominantly white communities,” Sellers and Michalski write. “In short, basic assumptions one might have about resource allocation are brought into question.”

Sellers and Michalski also estimate that election spending in the four states is typically in the range of $4.50 to $8.50 per capita. This is in line with other research, including a 2018 data collection project on elections held in more than half of states from 2009 to 2016, led by researchers at the University of North Carolina at Chapel Hill. That research estimates an average U.S. cost per voter of $8 per election, but substantial variation across states, with costs as high as $15 per voter in Florida and as low as $2 per voter in Michigan.

Sellers and Michalski also find wide variation in election spending. For example, in California many cities “spend less than a dollar per person per year on election expenditures, while others spend many multiples more,” they write. Those findings hold for the other states in the study, and, generally, wealthier cities do not necessarily spend more per capita to administer elections than cities with lower tax revenues.

Spending tends to be higher in areas where governments overlap: “In many places, municipalities and counties work in concert to organize, run, and fund elections,” Sellers and Michalski write.

Election administration spending can vary even within counties. Someone living in a large city that is part of a county with sprawling suburbs might take part in elections funded at both the city and county levels, while a suburban voter might only have elections funded by the county.

4. Explain why election administration funding matters.

One big reason funding matters: Election officials need to be able to purchase technology and ballot designs that accurately records voters’ choices.

For example, the 2000 presidential election between George W. Bush and Al Gore was notably affected by punch card ballots, with so-called “hanging chads” making voter intentions unclear and directly leading to the 2002 Help America Vote Act, which provided federal funding to upgrade local voting systems.

Scholars who study elections use something called the residual vote rate to measure the relative ability of election agencies to perform their fundamental task of recording voter intentions. As Stewart writes in a 2018 MIT Election Lab blog post, “the number of residual votes is usually calculated by taking the number of people who turned out and subtracting the number of votes cast for candidates.”

In other words, a residual vote is when a ballot is cast that includes votes for some but not all races on the ballot. The authors of a 2020 paper in the Public Administration Review explore residual vote rates in North Carolina by dividing the number of ballots cast in presidential election years from 1996 to 2012 by the number of votes for president.

Presidential ballots often also include races for local or state offices, and ballot measures. For example, a residual vote would be counted when a ballot includes a vote for a senate race and a ballot measure, but is missing a vote for president.

“Though some proportion of residual votes might be the choice of the voter (some people choose not to vote for particular offices), scholarship revealed that residual votes were systematically related to the type of voting equipment and ballot design,” the authors write.

Sufficient funding generally allows people running and working for organizations to develop expertise and “provide for better technology and assistance,” the authors write, citing past research. The authors further explain in the paper that “the residual vote rate is an important managerial outcome of election administration.”

Although the authors analyze only one state, they note that, over time, they are able to explore residual voting in the same local administration organizations, which differ in their ability to run elections but have the same funding mechanisms.

“We find that both managerial capacity and better technology significantly reduce the residual vote rate as would be predicted by theory and literature,” the authors conclude.

5. Know that the health of the U.S. economy may affect election administration spending.

Research has found that how the broader economy is doing can affect spending on election administration.

A 2020 paper in American Politics Research examines county-level spending on elections from 2005 to 2016 in Georgia, New Jersey, North Carolina and Ohio. This timeframe overlapped with the Great Recession, which began in late 2007 and ended in mid-2009. The authors note they chose those states based primarily on the availability of detailed financial data for county election offices.

During and after the recession, election-related spending in these states fell sharply, and stayed lower than before the recession, even as the economy slowly began to recover.

“Unfortunately, just because democracy may need significant funds to conduct an election, it does not always mean that election administrators have sufficient resources,” the authors conclude.

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When sports franchises want a new or revamped stadium, they often turn to taxpayers for help with financing. For example, in June 2023, Nevada legislators approved $380 million in public funding for a 30,000-seat ballpark for the Oakland A’s, who are expected to make the move to Las Vegas in 2028.

Proponents estimate the A’s stadium in Las Vegas will create thousands of jobs and have an annual economic impact of $1.3 billion — more on that in the video below.

But economic research for decades has found that, by and large, the fiscal returns for residents — in the form of increased economic activity and job growth — are far smaller than public expenditures, which have recently approached or exceeded half a billion dollars per stadium.

Learn about the research in our companion explainer and research roundup.

Journalists should look closely at the political context around these major financial commitments, and question estimated fiscal returns. This is not just a topic for sports or business journalists covering major professional teams — even minor league teams have meant financial hardship for towns that took on debt to attract them. Here are 4 tips to help you get started in your reporting.

1. Interrogate economic impact statements or fiscal estimates from franchise owners.

Teams often produce economic impact statements or fiscal estimates claiming that building new stadiums or revamping existing ones will result in a fiscal and jobs boom for a city or region.

What assumptions do these economic impact statements or fiscal estimates make? Do they fully explain how they arrived at their numbers? If not, will the team publicly provide those behind-the-scenes details? Know that franchises may not make their analyses public.

For example, reporter Jon Styf at digital news outlet The Center Square obtained a two-page document showing economic impact estimates from the state of nearly $1 billion per year from a proposed retail and housing development around a new stadium for the National Football League’s Tennessee Titans.

The document also included economic impact estimates of around half a billion dollars from other cities hosting major events, such as the Super Bowl. Styf reached out to economists to find out whether those estimates were reasonable — the economists questioned their credibility.

In short, avoid reporting team-published estimates at face value. Run them by an economist or two who study this topic. Reach out to the North American Association of Sports Economists for help finding experts. FieldofSchemes, a blog run by journalist Neil deMause that covers sports economics, is another place to look for informed perspectives on economic impact estimates.

2. Know that public financing for a sports stadium can happen either through a legislature or through a direct decision by voters.

The Las Vegas funding happened via lawmakers, for example.

While Kansas City voters in April 2024 voted down public funds for a new stadium for MLB’s Royals, 7 in 10 voters in Oklahoma City who cast ballots in December 2023 said yes to $900 million for a new arena for the NBA’s Thunder. (Dozens of local economists had urged Oklahoma Cityans to reject the measure.)

Public votes may go either way, and can be influenced by campaigns from local groups in favor or opposed — but the legislative pathway is almost always successful, says Kennesaw State University economist John Charles Bradbury.

3. Understand how states and localities finance stadium construction.

These may include municipal bonds or taxes, such as sales taxes, sin taxes on things like alcohol and tobacco, and visitor taxes on hotels and rental cars.

Officials may claim visitor taxes are a way to pass the cost to out-of-towners. As Bradbury and co-authors note in a September 2023 paper in the Journal of Policy Analysis and Management, local people also rent cars. And residents with lower incomes are more likely to use extended stay hotels and have to pay the higher taxes.

Hotel owners may also draw lower revenues as they reduce pre-tax prices in order to retain customers — or, they may raise prices, passing the tax to customers but deterring future bookings.

4. Scrutinize smaller localities issuing bonds for minor or major league stadiums.

Pearl, Mississippi, issued tens of millions of dollars in bonds to build a new ballpark for an Atlanta Braves minor league affiliate in the early 2000s.

But, due to lack of attendance and lower economic impact than boosters estimated, the city had trouble paying the debt.

Credit agencies reduced the city’s bonds to junk.

(They’ve since rebounded.)

Bonus viewing: Healthy journalistic skepticism of economic impact claims

Alan Snel, publisher of LVSportsBiz.com, expressed healthy journalistic skepticism about economic impact numbers from sports franchises on the Dec. 29, 2023 edition of public affairs show Nevada Week, which is produced by Vegas PBS.

Host Amber Renee Dixon asked Snel about economic impact estimates for a new ballpark for the A’s that representatives from economic advisory firm Applied Analysis had presented to state lawmakers.

“They said they expect a $1.3 billion economic impact per year from the stadium and generating about $17 million in total tax revenue each year,” Renee Dixon said. “Those numbers don’t sit well with you. Why is that?”

Snel explained those estimates were “based on certain expectations” about attendance. He then said he had recently interviewed Michael Crome, Chief Financial Officer of the Las Vegas Raiders, which moved from Oakland to Las Vegas in 2020. “And they came out with a press release saying that the stadium and the visitorship, thanks to the Raiders events and also the stadium events, generated $2.29 billion,” Snel said. “That’s nearly $2.3 billion in revenue.”

Snel continued, “And I said to the Raiders, if you want to sit down and explain the math, we will report that. And I think that’s responsible journalism. But just putting these broad, general multibillion dollar figures out there without explaining the math is just — it’s just not an accurate portrait of what’s going on.”

The post Covering sports stadium financing? Read these 4 tips. appeared first on The Journalist's Resource.

In June 2023, Nevada legislators approved $380 million in public funding for a 30,000-seat ballpark for the Oakland A’s, who are expected to throw their first pitch in Las Vegas in 2028 after Major League Baseball owners approved the franchise move in November.

It’s the latest public commitment of hundreds of millions of dollars for a professional sports stadium. In the U.S., most franchises in the four major sports leagues — MLB, the National Football League, the National Basketball Association and the National Hockey League — are valued at over $1 billion.

Across those leagues there have been eight new stadiums or arenas built since 2020, at a total construction cost of roughly $3.3 billion, according to a September 2023 paper in the Journal of Policy Analysis and Management. About $750 million in public funds went toward those construction projects, the paper finds.

When government dollars are allocated it’s usually through a legislature passing a law, or by public vote. Voters in Kansas City, for example, in April 2024 widely rejected a sales tax bump to pay for a new downtown stadium for MLB’s Royals.

“I like to say that you can fit a majority of the city council in the owner’s box but you can’t fit a majority of the electorate,” says Kennesaw State University economist John Charles Bradbury.

The approved public funding in Las Vegas represents about one quarter of the total cost of the planned stadium, pegged at $1.5 billion. Proponents estimate the A’s stadium in Las Vegas will create thousands of jobs and have an annual economic impact of $1.3 billion, news outlets have reported.

Economic research for decades has found that, by and large, the fiscal returns for residents — in the form of increased economic activity and job growth — are far smaller than public expenditures, which have recently approached or exceeded half a billion dollars per stadium.

This primer will help journalists understand the history of public financing for stadium construction and empower them to use academic research to interrogate claims that these projects mean big bucks for communities.

The research also finds:

• Journalists often report figures from press releases and economic impact statements without questioning the assumptions of those analyses.
• Of the dozens of stadiums built in the past two decades for the four largest American sports leagues, about 4 in 10 were financed at least in part with municipal bonds exempt from federal taxes — which places part of the financial burden of stadium financing on residents nationwide.
• Football and baseball stadiums may increase foot traffic to nearby businesses, but basketball and hockey arenas do not.
• Overall, stadiums tend to shift economic activity, not create new spending.
• Expansion teams are likely to favor markets that already have strong employment and business growth.

A coming stadium construction boom?

Las Vegas is hardly alone. Economists have found that every 30 years or so there’s a wave of public financing for building stadiums or revamping existing ones.

A construction boom may already be under way in the U.S.

For example, Wisconsin will provide $500 million to renovate the Milwaukee Brewers ballpark, and more than $1 billion in public bonds will go toward a new stadium for the NFL’s Tennessee Titans. And the MLB’s Tampa Bay Rays have asked St. Petersburg city councilors to approve more than $400 million for a new ballpark along with nearby infrastructure improvements.

If you’re covering public financing for sports franchises, you’ll want to know what the research says about this topic. This is critical to providing thorough coverage to audiences.

A brief history of public financing for sports stadiums

Modern stadiums were first constructed during the early and mid-1900s, around the two world wars.

“Sports venues were almost exclusively privately financed until the 1930s, when they became largely public ventures,” write the authors of a recent paper in the Journal of Policy Analysis and Management, featured in the research roundup below.

More stadiums were built as leagues expanded and teams moved cities throughout the 1960s and 1970s.

Another construction boom came in the 1990s, with many new stadiums replacing older ones, along with new venues for expansion franchises.

“The median public share of venue construction costs declined from 70% in the 1990s and 2000s to approximately half of construction costs in the 2010s,” write the authors of the Journal of Policy Analysis and Management paper. “Newly opened and planned venues in the 2020s have received roughly 40% of funding from taxpayers.”

While the share of public financing has fallen, the authors find that the amount of public money has risen, from a median of $168 million in public funds per stadium in the 1990s, to $350 million in the 2010s, to $500 million in the 2020s across the four major U.S. sports leagues.  

Even stadiums ostensibly built with private funds can come with public costs.

For example, the New England Patriots built Gillette Stadium in 2002 without direct public dollars, but the franchise benefitted from at least $70 million in state money for nearby road, sewer and other infrastructure improvements, according to the Boston Globe, which the paper authors cite.

Economic activity and stadiums: ‘A transfer of wealth’

While Fenway Park in Boston and Wrigley Field and Soldier Field in Chicago have stood for around 100 years, many stadiums built in the past 50 years have already been replaced for a variety of reasons, despite better construction materials and methods.

For example, the Texas Rangers’ ballparks have been replaced every 27.5 years, on average, while Atlanta Braves’ ballparks have been replaced after 26 years, on average. Among the major sports leagues, 31 stadiums and 31 arenas will be 30 years old or more by 2030, according to Bradbury and co-authors in the Journal of Policy Analysis and Management paper.

Journalists covering asks of public money for private sports projects should be aware of the large body of research on these public investments.

Despite perennial claims from team owners that building new stadiums or revamping existing ones will result in a fiscal and jobs boom for a city or region, research consistently shows that the hundreds of millions of public dollars that are often outlaid are not typically a sound investment.

“You might see a little bit of a resurgence in the area right around the stadium, but it comes at a cost to less commerce in the outlying area, which is exactly what we’d expect,” says Bradbury, who is the current president of the North American Association of Sports Economists. “This is just a transfer of wealth within the community.”

This transfer of wealth may indeed be the point for some city officials, as College of the Holy Cross economist Victor Matheson explains in an October 2018 essay, also in the Journal of Policy Analysis and Management.

For example, when the taxpayers of Arlington, Texas, finance local stadiums, such as for the Dallas Cowboys and the Rangers, the games those teams play move consumer dollars from other parts of the state to Arlington.

“While, again, regional economic activity is unchanged, Arlington’s economy benefits at the expense of other cities and towns in the area,” Matheson writes. He also notes that fiscal reports produced by sports franchises “have been shown to suffer from significant theoretical flaws that make their conclusions suspect at best, and simply false at worst.”

But Matheson argues that while the current level of public spending on sports stadiums is out of balance with the returns on those investment, in certain circumstances some level of public funding may be appropriate.

He points to the 2004 Athens Olympics as a catalyst for infrastructure development there, and a minor league baseball stadium in Worcester, Massachusetts, as providing the political impetus for $35 million in transportation funding from the state, including to make a particularly dangerous intersection near the ballpark safer.

“Obviously, it would be better for local taxpayers to get the needed infrastructure improvements without the wasteful expense of hosting the Olympics or building a baseball stadium, but government activities are not always without friction, and using a stadium project to spur other more useful infrastructure projects may be a second-best solution,” Matheson writes.

The cost-per-taxpayer of a stadium partially financed through public funds may be small in some cases, but it can also be relatively large. Oklahoma City Thunder ownership, for example, is contributing $50 million to build their new arena, compared with the public outlay of $900 million, which comes out to thousands of dollars per adult in the city.  

“People often ask me, they’ll say, ‘Well, you’re always against stadiums.’ And I’ll say, ‘Well, yeah, my guess is most pulmonologists are against smoking,’” says Bradbury. “I mean, the evidence is clear. And I think that journalists feel a need to cover all sides of an issue, and I totally understand that. But it’s about accurate coverage, not equal-balance coverage.”

Research roundup

Public Policy Toward Professional Sports Stadiums: A Review
John Charles Bradbury, Dennis Coates and Brad Humphreys. Journal of Policy Analysis and Management, September 2023.

The study: The authors break down a range of policy considerations for public funding of stadiums. They provide a history of stadium funding since the 1900s, examine research efforts to quantify intangible social benefits of sports teams, describe prominent public funding mechanisms and cast a critical eye toward news reporting.

The findings: With many large U.S. cities facing fiscal crises in the 1980s, government officials began to push the narrative of sports stadiums as economic drivers, “where each dollar spent generates more than one dollar of economic activity as it is recirculated within the community — thereby growing employment income, property values and tax revenues,” the authors write.

Economists began to study the issue around this time. By the turn of the century, “economists were largely in agreement that stadiums were poor public investments,” in terms of tangible benefits, like jobs and spending, “and more recent studies continue to confirm these findings.” Economists then began to explore whether there were intangible benefits to residents of a city with a professional sports franchise — the cultural pride from living in a “big league” city, for example.

One way economists do this is through something called the contingent valuation method, which surveys residents on what they would personally pay for their city to host a sports team. These individual values are then extrapolated to a wider population to put a dollar value on the intangible factors residents enjoy from simply having a professional franchise, whether they go to games or not. Based on results from seven studies conducted in the 2000s and 2010s, “non-use values” amount to “13% of total capital construction costs and 16% of public contributions,” suggesting that “intangible social benefits of hosting professional sports teams are well below levels needed to justify typical subsidies.”

In looking at news coverage of public subsidy proposals for sports franchises, the authors note that “economic impact estimates from advocacy reports may be repeated without external validation of credibility, and press release statements from stadium boosters are quoted in stories without critical assessment.”

The authors write: “As a potential institutional reform, communities should assess all stadium proposals through referendums and initiatives, a once-common practice which has declined over the last few decades. Public votes ensure that subsidies are congruent with voter preferences and allow time for careful consideration of all relevant costs and benefits, so that voters can make informed decisions.”

Growth Effects of Sports Franchises, Stadiums and Arena: 15 Years Later
Dennis Coates. Chapter from The Economic Impact of Sports Facilities, Franchises, and Events, October 2023.

The study: The author, who conducted foundational research with Brad Humphreys starting in the mid-1990s into how sports stadiums affect per capita income, returns to this question with another 17 years of data, from 1969 to 2011. This analysis adds hockey and soccer franchises in addition to MLB, NFL and NBA — along with the American Basketball Association, which merged with the NBA in 1976 — and covers all urban areas in the U.S., including those without a professional team.

The findings: Average personal income grew about 1.4% per year over the period studied, regardless of whether there was a sports stadium in the area. The economic effects of sports franchises account for less than 1.5% of local economic activity, measured by personal income, wages and salaries, and wages per job.

The author writes: “The results of this exercise are largely consistent with the findings of Coates and Humphreys and of numerous other studies that have found that the effect of sports franchises and stadium and arena construction on local economies is weak or nonexistent. Indeed, franchises, stadiums, and arenas may be harmful rather than beneficial to the local community.”

Do Local Businesses Benefit from Sports Facilities? The Case of Major League Sports Stadiums and Arenas
Timur Abbiasov and Dmitry Sedov. Regional Science and Urban Economics, January 2023.

The study: The authors explore a single economic consequence of sports stadiums — foot traffic to nearby retail and food establishments — in a single year, 2018, for MLB NBA, NFL and NHL franchises. Precise foot traffic for 92 sports facilities and surrounding businesses is from SafeGraph, a company that tracks “location data of mobile devices with installed participating applications,” the authors write.

They acknowledge that “the grounds for subsidizing professional sports are weak,” based on past research, but also cite news reports suggesting businesses near sports stadiums suffered curtailed revenue during the COVID-19 pandemic.

The findings: Every 100 visits to a baseball stadium generates 29 visits to nearby restaurants and similar establishments, and six visits to retail stores. The authors find similar results for football stadiums, but little business sale spillover for basketball and hockey arenas. The authors note that professional football and baseball games typically draw much larger crowds than basketball and hockey games.

Basketball and hockey games have a slight negative effect on foot traffic to health, finance and education-related businesses. The authors note that these sports often have arenas located in central business districts, which may lead people who are not going to a game to avoid those areas during game time.

The authors “find that a median sports facility generates approximately $11.3 million of annual additional spending for food and accommodation and retail businesses, with the aggregate spillovers varying substantially across facilities and sports.”

They do not account for negative effects of sports stadiums — such as increased crime, as explained in the next paper — or the revenue of nearby businesses compared with the public costs of building a stadium or improving an existing one.

The authors write: “Our results indicate that the chances of a community economically benefitting from a sports facility via the spillover channel are higher if the facility hosts a popular team and is visited frequently.”

The Impact of Professional Sports Franchises and Venues on Local Economies: A Comprehensive Survey
John Charles Bradbury, Dennis Coates and Brad Humphreys. Journal of Economic Surveys, September 2022.

The study: The authors review the findings of more than 130 studies on economic outcomes of sports stadiums published between 1974 and 2022, the bulk of them published since 2000.

The findings: Local economic activity is by and large unaffected by sports stadiums, “and the level of venue subsidies typically provided far exceeds any observed economic benefits,” the authors write. There is “deep agreement in research findings” that “sports venues are not an appropriate channel for local development policy,” they add.

Sports stadiums can lead to positive effects for communities, such as improved amenities, like pedestrian-friendly zones. But they also come with negative effects. For example, research links sports events with crime. The “positive association between crime and sporting events is perhaps the most robust empirical finding in the economic effects of sports literature,” the authors write.

Why do sports stadiums continue to garner public subsidies? Among other reasons, such as team owners threatening to relocate, the authors note that the benefits of sports stadium subsidies are concentrated in a few hands — namely and primarily the owners.

Costs, meanwhile, are spread across taxpayers. The public cost of Camden Yards in Baltimore came to $15 per local household per year, according to research from the Brookings Institution that the authors cite. They suggest this creates a situation in which wealthy beneficiaries have great incentive to lobby politicians and advertise in favor of subsidies, with little incentive to mobilize opposition because each taxpayer’s individual cost may be low.

The authors write: “Though findings have become more nuanced, recent analyses continue to confirm the decades-old consensus of very limited economic impacts of professional sports teams and stadiums. Even with added nonpecuniary social benefits from quality-of-life externalities and civic pride, welfare improvements from hosting teams tend to fall well short of covering public outlays.”

Tax-Exempt Municipal Bonds and the Financing of Professional Sports Stadiums
Austin Drukker, Ted Gayer and Alexander Gold. National Tax Journal, March 2020.

The study: Of the 57 stadiums built in the past two decades for the four largest American sports leagues, about 4 in 10 were financed at least in part with municipal bonds exempt from federal taxes. State or local governments issue the bonds, then the interest bond buyers earn is exempt from federal taxes, meaning “tax-exempt municipal bonds confer an indirect federal subsidy to the issuers,” the authors write. Bond buyers accept lower interest rates — saving interest payment dollars for states and localities — because they know they will get a tax break on their investment return.

NFL stadiums are the most expensive, with an average cost of $1 billion. But baseball stadiums are most heavily financed through tax-exempt bonds. On average, $466 million of baseball stadium costs are financed through such bonds. The authors examine the estimated value of those bonds issued since 2000.

The findings: The value of the federal tax exemption is $3.6 billion across the $16.7 billion worth of bonds issued to finance stadium construction, the authors estimate. But the estimated loss in federal tax revenue is considerably higher: $4.3 billion. The authors explain that the reason for the difference is that a portion of bond buyers would still buy those bonds at a lower return rate than the subsidy offers.

The authors write: “Most residents of, say, New York, Massachusetts, or California — unless they are avid fans — gain nothing from the Washington-area football team’s decision to locate in Virginia, Maryland, or the District of Columbia. Yet, under current federal law, taxpayers throughout the country ultimately subsidize the stadium, wherever it is located … Ultimately, the problem is one of rent seeking, since professional sports leagues are able to extract local and federal subsidies by exerting concentrated power while the costs of the subsidies are diffuse.”

Economic Development Effects of Major and Minor League Teams and Stadiums
Nola Agha and Daniel Rascher. Journal of Sports Economics, November 2020.

The study: The authors explore whether new stadiums for major and minor league teams affect economic development, measured by employment and business growth. They use Census Bureau data from 2004 to 2012 covering 871 markets. There were 65 new teams, 67 teams that departed a city and 68 new stadiums built during the period studied. The included top-tier professional leagues and their development affiliates are MLB, NFL, NBA, NHL, Major League Soccer, and the Women’s National Basketball Association. The WNBA saw three teams join and five leave the league but was the only professional league without a new arena during the period studied.

The findings: The authors note that much research has focused on the economic effects of major league venues. Stadiums and arenas built between 2000 and 2018 cost more than $40 billion total. Spending on minor league venues account for a sizeable chunk over that time — $9.6 billion, according to the authors, and many of those developmental team venues are in the same market as major league teams.

On the whole, new major league teams and new stadiums do not affect economic development, and the findings suggest teams tend to enter markets with strong employment and business growth. New minor league sports teams also do not tend to affect employment, but for markets between 100,000 and 499,000 people, the findings suggest that new minor league sports stadiums can lead to a slight uptick in new businesses.

The authors write: “Overall, we find no substantial evidence that entry of a new team or stadium is associated with any net gains related to economic development, other than for minor league team entry in smaller markets and employment effects limited to the period of construction.”

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New York Times investigative reporter Hannah Dreier wanted to know what happened to the hundreds of thousands of migrant children who came to the U.S. alone in recent years through the country’s southern border. Most sought to escape extreme poverty in Guatemala, Honduras and El Salvador.

In her five-part series, “Alone and Exploited,” Dreier demonstrates how a long chain of government failures and willful ignorance allowed this “new economy of exploitation” to grow and thrive.

“This shadow work force extends across industries in every state, flouting child labor laws that have been in place for nearly a century,” she writes in the first story in the series, published in February 2023.

“Companies ignore the young faces in their back rooms and on their factory floors. Schools often decline to report apparent labor violations, believing it will hurt children more than help. And [the U.S. Department of Health and Human Services] behaves as if the migrant children who melt unseen into the country are doing just fine.”

The series also reveals:

• More than 250,000 migrant children arrived alone in the U.S. in 2021 and 2022, a sharp increase over prior years. As emergency shelters ran out of room, the federal government pressed case managers to work faster to place kids in private homes and loosened some restrictions to make vetting sponsors easier.
• The U.S. government lost track of many migrant children shortly after they left the shelters. “While H.H.S. [the Department of Health and Human Services] checks on all minors by calling them a month after they begin living with their sponsors, data obtained by The Times showed that over the last two years, the agency could not reach more than 85,000 children,” Dreier writes in the first story in the series. “Overall, the agency lost immediate contact with a third of migrant children.”
• Federal officials missed or overlooked warnings signs about child labor violations, including reports from social workers about dangerous working conditions and reports from the U.S. Department of Labor outlining evidence of child labor trafficking.
• Private audits ordered by several big companies consistently missed child labor violations. “Children were overlooked by auditors who were moving quickly, leaving early or simply not sent to the part of the supply chain where minors were working, The Times found in audits performed at 20 production facilities used by some of the nation’s most recognizable brands,” Dreier writes in the last article in the series, published in December 2023.

Federal and state officials responded quickly to Dreier’s reporting by changing laws, strengthening programs and overhauling some federal agencies. Days after the first story ran, President Joe Biden’s administration announced a crackdown on child labor exploitation. Congress and the Department of Labor launched their own investigations.

Meanwhile, many major companies, including McDonald’s, Costco and PepsiCo, announced their own reforms aimed eliminating child labor across their supply chains, Dreier reported in February 2024.

I interviewed Dreier to learn more about her series and the database she created to ground her coverage. Dreier, who is on maternity leave, answered my five questions by email.

In the short Q&A below, she discusses the database, which contains key details the federal government collected on more than 550,000 migrant children from January 2015 through May 2023, and why The New York Times chose to make it public. Dreier also offers tips to help other journalists use the anonymized data to report on migrant children and labor issues in their states and communities.

Her responses have been lightly edited to match The Journalist’s Resource’s editorial style.

Denise-Marie Ordway: Why did you create this database and how did it help you report out the series?

Hannah Dreier: This was a story that focused on people and on-the-ground reporting, but it started with data. I started out in early 2022 with a question: What happened to the hundreds of thousands of young people who were crossing the southern border by themselves?

I knew from years of immigration reporting that some of these children ended up working industrial jobs. But little was known about the startling scope of child labor throughout the United States, or the industry and governmental failures that have allowed it to thrive.

My first, and largest, hurdle was figuring out how to find children in this hidden workforce. The government provides shelter to children when they arrive, but after releasing them to sponsors, it doesn’t track them further. To find where children were working, I had to develop a new approach to analyzing federal data.

I quickly realized that children released to distant relatives and strangers were the most likely to be put to work. So I filed multiple FOIA [Freedom of Information Act] requests with the Department of Health and Human Services — and eventually sued them in federal court. I was able to obtain ZIP code-level data showing where children had been released to these nonparent sponsors. I then overlaid this data with U.S. Census population-density data to pinpoint parts of the country with especially high concentrations of children living far from their close relatives.

The resulting database guided two years of reporting across 13 states.

The data pointed to spots I never would have thought of: Flandreau, South Dakota; Parksley, Virginia; Bozeman, Montana. I started visiting these towns for weeks at a time, embedding in schools, and accompanying families to weddings and quinceañeras. I sat in factory parking lots during the midnight shift change and waited outside day labor sites before dawn. I found town after town where migrant child labor was an open secret.

Ordway: What made you decide to make this data public? Should more journalists and news outlets do this?

Dreier: Yes! And I hope more reporters use this data to dig into migrant child labor in America.

After I wrote a Times Insider piece explaining my process for mapping migrant child labor, Congressional staffers, academics, other journalists and even Department of Labor investigators requested access to our database. As part of its commitment to exposing the full scope of child labor, The Times made this data public, along with a detailed map that outlined outcomes for more than 550,000 children over a period of eight years.

We found migrant child labor in all 50 states. It’s clear there’s more to this story than what one journalist or even a team of reporters can report.

Ordway: How do you recommend other journalists use this database?

Dreier: Journalists at different outlets around the country have already picked up on some child labor stories, and this data can help them tell new stories. For local reporters, the database provides a previously unavailable level of detail about migrant children, including where kids are coming from, how long they’re staying in government-run shelters, and what kind of relationships they have with their sponsors (if they’re being released to aunts and uncles, distant cousins, strangers, etc.).

It’s been great to see reporters starting to use the database to fuel their own reporting, including at The Cincinnati Enquirer and Atlanta Journal-Constitution.

Ordway: What advice would you give other journalists who’d like to create databases for their own reporting projects?

Dreier: Though the heart of this reporting was the stories of the children themselves, I used data to add sweep and bring home to readers just how widespread this problem has become.

We found useful data everywhere. It doesn’t always take a federal lawsuit to shake it loose. We used court records from PACER [the federal Public Access to Court Electronic Records system] and state courts, as well as documents from dozens of FOIA requests to the Department of Labor and state labor agencies to hunt down outcomes the government does not track.

We built a database of migrant children killed on the job, including a 15-year-old who fell on his first day roofing and a 14-year-old who was hit by a car while delivering food.

Another database showed how rarely the government prosecuted child labor trafficking cases. I also tracked serious workplace injuries suffered by children, including crushed limbs and seared lungs.

A lot of data is sitting there for the taking, and doesn’t require submitting any requests at all. I’d encourage reporters to spend time on the websites of the agencies they’re reporting on — for me, that was OSHA [the Occupational Safety and Health Administration], DOL [the Department of Labor], HHS [the Department of Health and Human Services], SEC [the Securities and Exchange Commission], and CBP [Customs and Border Protection].

I also found it helpful to try site searches of these websites (by adding “site:hhs.gov” to Google searches for example), and to add the search term .csv or .xlsx, because some databases are posted to the site but not listed anywhere.

Ordway: When you ask government agencies for data such as this, how do you make sure you receive it in a form that you can easily use for reporting purposes?

Dreier: I always ask FOIA officers to email me records and to send data as a spreadsheet, but government offices often ignore that request.

With this project, some state agencies and police departments would send records only in hard copy or on CDs.

HHS gave us thousands of rows of data in the form of poorly rendered PDFs. We resolved this issue by scanning hundreds of pages of documents, and then using online tools to convert them to searchable text and spreadsheets.

For me, the most important thing is to get the records. From there, it’s almost always possible to find some way to make them useable … even if it ends up being a time-consuming process.

Read the stories

Alone and Exploited, Migrant Children Work Brutal Jobs Across the U.S.

As Migrant Children Were Put to Work, U.S. Ignored Warnings

The Kids on the Night Shift

Children Risk Their Lives Building America’s Roofs

They’re Paid Billions to Root Out Child Labor in the U.S. Why Do They Fail?

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