nep-hea New Economics Papers
on Health Economics
Issue of 2008‒12‒01
twenty papers chosen by
Yong Yin
SUNY at Buffalo, USA

  1. Interface between economic development, health and environment in India: An econometric investigation. By Nagar, A.L.; Shovon Ray, Amit; Sawhney, Aparna; Samanta, Sayan
  2. Unwed Mothers‘ Private Safety Nets and Children‘s Socioemotional Wellbeing By Rebecca M. Ryan; Ariel Kalil; Lindsey J. Leininger
  3. Paternal Incarceration and Children’s Aggressive Behaviors: Evidence from the Fragile Families and Child Wellbeing Study By Christopher Wildeman
  4. Parental Incarceration and Child Wellbeing: Implications for Urban Families By Amanda Geller; Irwin Garfinkel; Carey Cooper; Ronald Mincy
  6. Immigration and low birthweight in the US: The role of time and timing By Lisa M. Bates; Julien O. Teitler
  7. Partnership Instability and Child Wellbeing during the Transition to Elementary School By Carey E. Cooper; Cynthia A. Osborne; Audrey N. Beck; Sara S. McLanahan
  8. The Effects of Maternal Employment on Childhood Obesity in the United States By Jackie Araneo
  10. Height, Health and Cognitive Function at Older Ages By Anne Case; Christina Paxson
  11. Height, health, and inequality: the distribution of adult heights in India By Angus Deaton
  12. The Effects of Female Sports Participation On Alcohol Behavior By Elizabeth Wilde
  13. Population Aging and Economic Growth in Asia By David E. Bloom; David Canning; Jocelyn Finlay
  14. An Index to Measure Health Status By Lee, Jonq-Ying; Rampersaud, Gail S.; Brown, Mark G.
  15. Inequity in a market-based health system: evidence from Canada's dental sector By Michel Grignon; Jeremiah Hurley; Li Wang; Sara Allin
  16. Private Health Insurance in Canada By Jeremiah Hurley; Emmanuel Guindon
  17. International Comparison of Public Sector Performance: The Use of Anchoring Vignettes to adjust Self-Reported Data By Rice, N; Robone, S; Smith, P.C
  18. Health and income: A robust comparison of Canada and the US By Jean-Yves Duclos; Damien Echevin
  19. Is the risk taking of HIV-infection influenced by income uncertainty? : Empirical Evidence from Sub-Saharan Africa By Djemaï, Elodie
  20. Cumulative Effects of Job Characteristics on Health By Jason M. Fletcher; Jody L. Sindelar; Shintaro Yamaguchi

  1. By: Nagar, A.L. (National Institute of Public Finance and Policy); Shovon Ray, Amit; Sawhney, Aparna; Samanta, Sayan
    Abstract: This paper analyses interrelationships between `economic development', `health', and `environment' in a simultaneous equations framework. Four structural equations have been postulated to explain changes in four endogenous variables in terms of several predetermined variables. The endogenous variables chosen for the model are GDPPC (per capita gross domestic product), LE (life expectancy), NOCRD (number of cases of respiratory diseases) and PM10 (respirable suspended particulate matter). We assume that GDPPC describes economic development prominently and, therefore, use it as one of the endogenous variables in lieu of economic development. LE and NOCRD are assumed to reflect health effects in the economy, and PM10 is used as a proxy of environmental stress. The four endogenous variables are supposed to be jointly determined in terms of several exogenous variables represented through indices of physical infrastructure (PI), social infrastructure (SI) and air pollution index (API). We construct the three indices by the principal components method and thus effectively use only these three predetermined (exogenous) variables to simultaneously determine changes in the four endogenous variables listed above. The model is postulated in loglinear form and estimated by the two-stage least-squares method using data from the Indian economy 1980-81 to 2004-05. It follows from the estimated structural equations that while physical infrastructure is significant in determining GDPPC, the GDPPC is also directly influenced by improved health outcomes like longevity (LE) and lower morbidity from respiratory diseases (NOCRD). The long term health outcome (LE) is determined by the level of per capita GDP and it is positively affected by social infrastructure. The third structural equation shows that the immediate, or short run, health outcomes like morbidity from respiratory disorders are influenced by environmental stress (PM10) besides the level of GDPPC. Finally, the environmental stress (PM10) is determined by the level of per capita GDP and the air pollution index (API) representing various sources of air pollution. It is true that our simplified model illustrates the effects of specific type of air pollutant, viz., respirable particulate matter, however, it is among the most significant environmental problems threatening human health in India. Nevertheless, there is scope to build more comprehensive environmental stress indices which reflect surface water quality, ground water quality, soil pollution etc. which have feedback effects with health and economic development. Also many of the components of PI, SI and API may not be truly exogenous in a larger model (e.g. transport and communication in PI, education and health care systems in SI, and industrial production, vehicular traffic, urbanisation in API.) The two weaknesses of our model stem from data limitation and a concern to simplify the model. Although our model is highly simplified, nonetheless, it provides key insights into the nature of economic development in India during the last 25 years: First, the environmental stress has had a high cost on income and health . from the derived reduced form, a 1 percent increase in the air pollution index leads to a decrease of about 8 percent in the per capita income, a decrease of about 0.7 percent in the life expectancy, and an increase of about 19 percent in the number of cases of respiratory diseases. Second, the social infrastructure plays a more vital role in economic development, health, and environment than the physical infrastructure, since the absolute values of elasticities of endogenous variables with respect to SI are invariably greater than those with respect to PI. Although physical infrastructure is important for economic development, it comes in the last of our preference order. In the final run-up, there is need to pay more attention to provide better social infrastructure and to reduce air pollution.
    Date: 2008–10
  2. By: Rebecca M. Ryan (University of Chicago); Ariel Kalil (University of Chicago); Lindsey J. Leininger (University of Chicago)
    Abstract: Using longitudinal data from the Fragile Families and Child Wellbeing Study (N = 1,162) and the National Evaluation of Welfare-to-Work Strategies (N = 1,308), we estimate associations between material and instrumental support available to unwed, low-income mothers and young children‘s socioemotional wellbeing. In multivariate OLS models, we find mothers‘ available support is negatively associated with children‘s behavior problems and positively associated with prosocial behavior in both datasets; associations between available support and children‘s internalizing and prosocial behaviors attenuate but remain robust in residualized change models. Overall, results support the hypothesis that the availability of a private safety net is positively associated with children‘s socioemotional adjustment.
    Date: 2008–03
  3. By: Christopher Wildeman (Princeton University)
    Abstract: Incarceration diminishes the life-chances of adults, but little is known about how parental incarceration affects children. Effects on early childhood aggressive behaviors are especially significant because of connections between early childhood aggression and future criminality. Using data from the Fragile Families and Child Wellbeing Study, a longitudinal birth cohort study of children born in urban centers at the close of the 20th century, this paper considers the effects of paternal incarceration on children’s aggressive behaviors at age 5. Results show strong effects of paternal incarceration on aggressive behaviors for boys but not girls. Results also show that effects are concentrated among boys living with a father at the time of his incarceration. The use of various modeling strategies and alternate dependent and independent variables demonstrates the robustness of the finding – and shows that effects are largest on physically aggressive acts, precisely the acts most strongly connected with future criminal activity. By increasing boy’s aggression, paternal incarceration may promote the intergenerational transmission of crime and incarceration. In so doing, high levels of paternal incarceration could not only compromise public safety but also provide the groundwork for a permanently disadvantaged class for whom contact with the criminal justice system is normal.
    Date: 2008–01
  4. By: Amanda Geller; Irwin Garfinkel; Carey Cooper; Ronald Mincy
    Abstract: Using a population-based, longitudinal family survey (N=4,898), we identify a set of economic, residential, and developmental risks particular to the children of incarcerated parents. We use parental reports of incarceration history, demographic background, and a rich set of child and family outcomes, in a series of multivariate regression models. Children of incarerated parents face more economic and residential stability than their counterparts. Children of incarcerated fathers also display more behavior problems, though other developmental differences are insignificant. Several family differences are magnified when both parents have been incarcerated. We find that incarceration identifies families facing severe and unique hardship. Given the prevalence of incarceration, this means a large population of children suffers unmet material needs, residential instability, and behavior problems. These risks may be best addressed by using the point of incarceration as an opportunity for intervention, and the administration of age-appropriate social services.
    Date: 2008–05
  5. By: Sharon Bzostek (Princeton University); Audrey Beck (Princeton University)
    Abstract: Dramatic changes in family demography in the United States have led to increasing numbers of children living in “non-traditional” households. A large body of literature documents the association between living in a non-traditional family structure/familial instability and children’s cognitive and behavioral outcomes. In contrast, relatively little research has focused on the relationship between family structure and instability and children’s physical health outcomes, despite the fact that there is good theoretical reason to expect that family structure and instability might be associated with children’s physical health. The current study uses data from the Fragile Families and Child Wellbeing Study to assess whether family structure and familial instability are associated with a variety of children’s physical health outcomes. The paper pays particular attention to possible mediating mechanisms and utilizes longitudinal data to address potential problems of selection bias and reverse causality. The results suggest that children living with two married biological parents tend to fare better than children living in less traditional family structures across a variety of physical health outcomes, and that at least some portion of these relationships are likely the result of selection bias and/or reverse causality.
    Date: 2008–05
  6. By: Lisa M. Bates (Columbia University); Julien O. Teitler (Columbia University)
    Abstract: The literature exploring the health consequences of immigration is largely dominated by efforts to replicate, across outcomes and populations, and explain two widely observed findings: that foreign nativity is protective (yielding the “healthy migrant effect” or “immigrant paradox”) and that the health advantage of immigrants diminishes over time in the host country. In this study, we focus on the second of these patterns and provide evidence that a lifecourse perspective can help to explain the apparent deterioration in health by incorporating attention to immigrants’ timing of arrival. We examine the role of immigrants’ exposure to the US, in terms of both age at immigration and length of residence, in shaping birthweight, a well measured and consequential marker of health, and maternal smoking, an important risk factor for low birthweight.
    Date: 2008–07
  7. By: Carey E. Cooper (Princeton University); Cynthia A. Osborne (University of Texas at Austin); Audrey N. Beck (Princeton University); Sara S. McLanahan (Princeton University)
    Abstract: Data from the Fragile Families and Child Wellbeing Study (N = 2,957) are used to examine partnership instability and children’s wellbeing during the transition to elementary school. We find that coresidential transitions are related to externalizing, attention, and social problems. Mothers’ mental health and use of harsh parenting partially mediate the associations between coresidential transitions and child outcomes at age five. The impact of coresidential transitions on externalizing, attention, and social problems is stronger for boys than girls. Also, non-coresidential transitions predict externalizing and attention problems for White children but not for Hispanic children. Finally, the association between coresidential transitions and verbal ability is stronger for children with highly educated mothers than for children of less educated mothers.
    Date: 2008–05
  8. By: Jackie Araneo
    Abstract: Childhood obesity is a growing problem in the United States. The Center for Disease Control (CDC), based on data from the National Health and Nutrition Examination Survey (NHANES), reports that from 1971 to 2004, obesity rates have increased from 5% to 13.9% among two- to five-year-olds, from 4% to 18.8% among six- to eleven-year-olds, and from 6.1% to 17.4% among twelve- to nineteen-year-olds (CDC, 2007). Increases in childhood obesity have been especially pronounced among low-income children from racial and ethnic minority groups. This vast increase in the number of obese children is a major cause for alarm because of the many health problems associated with being overweight.
    Date: 2008–04
  9. By: Kate S. Adkins (Ohio State University); Claire M. Kamp Dush (Ohio State University)
    Abstract: We used two waves of the Fragile Families Study (N = 2639) to examine links between control and violence with maternal mental health and relationship dissolution. Mothers in controlling-only or controlling and violent unions had more symptoms of depression and anxiety and greater odds of dissolution than mothers not experiencing violence or control. Over time, all mothers increased in depressive symptoms, but the magnitude of the increase in depressive symptoms was greatest for mothers in violent and controlling stable unions followed by those in controlling-only stable unions. Mothers dissolving violent and/or controlling unions also experienced increases depressive symptoms over time. Results indicate negative consequences for both mothers who remain in and leave violent and controlling unions.
    Date: 2008–06
  10. By: Anne Case (Princeton University); Christina Paxson (Princeton University)
    Abstract: Research across a number of disciplines has highlighted the role of early life health and circumstance in determining health and economic outcomes at older ages. Nutrition in utero and in infancy may set the stage for the chronic disease burden that an individual will face in middle age (David J. Barker, 1998; Barker et al. 1989; Johann Eriksson et al. 2001). Childhood health may also have significant effects on economic outcomes in adulthood. Collectively, a set of childhood health measures can account for a large fraction of the explained variance in employment and social status observed among a British cohort followed from birth into adulthood (Anne Case, Angela Fertig and Christina Paxson 2005).
    Date: 2008–01
  11. By: Angus Deaton (Princeton University)
    Abstract: This paper explores the relationship between adult heights and the distribution of income across populations of individuals. There is a long literature that examines the relationship between mean adult heights and living standards. If adult height is set by the balance between food intake and charges to disease in early childhood, it is informative about economic and epidemiological conditions in childhood. Because taller populations are better-off, more productive, and live longer, the relationship between childhood conditions and adult height has become an important focus in the study of the relationship between health and wealth. Here I follow one of the tributaries of this main stream. A relationship between income and height at the individual level has implications for the effects of income inequality on the distribution of heights. These relationships parallel, but are somewhat more concrete than, the various relationships between income inequality and health that have been debated in the economic and epidemiological literatures, Richard G. Wilkinson (1996), Angus Deaton (2003).
    Date: 2008–01
  12. By: Elizabeth Wilde (Columbia University)
    Abstract: Most existing research on the effects of girls’ participation in high school sports focuses on short term outcomes without accounting for selection effects. In this research, I examine the effect of athletic participation in high school on longer term outcomes, using Title IX as a source of exogenous variation in athletic participation. I use the change in girls’ sports participation between cohorts within high schools surveyed by the High School and Beyond Survey to measure the effect of participation in high school sports on women's later alcohol behavior. I find that several years after high school, women in cohorts within high schools exposed to more athletics, drink substantially more alcohol than women within the same high school exposed to less athletics. Relative to the mean alcohol behavior of the sample, these differences are both statistically significant and sizable.
    Keywords: determinants of health, high school athletics, alcohol, Title IX
    JEL: I10 I20 I28
    Date: 2008–05
  13. By: David E. Bloom (Harvard School of Public Health); David Canning (Harvard School of Public Health); Jocelyn Finlay (Harvard School of Public Health)
    Abstract: The decline in the total fertility rate between 1960 and 2005, coupled with an increase in life expectancy and the dynamic evolution of past variation in birth and death rates, is producing a significant shift in age structure in Asia. The age distribution has shifted from one with a high youth-age population share to one with a high old-age population share. We illustrate the role of these separate forces in shaping the age distribution. We also argue that the economic consequences of population aging depend on behavioral responses to the shift in age structure: the female labor force participation response to the decline in fertility, child quality/quantity trade-off in the face of the fertility decline, savings adjustments to an increase in life expectancy, and social security distortions insofar as the pace of life expectancy improvements is faster than the pace of policy adjustments. We estimate the association between old- and youth-age population shares and economic growth. The results suggest that population aging may not significantly impede economic performance in Asia in the long run.
    Keywords: Global health, fertility, Asia, labor, Aging.
    Date: 2008–11
  14. By: Lee, Jonq-Ying; Rampersaud, Gail S.; Brown, Mark G.
    Abstract: In this study we developed a health status index using the commonly recorded health measures by doctors and hospitals. This health status index has a minimum possible value of 7 (the least healthy) and a maximum value of 21 (the healthiest). Using the NHANES data, we explored the relationship of this health status index and nutrient intakes, lifestyle, and demographics of the respondent. Regression results showed that as the age of the respondent, being non-Hispanic black, participants of food stamp programs, high percent of calories that came from fat intakes, high percent of calories in beverages that came from soft drinks, smoking, and on special diets are negatively related to the value of the health status index (i.e., the person became less healthy); household income, college education, eating breakfast, and the amount of exercise are positively related value of the health status index (the person became healthier). These results indicate that the health status index developed in this study had the desired properties.
    Keywords: health index, HNANES, nutrients, Food Consumption/Nutrition/Food Safety,
    Date: 2008–05
  15. By: Michel Grignon (Department of Economics, Centre for Health Economics and Policy Analysis, Department of Health, Aging and Society, McMaster University); Jeremiah Hurley (Department of Economics, Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, McMaster University); Li Wang (Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, McMaster University); Sara Allin (London School of Economics and Political Science, European Observatory on Health Systems and Policies)
    Abstract: We study the extent and drivers of income-related inequity in utilization of dental services in Canada using the concentration-index approach that has been widely applied to study equity in physician and hospital services. Because dental care is almost wholly privately financed in Canada, our estimates provide a benchmark for income-related inequity of utilization in private health systems. Although a number of studies document a link between income and utilization, our study is one of the few measuring income-related inequity in dental care utilization. A unique feature of our study is that we analyze separately equity in total dental visits and in preventive visits. This is important because the case for equity is much clearer for preventive dental care. We also examine the impact of controlling for need using a wider variety of need indicators than previous analyses. We confirm that most oral health indicators perform poorly as need adjustors because they reflect past dental care use: individuals with higher levels of utilization also are in better oral health. Our most important finding is that access to preventive care is the most pro-rich type of dental care utilization and that income-related inequity in preventive dental care utilization is three times larger than what is measured for specialist services utilization in Canada.
    Keywords: Canada, Equity, Dental care, Prevention
    Date: 2008
  16. By: Jeremiah Hurley (Department of Economics, Centre for Health Economics and Policy Analysis, McMaster University); Emmanuel Guindon (Centre for Health Economics and Policy Analysis, McMaster University)
    Abstract: Although a majority of Canadians hold some form of private health care insurance -- most commonly obtained as an employment benefit -- private insurance finances only 12% of health care expenditures in Canada and its financing role is essentially limited to complementary coverage for services not covered by public insurance programs. Private supplementary insurance for services covered by the public insurance system does not exist in Canada. This limited role for private insurance in health care reflects the core policy vision for health care financing in Canada, which emphasizes equal access to medically necessary health care, especially physician and hospital services. Compared to many other countries, Canada’s private health insurance market is relatively uncomplicated, viewed in terms of either the products offered or the regulations imposed. Although Canadians regularly debate the relative split between public and private finance overall, and a small set of advocates have persistently pressed for a greater role for private insurance, private insurance has not figured prominently in Canada’s health care policy debates, which since the late 1960s have focused on the publicly funded health care system. Three Canadian health care policy challenges, however, are drawing the role of private health insurance into the centre of policy debate. The first has been the emergence in the last ten years of long wait times for some common, high-profile services such as orthopaedic surgery, eye surgery, diagnostic imaging, and cancer treatments. These wait times have fuelled advocates for parallel private finance alongside public insurance and for loosening restrictions on supplementary private insurance. Such advocates were emboldened by a landmark 2005 Supreme Court of Canada ruling (Chaoulli vs. Government of Quebec) that, in the presence of excessive wait times in the public system, Quebec’s statute prohibiting private insurance for publicly insured services violated Quebec’s Charter of Rights. Though the ruling has only narrow application to Quebec, the judgement has given momentum to those advocating for a fundamental change in the role of private insurance in Canadian health care. The second element drawing private insurance into the centre of policy debate is the growing importance of pharmaceuticals in the modern pantheon of medically necessary therapies. Prescription drugs are excluded from the core services covered by Canadian Medicare, so the majority of pharmaceutical costs are privately financed. Many Canadians, however, are either uninsured or underinsured for prescription drugs. This has prompted many to call for an expansion of public financing for prescription drugs (National Forum on Health 1997;Commission on the Future of Health Care in Canada 2002;Senate of Canada 2002). Some proposals call for full public coverage that would supplant the currently large role of private insurance in this sector; others, call for various types of public-private partnerships to ensure universal coverage. All of them force the question of the desired role for private insurance in this increasingly important and expensive sector of health care. Finally, policy makers and system analysts increasingly appreciate the interactions between the publicly and privately financed components of the overall health care system. Unequal access to privately insured services can lead to unequal access to and use of publicly insured services. Both Stabile ( 2001) and Allin and Hurley ( 2008), for instance, find that other things equal, those with private drug insurance use more publicly financed physician services (an effect unlikely to be driven by selection. This type of evidence prompts hard questions regarding the scope of policies necessary to achieve objectives set for the publicly financed health system. This chapter reviews the role of private health insurance in Canada. It begins with a brief overview of the Canadian health care system; considers the historical path that led to the current role for private health insurance; examines the current market for private health insurance; assesses the evidence for how private insurance contributes to or detracts from health financing goals; and offers some concluding comments on private health insurance in Canada.
    Date: 2008
  17. By: Rice, N; Robone, S; Smith, P.C
    Abstract: International comparison of performance has become an influential lever for change in the provision of public services. For health care, patients’ views and opinions are increasingly being recognized as legitimate means for assessing the provision of services, to stimulate quality improvements, and more recently, in evaluating system performance. This has shifted the focus of analyses towards the use of individual-level surveys of performance from the perspective of the user and raises the issue of how to compare appropriately self-reported data across institutional settings and population groups. This represents a major challenge for all public services, the fundamental problem being that comparative evaluation needs to take account of variations in social and cultural expectations and norms when relying on self-reported information. Using data on health systems responsiveness across 18 OECD countries contained within the World Health Survey, this paper outlines the issues that arise in comparative inference that relies on respondent self-reports. The problem of reporting bias is described and illustrated together with potential solutions brought about through the use of anchoring vignettes. The utility of vignettes to aid cross-country analyses and its implications for comparative inference of health system performance are discussed.
    Keywords: Health system performance, Responsiveness, Cross-country comparison, Vignettes.
    Date: 2008–11
  18. By: Jean-Yves Duclos (CIRPÉE and Département d’économique, Université Laval); Damien Echevin (GREDI, Département d'économique, Université de Sherbrooke)
    Abstract: This paper uses sequential stochastic dominance procedures to compare the joint distribution of health and income across space and time. It is the first application of which we are aware of methods to compare multidimensional distributions of income and health using procedures that are robust to aggregation techniques. The paper’s approach is more general than comparisons of health gradients and does not require the estimation of health equivalent incomes. We illustrate the approach by contrasting Canada and the US using comparable data. Canada dominates the US over the lower bi-dimensional well-being distribution of health and income, though not generally in terms of the marginal distribution of health. The paper also finds that well-being for both Canadians and Americans has not generally improved during the last decade over the joint distribution of income and health, in spite of the fact that the marginal distributions of income have improved during that period.
    Keywords: Health inequality, Self-reported health status, Income distribution, Stochastic dominance, Social welfare
    JEL: I10 I32 I38 D63 D30 H51
    Date: 2008
  19. By: Djemaï, Elodie
    Abstract: This paper questions the positive relationship between HIV prevalence and income in Sub-Saharan Africa. In this paper, we hypothesize that a greater economic instability would reduce the incentives to engage in self-protective behaviors inducing people to increasingly take the risk of HIV-infection and hence causing a rise in HIV prevalence. We provide a simple model to stress on the effects of an increase in income risk in the incentives for protection. We test the prediction using a panel of Sub-Saharan African countries over the period 1980-2001. It is shown that the epidemic is widespread in countries that experience a great macroeconomic instability over the whole period. When introducing income instability, wealth is devoid of predictive power and the puzzle of the positive relationship between income and prevalence in Africa is lifted. Additional finding states that the risk taking of HIV-infection increases when the individuals are facing frequent and large crop shocks.
    Keywords: HIV/AIDS epidemic; incentives; self-protection; macroeconomic instability; Sub-Saharan Africa
    JEL: J10 I12 C23
    Date: 2008
  20. By: Jason M. Fletcher; Jody L. Sindelar; Shintaro Yamaguchi
    Abstract: We present what we believe are the best estimates of how job characteristics of physical demands and environmental conditions affect individual’s health. Five-year cumulative measures of these job characteristics are used to reflect findings in the physiologic literature that cumulative exposure is most relevant for the impact of hazards and stresses on health. Using data from the Panel Study of Income Dynamics we find that individuals who work in jobs with the ‘worst’ conditions experience declines in their health, although this effect varies by demographic group. For example, for non-white men, a one standard deviation increase in cumulative physical demands decreases health by an amount that offsets an increase of two years of schooling or four years of aging. Job characteristics are found more detrimental to the health of females and older workers. These results are robust to inclusion of occupation fixed effects, health early in life and lagged health.
    Keywords: Health, occupational characteristic
    JEL: I10 J28
    Date: 2008–11

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