nep-hea New Economics Papers
on Health Economics
Issue of 2008‒10‒13
eight papers chosen by
Yong Yin
SUNY at Buffalo, USA

  1. Intrafamily Resource Allocations: A Dynamic Model of Birth Weight By Del Bono, Emilia; Ermisch, John; Francesconi, Marco
  2. Vertical relationships between health insurers and healthcare providers By Michiel Bijlsma; Arno Meijer; Victoria Shestalova
  3. Mismatches in the Formal Sector, Expansion of the Informal Sector: Immigration of Health Professionals to Italy By Jonathan Chaloff
  4. Nurse Workforce Challenges in the United States: Implications for Policy By Linda H. Aiken; Robyn Cheung
  5. Drug pricing and risk sharing agreements By Stefano Capri; Rosella Levaggi
  6. Polarisation and Health By Blanco Pérez, Cristina; Ramos, Xavi
  7. Race, Ethnicity and the Dynamics of Health Insurance Coverage By Fairlie, Robert W.; London, Rebecca A.
  8. Informal Care and Labor Supply By Fevang, Elisabeth; Kverndokk, Snorre; Roed, Knut

  1. By: Del Bono, Emilia (ISER, University of Essex); Ermisch, John (University of Essex); Francesconi, Marco (University of Essex)
    Abstract: This paper estimates a model of dynamic intrahousehold investment behavior which incorporates family fixed effects and child endowment heterogeneity. This framework is applied to large American and British survey data on birth outcomes, with focus on the effects of antenatal parental smoking and maternal labor supply net of other maternal behavior and child characteristics. We find that maternal smoking during pregnancy reduces birth weight and fetal growth, while paternal smoking has virtually no effect. Mothers' work interruptions of up to two months before birth have a positive effect on birth outcomes, especially among British children. Parental behavior appears to respond to permanent family-specific unobservables and to child idiosyncratic endowments in a way that suggests that parents have equal concerns, rather than efficiency motives, in allocating their prenatal inputs across children. Evidence of equal concerns emerges also from the analysis of breastfeeding decisions, although the effects in this case are weaker.
    Keywords: birth outcomes, smoking, mother's work, sibling estimators, instrumental variables, child health production functions
    JEL: C33 D13 I12 J13
    Date: 2008–09
  2. By: Michiel Bijlsma; Arno Meijer; Victoria Shestalova
    Abstract: The current institutional reforms in the Dutch healthcare sector may increase the extent of vertical relations (such as vertical contracts and vertical integration) between insurers and healthcare providers. Vertical relations may have both welfare increasing and welfare reducing effects. In this study, we focus on the latter, in particular on anticompetitive foreclosure. We distinguish three possible mechanisms that may lead to anticompetitive foreclosure, called respectively ‘exclusivity’, ‘sabotage’, and the ‘waterbed effect’. We discuss under which conditions they come into play and which policy measures can prevent them.
    Keywords: healthcare reform; selective contracting; vertical integration; foreclosure
    JEL: D4 I11 I18
    Date: 2008–08
  3. By: Jonathan Chaloff
    Abstract: Italy has an aging population which is placing a strain on the public health system and on families. At the same time, it has a distorted market of supply of health professionals. Past over enrolment in medical faculties has produced a current glut of doctors, although shortages will appear as this cohort retires. It is difficult for foreign-trained doctors, and Italian-trained foreigners, to practice medicine in Italy. In nursing, the situation is more critical, with far fewer graduates of nursing schools than necessary even to meet replacement needs. Care for the aged, which was traditionally borne by families, has increasingly been delegated to informal immigrant workers. In the absence of major changes in the care industry, recruitment efforts for nurses and other health technicians has expanded to include other source countries. Obstacles to international recruitment of nurses have been reduced, both by simplifying recognition of foreign qualifications and by exempting nurses from limits on labour migration to Italy. However, a ban on permanent employment in the public sector has relegated foreign nurses largely to private sector and shorter-term contract work. National and local health authorities have also become involved in supporting international recruitment of nurses, often through private agencies. In the home-care sector, families have been granted more opportunities to hire care workers from abroad legally, and many local authorities are attempting to integrate this spontaneous private care into their eldercare system through skill upgrades and support. Nonetheless, international migration will not be sufficient to solve Italy’s health care professional needs. <BR>Le vieillissement de la population en Italie pèse lourdement sur le système de santé public et les familles. Parallèlement, l’offre de professionnels de la santé sur le marché du travail est déséquilibré. Dans le passé, le nombre excessif d’inscriptions dans les facultés de médecine a entrainé une surabondance de médecins, mais des pénuries apparaîtront au fur et à mesure qu’ils partiront à la retraite. Il est difficile pour les médecins ayant étudié à l’étranger et les immigrés qui se sont qualifiés en Italie d’exercer la médecine dans ce pays. En ce qui concerne les infirmières, la situation est plus critique, avec un trop petit nombre de diplômés des écoles d’infirmières, même pour satisfaire uniquement les besoins de remplacement. Les soins aux personnes âgées, incombant traditionnellement aux familles, ont été de plus en plus délégués aux immigrés du secteur informel. En l’absence de changements majeurs dans les politiques de la santé, des efforts ont été faits pour recruter des infirmières et personnels de santé dans d’autres pays d’origine. La simplification de la reconnaissance des qualifications acquises à l’étranger et l’exemption de quotas d’infirmières étrangères sur le marché du travail en Italie ont réduit les obstacles au recrutement international d’infirmières. Cependant, l’interdiction de les employer de façon permanente dans le secteur public a relégué la majorité des infirmières étrangères dans le secteur privé et dans les contrats de travail à court terme. L’administration sanitaire nationale et locale a aussi contribué au recrutement international des infirmières souvent par le biais d’agences privées. Dans le secteur des soins à domicile, les familles se sont vu octroyer plus d’opportunités pour recruter légalement à l’étranger du personnel de soins à domicile. Beaucoup d’autorités locales s’efforcent d’intégrer ce type de soins privés dans leurs systèmes de soins aux personnes âgées en assistant les personnels soignants privés et en renforçant leurs compétences. Néanmoins, les migrations internationales ne seront pas suffisantes pour répondre aux besoins de l’Italie en professionnels de la santé.
    JEL: I19 J61
    Date: 2008–10–01
  4. By: Linda H. Aiken; Robyn Cheung
    Abstract: The United States has the largest professional nurse workforce in the world numbering close to 3 million but does not produce enough nurses to meet its growing demand. A shortage of close to a million professional nurses is projected to evolve by 2020. An emerging physician shortage will further exacerbate the nurse shortage as the boundaries in scope of practice necessarily overlap. Nurse immigration has been growing since 1990 and the U.S. is now the world’s major importer of nurses. While nurse immigration is expected to continue to grow, the shortage is too large to be solved by recruitment of nurses educated abroad without dramatically depleting the world’s nurse resources. Moreover, the domestic applicant pool for nursing education is very strong with tens of thousands of qualified applicants turned away annually because of faculty shortages and capacity limitations. The national shortage could be largely addressed by investments in expanding nursing school capacity to increase graduations by 25 percent annually and the domestic applicant pool appears sufficient to support such an increase. A shortage of faculty and limited capacity for expansion of baccalaureate and graduate nurse education require public policy interventions. Specifically public subsidies to increase production of baccalaureate nurses are required to enlarge the size of the pool from which nurse faculty, advanced practice nurses in clinical care roles, and managers are all recruited. Retention of nurses in the workforce is critical and will require substantial improvements in human resource policies, the development of satisfying professional work environments, and technological innovations to ease the physical burdens of caregiving. Because of the reliance of the U.S. on nurses educated abroad as well as the benefits to the U.S. of improving global health, the nation should invest in nursing education as part of its global agenda. <BR>Les États-Unis comptent le plus grand nombre d’infirmiers(ères) diplômés au monde – près de 3 millions – mais ils n’en forment pas suffisamment pour répondre à une demande en augmentation. Il devrait manquer près d’un million d’infirmiers(ières) diplômés, aux États-Unis, d’ici 2020. Et le déficit de médecins qui commence d’apparaître ne fera qu’exacerber le problème car les deux pratiques professionnelles sont nécessairement interdépendantes. L’immigration d’infirmiers(ères) n’a cessé d’augmenter depuis 1990 et les États-Unis sont désormais le premier pays d’accueil d’infirmiers(ères) étrangers au monde. Cette vague d’immigration devrait se poursuivre mais la pénurie est trop importante pour pouvoir être résorbée par des recrutements à l’étranger sans que cela ponctionne gravement les ressources en personnel infirmier au niveau mondial. Par ailleurs, les personnes désireuses de suivre une formation d’infirmier(ère) dans le pays sont nombreuses mais des dizaines de milliers de postulants qualifiés sont refusés chaque année en raison du manque de personnel enseignant et de l’insuffisance des capacités d’accueil dans les écoles d’infirmiers(ères). On pourrait largement pallier ces insuffisances en intensifiant les investissements consacrés aux écoles d’infirmiers(ières) de façon à accroître de 25 % par an le nombre des diplômés, ce qui paraît réaliste au regard du nombre actuel de candidats. Le manque de personnel enseignant et l’insuffisance des capacités de formation appellent l’intervention des pouvoirs publics. Précisément, des subventions publiques doivent aider à accroître le nombre d’infirmiers(ières) diplômés, ce qui élargira l’effectif au sein duquel on pourra recruter du personnel enseignant, des infirmiers(ères) cliniciens de haut niveau et des gestionnaires. Inciter les infirmiers(ères) à rester dans la profession est fondamental et cela nécessitera une amélioration significative des politiques de gestion des ressources humaines, la garantie d’un environnement de travail satisfaisant et des innovations technologiques pour alléger la charge physique que représente l’activité de soins. Compte tenu de l’importance des personnels infirmiers formés à l’étranger pour les États-Unis et des avantages qui résulteraient d’une amélioration générale de la santé publique, le pays devrait faire de l’investissement dans la formation d’infirmiers(ères) un des objectifs de l’action publique.
    Date: 2008–10–01
  5. By: Stefano Capri; Rosella Levaggi
    Abstract: In the recent past some forms of risk sharing agreements have been used in some countries in drug pricing. In this note we present a specific risk sharing agreement on effectiveness and show how such mechanism is going to affect the market in the long run. In particular, we will show how the regulator may create a trade off between expected afficacy and the number of patients to be treated using the pricing formula.
    Date: 2008
  6. By: Blanco Pérez, Cristina (Universitat Autònoma de Barcelona); Ramos, Xavi (Universitat Autònoma de Barcelona)
    Abstract: This paper examines the effect of income polarisation on individual health. We argue that polarisation captures much better the social tension and conflict that underlie some of the pathways linking income disparities and individual health, and which have been traditionally proxied by inequality. We test our premises with panel data for Spain. Results show that polarisation has a detrimental effect on health. We also find that the way the relevant population subgroups are defined is important: polarisation is only significant if measured between education-age groups for each region. Regional polarisation is not significant. Our results are obtained conditional on a comprehensive set of controls, including absolute and relative income.
    Keywords: polarisation, health, fixed-effects ordered logit model, conflict, psychosocial stress, social capital
    JEL: D31 I1
    Date: 2008–09
  7. By: Fairlie, Robert W. (University of California, Santa Cruz); London, Rebecca A. (Stanford University)
    Abstract: Using matched data from the 1996 to 2004 Current Population Survey (CPS), we examine racial patterns in annual transitions into and out of health insurance coverage. We first decompose racial differences in static health insurance coverage rates into group differences in transition rates into and out of health insurance coverage. The low rate of health insurance coverage among African-Americans is due almost entirely to higher annual rates of losing health insurance than whites. Among the uninsured, African-Americans have similar rates of gaining health insurance in the following year as whites. Estimates from the matched CPS also indicate that the lower rate of health insurance coverage among Asians is almost entirely accounted for by a relatively high rate of losing health insurance. In contrast to these findings, differences in health insurance coverage between Latinos and whites are due to group differences in both the rate of health insurance loss and gain. Using logit regression estimates, we also calculate non-linear decompositions for the racial gaps in health insurance loss and gain. We find that two main factors are responsible for differences in health insurance loss between working-age whites and minorities: job loss and education level. Higher rates of job loss account for 30 percent of the health insurance gap for African-Americans and Asians, and 16 percent of the health insurance gap for Latinos. Lower levels of education explain roughly 15 percent of the gap for African-Americans and Latinos (Asians' higher levels of education serve to close the gap). Higher rates of welfare and SSI participation among African-Americans also serve to widen the gap in health insurance loss by 8 percent.
    Keywords: race, health insurance, insurance dynamics
    JEL: I1 J15
    Date: 2008–09
  8. By: Fevang, Elisabeth (Ragnar Frisch Centre for Economic Research); Kverndokk, Snorre (Ragnar Frisch Centre for Economic Research); Roed, Knut (Ragnar Frisch Centre for Economic Research)
    Abstract: Based on Norwegian register data we show that having a lone parent in the terminal phase of life significantly affects the offspring's labor market activity. The employment propensity declines by around 1 percentage point among sons and 2 percentage points among daughters during the years just prior to the parent's death, ceteris paribus. Long-term sickness absence increases sharply. The probability of being a long-term social security claimant (defined as being a claimant for at least three months during a year) rises with as much as 4 percentage points for sons and 2 percentage points for daughters. After the parent's demise, earnings tend to rise for those still in employment while the employment propensity continues to decline. The higher rate of social security dependency persists for several years.
    Keywords: elderly care, labor supply, ageing, inheritance
    JEL: J14 J22
    Date: 2008–09

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