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on Health Economics |
| By: | Bernard Black; Alex Hollingsworth; Leticia Nunes; Kosali Simon |
| Abstract: | A large literature examines the effect of health insurance on mortality. We contribute by emphasizing two challenges in using the Affordable Care Act (ACA)’s quasi-experimental variation to study mortality. The first is non-parallel pretreatment trends. Rising mortality in Medicaid non-expansion relative to expansion states prior to Medicaid expansion makes it difficult to estimate the effect of insurance using difference-in-differences (DD). We use various DD, triple difference, age-discontinuity and synthetic control approaches, but are unable to satisfactorily address this concern. Our estimates are not statistically significant, but are imprecise enough to be consistent with both no effect and a large effect of insurance on amenable mortality over the first three post-ACA years. Thus, our results should not be interpreted as evidence that health insurance has no effect on mortality for this age group, especially in light of the literature documenting greater health care use as a result of the ACA. Second, we provide a simulation-based power analysis, showing that even the nationwide natural experiment provided by the ACA is underpowered to detect plausibly sized mortality effects in available datasets, and discuss data needs for the literature to advance. Our simulated pseudo-shocks power analysis approach is broadly applicable to other natural-experiment studies. |
| JEL: | I1 |
| Date: | 2019–02 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:25568&r=all |
| By: | Miglino, Enrico; Navarrete H., Nicolas; Navarrete H., Gonzalo; Navarrete H., Pablo |
| Abstract: | This paper estimates the effect of a permanent income increase for the elderly on their health outcomes. Our regression discontinuity design exploits an eligibility cutoff in a Chilean basic pension program that grants monthly payments of 40 percent of the minimum wage to pensionless retirees. Four years after applying pension, recipients are 2.5 percentage points less likely to die, with lower incidence of respiratory and circulatory diseases. The effect is concentrated on pension recipients living without working-age relatives, who have more children if living with recipients. This seems explained by pre-existing income transfers from working-age relatives to retirees, which cease when payments begin. Results suggest that increasing income for older individuals could reduce health inequalities across income groups, and mitigate the inter-generational transmission of poverty by alleviating the financial burden imposed on younger relatives. |
| Keywords: | Desarrollo, Economía, Productividad, |
| Date: | 2018 |
| URL: | http://d.repec.org/n?u=RePEc:dbl:dblwop:1245&r=all |
| By: | Antoine Parent (Observatoire français des conjonctures économiques); Olivier, Bureau D'economie Théorique Guillot (Bureau d'Economie Théorique et Appliquée (CNRS/Université de Strasbourd/UL/INRA/AgroParistech) (BETA)) |
| Abstract: | This article provides precise and detailed insight into the mortality of French soldiers during the First World War, focusing on their survival time during the conflict. The article clearly contributes to the longpursued yet unfinished endeavour that is a thorough and definitive demographic assessment of this war. To provide a general framework for the article’s conclusions, it bears recalling certain multinational data on the losses incurred during what has often and rightly been referred to as the “hecatomb” or “the great bloodletting”. According to an overall average estimate, the Great War caused the deaths of nearly 10 million soldiers, including more than 2 million Germans, nearly 2 million Russians, just under 1.5 million Frenchmen, 800,000 Britons, and 650,000 Italians, although these figures remain subject to debate. Counts include men from the most fertile age groups, between ages 19 and 40, that also made up the largest share of their countries’ labour forces. They form the “sacrificed generations”. As a proportion of its total population and among Allied countries, France suffered the greatest number of military deaths after Serbia, slightly fewer than the Ottoman Empire in relation to the Central Powers. Deaths as tallied above correspond to troops killed in action. If we include soldiers who were wounded, taken prisoner, and who went missing, it becomes apparent that the Central Powers were the more grievously impacted side, with Serbia maintaining its tragic frontrunner status among the Allies. About 500,000 soldiers died after 1918 from wounds received or diseases contracted during the war |
| Keywords: | Population; Soldiers; Mortality; WW1 |
| Date: | 2018–11 |
| URL: | http://d.repec.org/n?u=RePEc:spo:wpmain:info:hdl:2441/743lugucjm9h5aev6ttnkdni6d&r=all |
| By: | Pugatch, Todd (Oregon State University) |
| Abstract: | Extreme weather induced by climate change can have major consequences for human health. In this study, I quantify the effect of tropical storm frequency and severity on mortality using objective meteorological data and the universe of vital statistics records from a large developing country, Mexico. Using a measure of storm exposure that accounts for both windspeed dispersion and population density along the storm track, I project changes in past storm-related mortality under various scenarios of continued climate change, while holding population and income at current levels. I find that storm-related deaths would have risen under most climate change scenarios considered, with increases of as much as 52% or declines of as much as 10%, depending on the interplay between increasing storm severity and decreased frequency. |
| Keywords: | climate change, human health, human mortality, natural disasters, hurricanes, tropical cyclones, tropical storms, developing countries, Latin America, Mexico |
| JEL: | I15 J10 O13 |
| Date: | 2019–01 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp12117&r=all |
| By: | Serratos-Sotelo, Luis (Lund University); Bengtsson, Tommy (Lund University); Nilsson, Anton (Lund University) |
| Abstract: | This study explores the impact an exogenous improvement in childhood health has on later-life outcomes. Using extensive and detailed register data from the Swedish Interdisciplinary Panel, we follow individuals exposed to the introduction of the first vaccine against polio in Sweden (birth cohorts 1937-1966) until adulthood in order to quantify the causal effect of polio vaccination on long-term economic outcomes. The results show that, contrary to what has been found in the literature for other health-related interventions, including other vaccines, exposure to the vaccine against polio did not seem to have any long-term effects on the studied adult economic outcomes. Upon closer inspection of how the disease affects children, this might be explained by the fact that no scarring effects from exposure to high incidence of polio were found on adult income, educational achievement, or hospitalizations, which seems to suggest that those who contracted the illness but suffered only the milder symptoms of the disease made a full recovery and had no lifelong sequels as a consequence of the condition. The absence of scarring effects is hypothesized to be related to the pathology and epidemiology of the disease itself, which infects many, but scars only those who suffer the most recognizable paralytic symptoms. |
| Keywords: | vaccine, polio, income, education, early-life, Sweden |
| JEL: | I18 |
| Date: | 2019–01 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp12112&r=all |
| By: | Giuntella, Osea (University of Pittsburgh); La Mattina, Giulia (University of South Florida); Quintana-Domeque, Climent (University of Exeter) |
| Abstract: | We use a unique data set of linked birth records from Florida to analyze the intergenerational transmission of health at birth by parental gender. We show that both paternal and maternal birth weights significantly predict the child's birth weight even after accounting for all genetic and environmental factors that are common and time-invariant within a family. Our estimates reveal that a one standard deviation increase in mother's birth weight (535 grams) translates into a 0.13-0.23 standard deviations increase in child's birth weight (70-123 grams), accounting or not for maternal grandmother fixed effects. On the father's side, we find that a one standard deviation increase in father's birth weight (563 grams) translates into a 0.10-0.14 standard deviations increase in child's birth weight (51-73 grams), accounting or not for maternal grandmother fixed effects. The significant role of both maternal and paternal health at birth in explaining offspring health at birth is confirmed when using alternative metrics: intrauterine growth restriction, being small for gestational age, or being too heavy (i.e., macrosomic). |
| Keywords: | intergenerational transmission, health capital, birth outcomes, gender |
| JEL: | J1 |
| Date: | 2019–01 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp12105&r=all |
| By: | Wang, Rui (Tulane University); Chen, Xi (Yale University); Li, Xun (Wuhan University) |
| Abstract: | Flint changed its public water source in 2014, causing severe water contamination. We estimate the effect of in utero exposure to polluted water on health at birth using the recent Flint water crisis as a natural experiment. Matching vital statistics birth records with various sources of data, we employ a Difference-in-Differences (DID) approach as well as a Synthetic Control Method (SCM) to identify its causal impact on key birth outcomes. Our results suggest that the crisis modestly increased the rate of low birth weight (LBW) by 1.1-1.8 percentage points but had little effect on length of gestation or prematurity. The effects are larger for black or less educated mothers. Children born to disadvantaged mothers demonstrated 1.2-2.0 percentage points (or 10.4-17.4 percent) and 0.2- 0.6 percentage points (or 9.5-28.6 percent) rise in LBW and VLBW, respectively. We find little evidence that the Crisis increased fetal death, suggesting that the scarring effect in utero may dominate the channel of mortality selection. These results survive a rich set of placebo and falsification tests. Finally, our results lend support to three mechanisms at work linking water contamination and birth outcomes, i.e. biological effect, maternal stress, and avoidance actions. |
| Keywords: | water pollution, lead exposure, Flint infants, low birth weight |
| JEL: | I14 I18 Q53 Q58 |
| Date: | 2019–01 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp12115&r=all |
| By: | Rocío Álvarez-Aranda (Universidad Central de Chile); Serafima Chirkova (Universidad de Santiago de Chile); José Gabriel Romero (Universidad de Santiago de Chile) |
| Abstract: | We study how prenatal maternal stress, caused by sustained seismic activity, affects birth outcomes in Chile during the period 2011-2015. A mother-fixed-effect model together with the spatiotemporal variation of earthquakes in Chile allow us to deal with identification issues that have obscured previous estimates. Our findings show that prenatal maternal stress seems to affect fetal growth, because infants born to mothers exposed to earth tremors in early and/or mid gestation are more likely to be large for gestational age. The estimates suggest that relatively poorer Chilean mothers are more vulnerable to earthquakes, because their babies seem to drive the reported impacts on fetal growth. We discuss and provide evidence that suggests a possible mechanism that explains the varying results across socioeconomic status. Mothers with diabetes and/or hypertension are more likely to have large-for-gestational-age babies. Exposure to earth tremors seems to increase the incidence of these afflictions among the affected population, with the observed impact on diabetes being relatively higher among women with lower socio-economic status. |
| Keywords: | Maternal Stress, Birth Outcomes, Natural Disasters, Mother-Fixed-Effects |
| JEL: | C23 I12 J13 |
| Date: | 2018–12 |
| URL: | http://d.repec.org/n?u=RePEc:fem:femwpa:2018.30&r=all |
| By: | Bellés-Obrero, Cristina; Cabrales, Antonio; Jimenez-Martin, Sergi; Vall-Castello, Judit |
| Abstract: | We explore the effects of a child labor regulation that changed the legal working age from 14 to 16 over the health of their offspring. We show that the reform was detrimental for the health of the son's of affected parents at delivery. Yet, in the medium run, the effects of the reform are insignificant for both male and female children. The sons of treated mothers are perceived as still having worse health at older ages, even if their objective health status has recovered. These boys are also more likely to have private health insurance, which suggests more concerned mothers. |
| Keywords: | child health; education; Gender; minimum working age |
| JEL: | I12 I25 J13 J81 |
| Date: | 2019–01 |
| URL: | http://d.repec.org/n?u=RePEc:cpr:ceprdp:13451&r=all |
| By: | Bhalotra, Sonia R. (University of Essex); Rocha, Rudi (São Paulo School of Business Administration); Soares, Rodrigo R. (Columbia University) |
| Abstract: | We investigate universalization of access to health in Brazil. We find large reductions in maternal, foetal, neonatal and post-neonatal mortality, a reduction in fertility and, possibly on account of selection, no change in the quality of births. Using rich administrative data, we investigate changes in organization, access and outcomes, thereby illuminating the driving mechanisms. We find sharp increases in coverage of primary health facilities with GPs and outreach workers and, in line with this, increases in outpatient procedures, prenatal care visits, health-education activities and home visits by medical professionals. Consistent with an attempt to rationalize use of hospital resources, we find a decline in specialists and hospital beds per capita. Despite this, we see increases in hospital births, C-sections, and maternal hospitalization for complications, with no change in rates of infant hospitalization. |
| Keywords: | universal health coverage, health systems, primary care, maternal mortality, infant mortality, birth outcomes |
| JEL: | I12 I18 J10 J13 J24 O54 |
| Date: | 2019–01 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp12111&r=all |
| By: | Haan, Peter (DIW Berlin); Hammerschmid, Anna (DIW Berlin); Schmieder, Julia (DIW Berlin) |
| Abstract: | Case and Deaton (2015) document that, since 1998, midlife mortality rates are increasing for white non-Hispanics in the US. This trend is driven by deaths from drug overdoses, suicides, and alcohol-related diseases, termed as deaths of despair, and by the subgroup of low-educated individuals. In contrast, average mortality for middle-aged men and women continued to decrease in several other high-income countries including Germany. However, average mortality rates can disguise important differences between subgroups and the phenomenon of increasing mortality rates might also be present for subpopulations in these countries. Hence, we analyze how mortality in midlife is changing for several important demographic subgroups in Germany over the 1990 to 2015 period with a focus on deaths of despair. Our results show a very clear pattern: We find that mortality rates declined between 1990 and 2015, with no increases in deaths of despair for any of the subgroups. Thus, our findings starkly contrast with those for the US. |
| Keywords: | mortality, lifetime inequality, causes of death, deaths of despair, Germany |
| JEL: | I10 I14 J11 |
| Date: | 2019–01 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp12116&r=all |
| By: | Davillas, Apostolos; Pudney, Stephen |
| Abstract: | We investigate the utilisation of primary and secondary public healthcare services and the consequent public costs, using data from the British Understanding Society household panel. We use a sample of 2,314 adults who, at baseline in 2010/11, reported no history of diagnosed long-lasting health conditions and for whom a set of objective biomarkers were observed. Five years later, their utilisation of GP and hospital outpatient and inpatient services was observed. We develop an econometric technique for count data observed within ranges and a method of combining NHS episode cost data with Understanding Society data without exact individual-level matching. This allows us to estimate the impact of differences in personal characteristics and socio-economic status (SES) on cost outcomes. We find that a composite biomarker index approximating allostatic load is a powerful predictor of realised costs: among the group who are at least 1 standard deviation (SD) above mean allostatic load, we estimate that a reduction of 1 SD at baseline reduces GP, outpatient and inpatient cost outcomes by around 18%. In addition to the expected strong effect of ageing on cost, we also find a large gender difference: on average women experience costs at least 20% higher than comparable men, because of their greater utilisation of GP and outpatient services. There is a strong SES gradient in healthcare costs: the average impact of moving from no educational qualifications to intermediate or from intermediate to degree level is approximately 16%. Income differences, on the other hand, have negligible impact on future costs. |
| Date: | 2019–02–19 |
| URL: | http://d.repec.org/n?u=RePEc:ese:iserwp:2019-01&r=all |
| By: | Shan Huang; Martin Salm |
| Abstract: | Starting from December 2012, insurers in the European Union were prohibited from charging gender-discriminatory prices. We examine the effect of this unisex mandate on risk segmentation in the German health insurance market. While gender used to be a pricing factor in Germany's private health insurance (PHI) sector, it was never used as a pricing factor in the social health insurance (SHI) sector. The unisex mandate makes PHI relatively more attractive for women and less attractive for men. Based on data from the SOEP we analyze how the unisex mandate affects the difference between women and men in switching rates between SHI and PHI. We find that the unisex mandate increases the probability of switching from SHI to PHI for women relative to men. This effect is strongest for self-employed individuals and mini-jobbers. On the other hand, the unisex mandate had no effect on the gender difference in switching rates from PHI to SHI. Because women have on average higher health care expenditures than men, our results imply a reduction of advantageous selection into PHI. Our results demonstrate that regulatory measures such as the unisex mandate can reduce risk selection between public and private health insurance sectors. |
| Keywords: | Unisex mandate, public and private health insurance, risk selection, Germany |
| JEL: | I13 D82 H51 |
| Date: | 2019 |
| URL: | http://d.repec.org/n?u=RePEc:diw:diwwpp:dp1787&r=all |
| By: | Joan Costa-i-Font; Frank Cowell |
| Abstract: | Although measures of sensitivity to inequality are important in judging the welfare effects of health-care programmes, it is far from straightforward how to elicit them and apply them in health-care decision making. This paper provides an overview of the literature on the measurement of inequality aversion, examines some of the features specific of the health domain that depart from the income domain, and discusses its implementation in health system priority-setting decisions. We find evidence that individuals exhibit a preference for more equitable health distribution, but inequality aversion estimates from the literature are unclear. Unlike the income-inequality literature, standard approaches in the health-economics do not follow a ‘veil-of-ignorance’ approach and elicit mostly bivariate (income-related health) inequality aversion estimates. We suggest some ideas to reduce the disconnect between the income-inequality and health-economics literatures. |
| Keywords: | attitudes to inequality, inequality aversion, health, income, survey data, priority setting |
| JEL: | I19 |
| Date: | 2019 |
| URL: | http://d.repec.org/n?u=RePEc:ces:ceswps:_7503&r=all |
| By: | Philip Armour; Claire O’Hanlon |
| Abstract: | A substantial portion of the costs associated with, and the value to beneficiaries of, Social Security Disability Insurance is Medicare eligibility. However, the benefits of this eligibility can vary due to differences in state policies on supplemental Medicare coverage, also known as Medigap. Although Medigap policies are federally regulated to be issued to 65-and-over Medicare beneficiaries with specific restrictions over underwriting, these policies are left to states to regulate with regard to the under-65 SSDI population, generating substantial cross-state and temporal variation. This paper documents the variation in availability and generosity of under-65 Medigap eligibility for the SSDI population. Furthermore, it exploits this variation to provide initial estimates of how this eligibility affects the health status of non-Medicaid-eligible SSDI recipients. Our main finding is that requiring Medigap plans be offered for under-65 SSDI recipients substantially improves self-reported health of this population, with suggestive evidence that this improvement is stronger as underwriting restrictions increase and among SSDI beneficiaries with mental health conditions. The estimated effect is highly robust to alternative scaling or categorizations of self-reported health, choice of data set, inclusion of fixed effects, controls for local Medicare Advantage penetration, and falsification tests. This effect is nearly three times the size of the estimated increase in self-reported health in the Oregon Medicaid expansion. |
| JEL: | I13 H51 H55 J14 |
| Date: | 2019–02 |
| URL: | http://d.repec.org/n?u=RePEc:nbr:nberwo:25564&r=all |
| By: | Scott A. Carson |
| Abstract: | A population’s weight conditioned on height reflects its current net nutrition and demonstrates health variation during economic development. This study builds on the use of weight as a measure for current net nutrition and uses a difference-in-decompositions technique to illustrate how black and white current net nutrition varied with the transition to free-labor. Adult black age-related weight gain was greater with the transition to free-labor yet was not as large as the adult white age related weight gain. Agricultural worker’s current net nutrition was better than workers in other occupations, and agricultural workers’ net nutrition was better than workers in other occupations but was worse-off with the transition to free labor. Nativity had the greatest effect with weight changes and the transition to free-labor. Within-group weight variation was greater than across-group variation. |
| Keywords: | weight variation, current net nutrition, Oaxaca decomposition |
| JEL: | C10 C40 D10 I10 N30 |
| Date: | 2019 |
| URL: | http://d.repec.org/n?u=RePEc:ces:ceswps:_7502&r=all |
| By: | Michel, Chloe; Sovinsky, Michelle; Stern, Steven |
| Abstract: | Using data from the Panel Study of Income Dynamics on breast cancer diagnosis and lifestyle choices, we estimate how being diagnosed influences smoking, drinking, and exercising habits for more than 9,000 women over the period 1999 to 2011. These data allow us to learn more about the trade-offs women are willing to make between participating in unhealthy (but enjoyable) habits and increasing one's life expectancy. Our parameter estimates indicate that the impact of diagnosis has a different effect on smoking, drinking, and exercising behavior, and the impact also depends upon the recency of the diagnosis. We find that recently diagnosed women exercise and smoke less but do not change their drinking habits relative to healthy women. These changes are not always consistent with public information on cancer risk factors, but are rationalized after considering that lifestyle choices increase the utility of living. For a woman diagnosed with breast cancer, our results indicate that a woman will smoke only if the value placed on smoking is greater than 6% of the total utility from being alive. We find the threshold is lower for drinking where drinking has a positive impact on the value of life if the value placed on drinking is greater than 3% of the total utility from being alive. Finally, a woman with breast cancer will find it valuable to engage in exercise even when it brings disutility of 3% of the value of living. Using conventional estimates for the value of a year of life, we find that these choices imply that, per year, women value smoking at about $49,000 for smokers, drinking at about $29,500 for drinkers, and exercising at about $28,200 for exercisers. |
| Date: | 2019–02 |
| URL: | http://d.repec.org/n?u=RePEc:cpr:ceprdp:13537&r=all |
| By: | Heger, Dörte; Herr, Annika; Mensen, Anne |
| Abstract: | Increasing long-term care demand raises the need of high quality care in nursing homes. This study analyses whether higher prices have a causal effect on quality of care in Swiss nursing homes and assesses the extent of cross-subsidization between different price components. We use administrative data collected by the Swiss Federal Office for Statistics from 2012 to 2016 on all nursing homes in the twelve Swiss cantons with canton-wide fixed reimbursement rates for nursing care. We apply multivariate linear regressions and two-stage least square estimation techniques to estimate the effect of nursing care prices and prices for accommodation and services on care quality, measured by registered staffing levels. Our estimates show a positive impact of all price components on care quality. Although nursing homes are prohibited to use revenues from accommodation and services to cover nursing care, a 10% increase in that price component increases certified staffing levels by 0.7 to 1.7 nurses or four to ten percent (full-time-equivalent) for an average sized nursing home (50 beds). Thus, limiting care prices implicitly sets a limit for care quality and induces care providers to pass on costs to the residents. |
| Keywords: | long-term care,nursing home,prices,care quality,staffing levels |
| JEL: | I11 I18 J18 |
| Date: | 2018 |
| URL: | http://d.repec.org/n?u=RePEc:zbw:rwirep:788&r=all |
| By: | Carrillo, B.; |
| Abstract: | This paper uses birth cohorts spanning several hundred locations over 40 years to examine the long-term consequences of in utero exposure to abnormal rainfall events in Colombia. The identification strategy exploits exogenous variation in extreme droughts or floods experienced by individuals while in utero in their birth location. The results indicate that individuals prenatally exposed to adverse rainfall shocks are more likely to report serious mental illness, have fewer years of schooling, display increased rates of illiteracy, and are less likely to work. These results are larger in magnitude for individuals born in areas with higher risk of malaria, consistent with the notion that exposure to infectious and parasitic diseases may play an important role. |
| Keywords: | drought; heavy precipitation; early life health; later-life outcomes; |
| JEL: | I15 O13 O1 |
| Date: | 2019–02 |
| URL: | http://d.repec.org/n?u=RePEc:yor:hectdg:19/06&r=all |
| By: | López Bóo, Florencia (Inter-American Development Bank); Creamer, John (U.S. Census Bureau) |
| Abstract: | We explore the effects of a randomly assigned conditional cash transfer in Honduras (Bono 10000) on early childhood development. We find significant impacts on cognitive development in children 0-60 months, with an average effect size of 0.13 SD. We show differential impacts by type of transfer: 0-5-year-old children from families receiving the "health" transfer, which targeted families with 0-5-year-old children only, benefited significantly from the program, whereas 0-5 year-olds in families receiving the "education" transfer, which targeted 6-18 year-olds, perceived no benefit. In comparison with other programs, the effect of this impact is sizeable (0.34 SD on average). Although the overall program appears to have slightly changed some behaviors that might affect children (i.e. decreased probability of maternal employment, and increased maternal self-esteem), we did not find heterogenous impacts of the Bono across these variables. Results are explained mainly by differences in conditions: while the "education" component imposed conditions only on children of schooling age, the "health" transfer required regular health checkups of 0-5 year old children. The "health" transfer families were more likely to attend health checkups, which may have induced behavior changes that improved children's health and cognitive development, including purchasing more nutritious food. These results imply that cash without well-targeted conditions attached, might not be as effective for the development of young children. |
| Keywords: | Honduras, education, health, early childhood development, children, conditional cash transfers (CCTs), impact evaluation |
| JEL: | C93 J13 I25 I38 |
| Date: | 2019–01 |
| URL: | http://d.repec.org/n?u=RePEc:iza:izadps:dp12109&r=all |