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on Health Economics |
| By: | Doleac, Jennifer (University of Virginia); Mukherjee, Anita (University of Wisconsin-Madison) |
| Abstract: | The United States is experiencing an epidemic of opioid abuse. In response, many states have increased access to naloxone, a drug that can save lives when administered during an overdose. However, naloxone access may unintentionally increase opioid abuse through two channels: (1) reducing the risk of death per use, thereby making riskier opioid use more appealing, and (2) saving the lives of active drug users, who survive to continue abusing opioids. By increasing the number of opioid abusers who need to fund their drug purchases, naloxone access laws may also increase theft. We exploit the staggered timing of naloxone access laws to estimate the total effects of these laws. We find that broadening naloxone access led to more opioid-related emergency room visits and more opioid-related theft, with no reduction in opioid-related mortality. These effects are driven by urban areas and vary by region. We find the most detrimental effects in the Midwest, including a 14% increase in opioid-related mortality in that region. We also find suggestive evidence that broadening naloxone access increased the use of fentanyl, a particularly potent opioid. While naloxone has great potential as a harm-reduction strategy, our analysis is consistent with the hypothesis that broadening access to naloxone encourages riskier behaviors with respect to opioid abuse. |
| Keywords: | naloxone, opioids, moral hazard |
| JEL: | I18 K42 D81 |
| Date: | 2018–04 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp11489&r=hea |
| By: | Giuntella, Osea (University of Pittsburgh); Lonsky, Jakub (University of Pittsburgh) |
| Abstract: | This paper studies the effects of the 2012 Deferred Action for Childhood Arrivals (DACA) initiative on health insurance coverage, access to care, health care use, and health outcomes. We exploit a difference-in-differences that relies on the discontinuity in program eligibility criteria. We find that DACA increased insurance coverage. In states that granted access to Medicaid, the increase was driven by an increase in public insurance take-up. Where public coverage was not available, DACA eligibility increased individually purchased insurance. Despite the increase in insurance coverage, there is no evidence of significant increases in health care use, although there is some evidence that DACA increased demand for mental health services. After 2012, DACA- eligible individuals were more likely to report a usual place of care and less likely to delay care because of financial restrictions. Finally, we find some evidence that DACA improved self-reported health, and reduced depression symptoms, indicators of stress and anxiety, and hypertension. These improvements are concentrated among individuals with income below the federal poverty level. |
| Keywords: | health insurance, DACA, immigration, health care, health |
| JEL: | I10 J15 J61 |
| Date: | 2018–04 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp11469&r=hea |
| By: | Courtemanche, Charles (Georgia State University); Marton, James (Georgia State University); Ukert, Benjamin (University of Pennsylvania); Yelowitz, Aaron (University of Kentucky); Zapata, Daniela (Impaq International) |
| Abstract: | This paper examines the impacts of the Affordable Care Act (ACA) – which substantially increased insurance coverage through regulations, mandates, subsidies, and Medicaid expansions – on behaviors related to future health risks after three years. Using data from the Behavioral Risk Factor Surveillance System and an identification strategy that leverages variation in pre-ACA uninsured rates and state Medicaid expansion decisions, we show that the ACA increased preventive care utilization along several dimensions, but also increased risky drinking. These results are driven by the private portions of the law, as opposed to the Medicaid expansion. We also conduct subsample analyses by income and age. |
| Keywords: | Affordable Care Act, health insurance, Medicaid, health behavior, obesity, smoking, drinking, preventive care, screening |
| JEL: | I12 I13 I18 |
| Date: | 2018–04 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp11468&r=hea |
| By: | Gihleb, Rania (University of Pittsburgh); Giuntella, Osea (University of Pittsburgh); Zhang, Ning (University of Pittsburgh) |
| Abstract: | The opioid epidemic is a national public health emergency. As the number of fa- tal overdoses and drug abuse skyrockets, children of opioid-dependent parents are at increased risk of being neglected, abused or orphaned. While some studies have examined the effects of policies introduced by states to restrict prescription drug supply on drug abuse, there is no study analyzing their effects on children. This paper estimates the effect of must-access prescription drug monitoring programs (PDMPs) on child removals. To identify the effects of the programs on foster care caseloads, we exploit the variation across states in the timing of adoption of must-access PDMPs using an event-study approach as well as standard difference-in-difference models. Consistent with previous evidence examining the effects of PDMPs on drug abuse, we find that operational PDMP did not have any significant effects on foster care caseloads. However, the introduction of mandatory provisions reduced child removals by 10%. Exploring the reasons of removals, we show that these effects are driven by the reductions in cases of child neglect. There is also evidence of significant reductions in removal cases associated with child physical abuse. |
| Keywords: | opioid epidemic |
| JEL: | I12 I18 J13 |
| Date: | 2018–04 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp11470&r=hea |
| By: | Hayen, Arthur; Klein, Tobias; Salm, Martin |
| Abstract: | In light of increasing health care expenditures, patient cost-sharing schemes have emerged as one of the main policy tools to reduce medical spending. We show that the effect of patient cost-sharing schemes on health care expenditures is not only determined by the economic incentives they provide, but also by the way these economic incentives are framed. Patients react to changes in economic incentives almost twice as strongly under a deductible policy than under a no-claims refund policy. Our preferred explanation is that individuals are loss-averse and respond differently to both schemes because they perceive deductible payments as a loss and no-claim refunds as a gain. |
| Keywords: | framing; Health Insurance; loss aversion.; Patient cost-sharing |
| JEL: | D91 H51 I13 |
| Date: | 2018–05 |
| URL: | http://d.repec.org/n?u=RePEc:cpr:ceprdp:12908&r=hea |
| By: | Bellemare, Charles (Université Laval); Goussé, Marion (Université Laval); Lacroix, Guy (Université Laval); Marchand, Steeve (Université Laval) |
| Abstract: | We investigate the determinants and extent of labor market discrimination toward people with physical disabilities using a large scale field experiment. Applications were randomly sent to 1477 private firms advertising open positions. We find that average callback rates of disabled and non-disabled applicants are respectively 14.4% and 7.2%. We find this differential does not result from accessibility constraints related to firm infrastructures. We also find that mentioning eligibility to a government subsidy to cover the cost of workplace adaptation does not increase callback rates. Finally, we estimate that a lower bound of the proportion of discriminating firms is 49.7%. |
| Keywords: | discrimination, disabilities, partial identification |
| JEL: | J71 J68 |
| Date: | 2018–04 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp11461&r=hea |
| By: | Sullivan, Riley (Federal Reserve Bank of Boston) |
| Abstract: | The rise in the abuse of—and addiction to—opioids and the rapid increase in the number of fatal overdoses in recent years have made the opioid epidemic a priority for local, state, and federal policymakers. Understanding the epidemic’s direct fiscal impact is key to acknowledging its scope and magnitude. While opioid abuse has many direct and indirect fiscal costs, few studies quantify them. This report assembles available data on the impact of opioid epidemic on criminal justice, treatment, and related health expenditures in the New England states. The research finds that state governments in the region spend a higher percentage on total opioid-related costs and more per capita than the national averages. Across the region, treating opioid-use disorder—on both an emergency and a long-term basis—accounts for the majority of the costs. Estimates for medical treatment expenditures associated with opioid abuse reach as high as $340 million annually in Massachusetts alone. While providing new insight the author acknowledges that the costs considered in this policy report are incomplete. It’s plausible that the opioid epidemic’s impact on state revenues is also significant and could affect regional fiscal health. For example, individuals incarcerated for drug crimes or in residential treatment programs are not earning wages. Evidence also suggests that non-institutionalized individuals abusing opioids are more likely out of work than employed, likewise resulting in lost revenue (Krueger 2017). The author plans to conduct further research on opioid abuse’s impact on employment and labor force participation, which should contribute to a fuller understanding of the epidemic’s fiscal cost to the region. However, beyond the fiscal cost is the toll opioid abuse has taken on individuals, families, and communities. The costs analyzed in this report are just a small part of the greater damage inflicted across the region and the country. |
| Keywords: | opioids; New England; fiscal |
| Date: | 2018–05–01 |
| URL: | http://d.repec.org/n?u=RePEc:fip:fedbpr:2018_001&r=hea |
| By: | Bratsberg, Bernt (Ragnar Frisch Centre for Economic Research); Raaum, Oddbjørn (Ragnar Frisch Centre for Economic Research); Røed, Knut (Ragnar Frisch Centre for Economic Research) |
| Abstract: | Immigrants from low‐income source countries tend to be underrepresented in employment and overrepresented in social insurance programs. Based on administrative data from Norway, we examine how these gaps reflect systematic differences in the impacts of social insurance benefits on work incentives. Drawing on a benefit formula reform of the temporary disability insurance program, we identify behavioral employment and earnings responses to changes in benefits, and find that responses are significantly larger for immigrants. Among female immigrant program participants, earnings of the male spouse also drop in response to more generous benefits. We uncover stronger behavioral responses among natives with characteristics similar to those of immigrants. |
| Keywords: | immigrants, labor supply, social insurance |
| JEL: | H53 J15 J22 |
| Date: | 2018–04 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp11482&r=hea |
| By: | Kools, Lieke (University of Leiden); Koning, Pierre (Leiden University) |
| Abstract: | There is increasing evidence that graded return-to-work is an effective tool for the rehabilitation of sick-listed workers. Still, little is known on the optimal timing and level of grading in return-to-work trajectories, as well as the allocation of trajectories across worker types. To fill this gap, we analyze whether the effectiveness of graded return-to-work depends on the starting moment of the trajectory and the initial level of graded work resumption. We use administrative data from a Dutch private workplace reintegration provider. In order to correct for the selection bias inherent to the evaluation of activation strategies, we exploit the discretionary room of the case managers in setting up treatment plans. In correspondence with previous literature we find that graded return-to-work reduces sick spells with eighteen weeks within the first two years after reporting sick. However, the probability of work resumption after two years remains unchanged. Work resumption can be achieved faster when graded return-to-work is started earlier or at a higher rate of initial work resumption. These findings how- ever do not hold for individuals who have problems related to mental health. |
| Keywords: | activation, long-term sickness absence, graded return-to-work |
| JEL: | I18 C26 |
| Date: | 2018–04 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp11471&r=hea |
| By: | Aliprantis, Dionissi (Federal Reserve Bank of Cleveland); Schweitzer, Mark E. (Federal Reserve Bank of Cleveland) |
| Abstract: | This paper finds evidence that opioid availability decreases labor force participation while a large labor market shock does not influence the share of opioid abusers. We first identify the effect of availability on participation using the geographic variation in opioid prescription rates. We use a combination of the American Community Survey (ACS) and Centers for Disease Control and Prevention (CDC) county-level prescription data to examine labor market patterns across both rural and metropolitan areas of the United States from 2007 to 2016. Individuals in areas with higher prescription rates are less likely to participate after accounting for standard demographic factors and regional controls. This relationship remains significant for important demographic groups when increasingly strong panel data controls, including a full set of geographic fixed effects and measures of local labor market conditions in 2000, are introduced to the regressions. We also investigate the possibility of reverse causality, using the Great Recession as an instrument to identify the effect of weak labor demand on opioid abuse. The share abusing opioids did not increase after the onset of the Great Recession. The evidence on the frequency of abuse is more ambiguous since the identified increases could be the continuation of a pre-trend. |
| Keywords: | Opioid Prescription Rate; Labor Force Participation; Great Recession; Opioid Abuse; |
| JEL: | I10 J22 J28 R12 |
| Date: | 2018–05–15 |
| URL: | http://d.repec.org/n?u=RePEc:fip:fedcwp:1807&r=hea |
| By: | van den Berg, Gerard J. (University of Bristol); Drepper, Bettina (Tilburg University) |
| Abstract: | Empirical analyses of twin mortality often use models with dependent unobserved frailty terms capturing genetic and childhood environmental determinants. This ignores that mortality rates can be co-dependent due to bereavement effects, i.e. to a time-dependent causal effect of the loss of the co-twin on the mortality rate of the surviving twin. We develop a novel methodology and perform an empirical analysis based on a comprehensive model incorporating both types of dependence. We prove full identification without functional-form restrictions and we estimate models with data on twin pairs from the Danish Twin Registry. Among men, the loss of an identical co-twin at age 75 causally reduces the remaining lifetime on average by more than a year. This bereavement effect is less severe among non-identical twins or if the loss occurs at a higher age. Estimates of correlations between the frailty terms by zygosity and the ensuing implications for the relative importance of mortality determinants are highly sensitive to whether bereavement is taken into account. |
| Keywords: | mortality, longevity, duration, frailty, genetic determinants, hazard rate, identification, loss of co-twin |
| JEL: | C41 C32 I14 |
| Date: | 2018–04 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp11448&r=hea |
| By: | Ciccarelli, Carlo; De Fraja, Gianni; Tiezzi, Silvia |
| Abstract: | In this paper we study the ability of the 19-th century Italian government to choose profit maximising prices for a multiproduct monopolist. We use very detailed historical data on the tobacco consumption in 62 Italian provinces from 1871 to 1888 to estimate a differentiated product demand system. The demand conditions and the legal environment of the period made this market as close to a textbook monopoly as is practically possible. The government's stated aim for this industry was profit maximisation: since at the time tobacco revenues constituted between 10 and 15 percent of the revenues for the cash-strapped government, the stated aim was very likely the true one. Cost data for the nine products suggest that the government was not wide off the mark: the tobacco prices were ``not far'' from those dictated by the standard monopoly formulae for profit maximisation with interdependent demand functions. |
| Keywords: | 19-th century Italy; Demand for Tobacco; Habit formation.; Multiproduct monopoly profit maximisation; QAI demand system |
| JEL: | I18 L12 L66 N33 |
| Date: | 2018–05 |
| URL: | http://d.repec.org/n?u=RePEc:cpr:ceprdp:12907&r=hea |
| By: | Berthelon, Matias (Universidad Adolfo Ibañez); Kruger, Diana (Universidad Adolfo Ibañez); Sánchez, Rafael (Universidad Adolfo Ibañez) |
| Abstract: | There is a consensus in the literature on the relevance of the first 1,000 days since conception in the development of a child's cognitive and non-cognitive skills. However, little is known of the determinants of these skills at that age, as previous literature has focused on the effect of in utero and early childhood shocks on outcomes at birth or at age 7 and beyond. In this paper, we analyze the impact of prenatal stress on cognitive and non-cognitive development of the child by age 2. By exploiting a longitudinal dataset of children and their parents, we find that children who were exposed in-utero to maternal stress do not have different birth-weight relative to those who were not exposed, yet by age 2, exposed children had a lower level of development, cognition skills, and more attention problems relative to children not exposed to in utero stress. We also find that the negative impacts are observed if in-utero stress occurs during the first trimester of pregnancy. The negative impact on cognitive skills and development is concentrated on lower-income children and attention problems occur among high-income children, and boys suffer lower development and worse attention problems, while girls' cognition is negatively affected by in-utero stress. |
| Keywords: | in-utero, stress, early childhood development, maternal stress, maternal mental health, earthquake, Chile |
| JEL: | I10 I19 J13 |
| Date: | 2018–04 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp11452&r=hea |
| By: | Patnaik, Ila (National Institute of Public Finance and Policy); Roy, Shubho (National Institute of Public Finance and Policy); Shah, Ajay (National Institute of Public Finance and Policy) |
| Abstract: | India has experienced a remarkable proliferation of 48 Government Funded Health Insurance Schemes (GFHIS) from 1997 to 2018. We place the rise of this policy pathway in historical perspective. Under colonial rule, there was considerable importance placed upon public health as a local public good. After independence, the Bhore Committee build a paradigm of public sector health care, and the public health system degraded. In this environment, the political process faced a high disease burden coupled with a weak public health care system. This pressure led to the adoption of GFHIS as a convenient way forward. We identify four areas of concern in this new paradigm of Indian health policy: inefficient lack of focus upon public health, regulatory problems with private health care, weak regulation of health insurance companies, and fiscal risk. |
| Date: | 2018–05 |
| URL: | http://d.repec.org/n?u=RePEc:npf:wpaper:18/231&r=hea |
| By: | Damien Besancenot (LIRAES - EA 4470 - Laboratoire Interdisciplinaire de Recherche Appliquée en Economie de la Santé - UPD5 - Université Paris Descartes - Paris 5); Nicolas Sirven (IRDES - Institut de Recherche et Documentation en Economie de la Santé - Institut de la Recherche et Documentation en Economie de la Santé, LIRAES - EA 4470 - Laboratoire Interdisciplinaire de Recherche Appliquée en Economie de la Santé - UPD5 - Université Paris Descartes - Paris 5); Radu Vranceanu (ESSEC - Economics Department - Essec Business School) |
| Abstract: | This paper explains the observed hospital congestion in developing countries as the result of the interaction between ambulatory care physicians who refer patients to hospitals, and hospitals which must detect the severity of the incoming patientsdisease. In an imperfect information environment, physicians might refer to top-tier hospitals patients with mild diseases that could be properly addressed by regular hospitals, just to ful ll patientsdemand for the best care. Yet, the triage capability of top-tier hospitals declines if the hospital is subject to congestion, which, in turn, provides incentives to physicians to refer more patients to these hospitals. The model presents two equilibria, one with perfect triage, and another with triage errors and hospital congestion. In this last equilibrium, a higher hospital size raises the likelihood of congestion. |
| Keywords: | Hospital congestion,hospital size,referral system,health policy,developing countries |
| Date: | 2018–04–09 |
| URL: | http://d.repec.org/n?u=RePEc:hal:wpaper:hal-01791106&r=hea |
| By: | Zamora, B.; Parkin, D. Feng, Y.; Bateman, A.; Herdman, M.; Devlin, N. |
| Abstract: | This paper reports new methods for analysing the distribution of EQ-5D observations. The Health State Density Index and Health State Density Curve are used to summarise the extent to which people's self-reported health on the EQ-5D is concentrated on a few health states, or distributed more evenly over a wide range of health states. This information can be useful in understanding patients' treatment needs, as well as providing a way of comparing the nature of data provided by different patients or collected using different patient-reported outcome measures. |
| Keywords: | Economics of Health Technology Assessment; Health Statistics and Data Analyses |
| JEL: | I1 |
| Date: | 2018–04–01 |
| URL: | http://d.repec.org/n?u=RePEc:ohe:respap:001984&r=hea |
| By: | Cubi-Molla, P.; Shah, K.K; Garside, J.; Herdman, M.; Devlin, N. |
| Abstract: | Several studies have found differences in health state values by age. We investigate whether and how age affects respondents' Time Trade-Off (TTO) and Visual Analogue Scale (VAS) valuations of hypothetical EQ-5D health states using data from the 1993 MVH UK valuation study. The authors identify the existence of an inverse U-shaped age-utility pattern, with respondents in their forties tending to provide the highest values for the majority of the health states analysed. The TTO values obtained from the oldest respondents are systematically (and significantly, for the majority of profiles) lower than those obtained from younger age groups. Our study also finds that significant differences in values amongst age groups seem to be associated with profiles with level 3 in the mobility dimension or level 2 or 3 in the self-care dimension. VAS valuations appear to be less affected by age than TTO valuations. The authors conclude the paper with a thought-provoking debateby assessing the arguments for and against about a case for using age-specific utilities in HTA. Compared to previous research, this study analyses differences in utilities amongst a greater number of age-defined subgroups and at the individual health state level. It also examines how the findings relate to the various arguments for and against using age-specific utilities in HTA. |
| Keywords: | Economics of Health Technology Assessment; Health Statistics and Data Analyses |
| JEL: | I1 |
| Date: | 2017–04–01 |
| URL: | http://d.repec.org/n?u=RePEc:ohe:respap:001830&r=hea |
| By: | Barnsley, P.; Cubi-Molla, P.; Fischer, A.; Towse, A. |
| Abstract: | The quality of decision-making in key public sector bodies dealing with resource allocation is a major determinant of their efficiency. One of the most difficult and contentious areas of decision-making is the way that uncertainty is dealt with. This report is concerned with uncertainty as it affects the cost effectiveness aspects of health technology assessment (HTA). It includes a review of the policy documents governing cost benefit analysis and cost effectiveness analysis in respect of HTA in England and Wales, and the results of interviews with former decision makers at the National Institute for Health and Care Excellence (NICE). |
| Keywords: | Economics of Health Technology Assessment |
| JEL: | I1 |
| Date: | 2016–11–01 |
| URL: | http://d.repec.org/n?u=RePEc:ohe:respap:001764&r=hea |
| By: | O'Neill, P.; Cole, A.; Duran, A.; Devlin, N. |
| Abstract: | Between January 2007 and June 2016 nearly a quarter (89 of 407) of all National Institute for Health and Care Excellence (NICE)-reported decisions for individual technologies assessed through their technology appraisal (TA) process have been characterised by them as recommended in line with clinical practice (RiLCP), to be distinguished from recommended in line with marketing authorisation. These RiLCP decisions are counted as 'recommended' in NICE statistics summarising technology appraisal (TA) decision outcomes, and 44% percent (89 of 203) of all 'recommended' decisions in the period 2007-2016 are given this classification. The objectives of this study are twofold - First, we qualitatively assess documentation associated with RiLCP decisions to create a framework to describe common themes and criteria used to reach those decisions. Second, we assess the level of patient access associated with each RiLCP decision using a previously developed method – the 'M' score. |
| Keywords: | Economics of Health Technology Assessment |
| JEL: | I1 |
| Date: | 2016–12–01 |
| URL: | http://d.repec.org/n?u=RePEc:ohe:respap:001777&r=hea |
| By: | Feng, Y.; Devlin, N.; Bateman, A.; Zamora, B.; Parkin, D. |
| Abstract: | EQ-5D data are often summarised by an EQ-5D index, whose distribution for its original version, the EQ-5D-3L, often shows two distinct groups in patient populations, arising from both the distribution of ill health and how the index is constructed. To date, there is little evidence about the distribution of the EQ-5D-5L index. This project aims to - - explore whether or not the EQ-5D-5L index distribution also demonstrates this two-group distribution - test the extent to which clustering of EQ-5D-5L profile data drives any observed clustering of the EQ-5D-5L index, and the extent to which clusters result from the characteristics of the value sets used to create the index; - discuss the implications of our results for statistical analysis of EQ-5D-5L index data. The results highlight the importance of undertaking careful exploratory data analysis for health related quality of life measures such as the EQ-5D, to ensure that statistical testing takes account of clustering and other features of the data distribution. |
| JEL: | I1 |
| Date: | 2016–10–01 |
| URL: | http://d.repec.org/n?u=RePEc:ohe:respap:001756&r=hea |
| By: | Mulhern, B.; Feng, Y.; Shah, K.; van Hout, B.; Janssen, B.; Herdman, M.; Devlin, N. |
| Abstract: | Three EQ-5D value sets (the EQ-5D-3L, crosswalk and EQ-5D-5L) are now available for cost utility analysis in the UK and/or England. The value sets' characteristics differ, and it is important to systematically assess the implications of these differences for the value generated. The aim of this paper is to compare the characteristics of the three value sets. In this Research Report we analyse and compare the predicted values from each of the three value sets, and also compare EQ-5D-3L and EQ-5D-5L data from patients who completed both measures. We find there are systematic differences in the distribution of the EQ-5D-3L and EQ-5D-5L value sets. The EQ-5D-5L values are higher than the EQ-5D-3L values for matched states, and the overall range, and therefore differences between adjacent states is smaller than for the EQ-5D-3L. There are similar differences between the EQ-5D-5L and crosswalk value sets. In the patient data, the EQ-5D-5L value set produces higher values across all of the conditions included, and the differences are generally significant. There is some evidence that the value sets rank different health conditions in a similar order of severity, particularly for the most and least severe conditions. |
| Keywords: | Economics of Health Technology Assessment |
| JEL: | I1 |
| Date: | 2017–03–01 |
| URL: | http://d.repec.org/n?u=RePEc:ohe:respap:001821&r=hea |