nep-hea New Economics Papers
on Health Economics
Issue of 2009‒02‒14
twenty-one papers chosen by
Yong Yin
SUNY at Buffalo, USA

  1. Demand and supply of hospital services. International trends By Giovanni Iuzzolino
  2. Non-Parametric Inference for the Effect of a Treatment on Survival Times with Application in the Health and Social Sciences By de Luna, Xavier; Johansson, Per
  3. The Effect of CSB Services on Hospitalization Rates By Tanya Wanchek
  4. The Effect of Dental Hygiene Regulation on Access to Care By Tanya Wanchek
  5. The effect of benefits on disability uptake By Christian N. Brinch
  6. Incentives and Targets in Hospital Care: Evidence from a Natural Experiment By Carol Propper; Matt Sutton; Carolyn Whitnall; Frank Windmeijer
  7. Sibling-Linked Data in the Demographic and Health Surveys By Sonia Bhalotra
  8. Religion and Childhood Death in India By Sonia Bhalotra; Christine Valente; Arthur van Soest
  9. Norwegian Vocational Rehabilitation Programs: Improving Employability and Preventing Disability? By Westlie, Lars
  10. Awareness and AIDS: A Political Economy Model By Gani Aldashev; Jean-Marie Baland
  11. Social Health Insurance vs. Tax-Financed Health Systems--Evidence from the OECD By Wagstaff, Adam
  12. Cross-border purchases of health services : a case study on Austria and Hungary By Obermaier, Andreas J.
  13. Fungibility and the Impact of Development Assistance: Evidence from Vietnam's Health Sector By Wagstaff, Adam
  14. Month of Birth and Children's Health in India By Lokshin , Michael; Radyakin, Sergiy
  15. Dynamic Estimation of Health Expenditure: A new approach for simulating individual expenditure By Valerie Albouy; Laurent Davezies; Thierry Debrand
  16. The shortage of medical workers in sub-Saharan Africa and substitution policy By Arnaud Bourgain; Patrice Pieretti; Benteng Zou
  17. Grossman's Health Threshold and Retirement By Titus Galama; Arie Kapteyn; Raquel Fonseca; Pierre-Carl Michaud
  18. Preferences over the Fair Division of Goods: Information, Good, and Sample Effects in a Health Context By Jeremiah Hurely; Neil Buckley; Katherine Cuff; Mita Giacomini; David Cameron
  19. Visiting and Office Home Care Workers’ Occupational Health: An Analysis of Workplace Flexibility and Worker Insecurity Measures Associated with Emotional and Physical Health By Isik U. Zeytinoglu; Margaret Denton; Sharon Davies; M. Bianca Seaton; Jennifer Millen
  20. Car Driving and Public Transit Use in Canadian Metropolitan Areas: Focus on Elderly and Role of Health and Social Network Factors By Ruben G. Mercado; K. Bruce Newbold
  21. The effect of physician supply on health status as measured in the NPHS By Emmanuelle Pierard

  1. By: Giovanni Iuzzolino (Banca d'Italia)
    Abstract: This paper describes the main international trends in the demand for and supply and cost of hospital services in the last decades. In almost all countries, including Italy, there has been a substantial reduction in the total length of hospitalizations, a steady rise in the use of day-hospitals and a widespread reduction in the number and capacity of hospitals. These trends have been reinforced by reforms in payment systems and in particular by the use of case payments for reimbursing hospitals. By international standards, the Italian hospital system is characterized by relatively high fragmentation, a situation partly related to the weakness of nursing and residential care facilities in Italy, with an unbalanced "division of labour" between in-patient and out-patient care. This has consequences both for the unit costs of hospitalization and for the hospital component’s share of total health expenditure (in Italy above the OECD average). The higher cost of hospital services is also a reflection of the composition of hospital staff, which is strongly biased towards the medical component, especially in small hospitals.
    Keywords: hospital services, health expenditure
    JEL: H44 I10
    Date: 2008–10
  2. By: de Luna, Xavier (Umeå University); Johansson, Per (IFAU)
    Abstract: In this paper we perform inference on the effect of a treatment on survival times in studies where the treatment assignment is not randomized and the assignment time is not known in advance. Two such studies are discussed: a heart transplant program and a study of Swedish unemployed eligible for employment subsidy. We estimate survival functions on a treated and a control group which are made comparable through matching on observed covariates. The inference is performed by conditioning on waiting time to treatment, that is time between the entrance in the study and treatment. This can be done only when sufficient data is available. In other cases, averaging over waiting times is a possibility, although the classical interpretation of the estimated survival functions is lost unless hazards are not functions of waiting time. To show unbiasedness and to obtain an estimator of the variance, we build on the potential outcome framework, which was introduced by J. Neyman in the context of randomized experiments, and adapted to observational studies by D. B. Rubin. Our approach does not make parametric or distributional assumptions. In particular, we do not assume proportionality of the hazards compared. Small sample performance of the estimator and a derived test of no treatment effect are studied in a Monte Carlo study.
    Keywords: potential outcome, observational study, matching estimator, heart transplant, employment subsidy, survival function
    JEL: C12 C13 C14
    Date: 2009–01
  3. By: Tanya Wanchek (Center for Economic and Policy Studies)
    Abstract: In Virginia, Community Service Boards (CSBs) serve as a single point of entry into publicly funded mental health, mental retardation, and substance abuse services. CSBs are part of a move toward an integrated system of care, which focuses on establishing community services and making more efficient and effective use of state facilities. Today there are 40 CSBs throughout Virginia offering varying combinations of nine core services: emergency, local inpatient care, outpatient care, case management, day support, employment, residential, prevention and early intervention, and limited other services. Only emergency services and, subject to the availability of funds appropriated, case management services are mandated by the Code of Virginia. While the type and quantity of services at each CSB vary significantly, how this variation influences the health of the population is unclear. Our study outlines some of the major differences among CSBs and, using an instrumental variable (IV) approach, estimates how the availability and use of outpatient mental health services affects hospitalization rates among Medicaid recipients. The results are consistent with 1) individuals obtaining more outpatient services in localities that offers more services and 2) higher levels of outpatient services reducing the number of nights spent in a hospital. Understanding how the extensiveness of outpatient services provided to individuals with mentally illness influences hospitalization rates has important implications for health, as well as for the state’s budget and the criminal justice system.
    Keywords: mental health, outpatient services, hospitalization, Medicaid
    JEL: I11 I12 I18
    Date: 2009–01–29
  4. By: Tanya Wanchek (Center for Economic and Policy Studies)
    Abstract: By specializing in preventative oral healthcare, dental hygienists (DHs) have the potential to improve oral health in the United States. DHs decrease the cost and increase the availability of oral healthcare beyond what would be provided by dentists alone. Yet, laws and regulations in many U.S. states prevent DHs from fulfilling their potential. A prior study by Wing et al. (2005) found that states that impose more restrictions on the functions DHs are permitted to perform have lower wages and poorer oral health outcomes. This study adds entry restrictions, including educational and licensure requirements, to the analysis by developing a model in which a state’s entry and practice restrictions jointly affect the DH labor market and access to care. After evaluating anecdotal evidence from four case studies, we estimate the effect of variations in entry and practice restrictions across the U.S. using a three stage least squares (3SLS) estimation method. The results are consistent with the hypotheses that entry restrictions reduce employment rates, practice restrictions increase productivity and wage rates, and wage and employment rates are endogenous to each other and jointly influence access to care. The implication for states seeking to improve oral health is that both entry and practice laws and regulations must be considered jointly in order to significantly improve access to care.
    Keywords: Oral health, dental hygiene regulation, occupational licensure
    JEL: J44 I11 K23 J21
    Date: 2009–01–29
  5. By: Christian N. Brinch (Statistics Norway)
    Abstract: I study the effects of the level of disability benefits on disability uptake. Estimation of such effects is difficult because individual levels of disability pension benefits are closely related to individual characteristics that may also affect disability uptake through other mechanisms. I exploit variation in disability benefits related to individual characteristics only through birth cohort, due to special rules of the phasing in of the Norwegian National insurance scheme. These rules imply a nonlinear relationship between birth cohort and disability benefit level, which allows me to estimate the effects of benefits based on between-cohort differences, while controlling for age and year effects and hence implicitly linear trends in birth cohorts. The results show a statistically significant and strong positive effect of benefits on transitions to disability. The robustness of the results is studied in a number of tests based on sample partitions and other groups that are not exposed to the nonlinear relationship between birth cohort and disability benefit level.
    Keywords: Disability benefits; disability uptake; instrumental variables.
    JEL: I38 J22 J26
    Date: 2009–01
  6. By: Carol Propper; Matt Sutton; Carolyn Whitnall; Frank Windmeijer
    Abstract: Performance targets are commonly used in the public sector, despite their well known problems when organisations have multiple objectives and performance is difficult to measure. It is possible that such targets may work where there is considerable consensus that performance needs to be improved. We investigate this possibility by examining the response of the English National Health Service (NHS) to waiting time targets. Long waiting times have been a key issue for the NHS for many years. Using a natural policy experiment exploiting differences between countries of the UK, supplemented with a panel of data on English hospitals, we examine whether high profile targets to reduce waiting times met their goals of reducing waiting times without diverting activity from other less well monitored aspects of health care. Using this robust design, we find that targets led to a fall in waiting times without apparent reductions in other aspects of patient care.
    Keywords: health care, waiting times, targets, incentives
    JEL: I18 L32
    Date: 2008–10
  7. By: Sonia Bhalotra
    Abstract: This paper highlights an aspect of the enormous and little-exploited potential of the Demographic and Health Surveys, namely the use of data on siblings. Such data can be used to control for family-level unobserved heterogeneity that might confound the relationship of interest and to study correlations in sibling outcomes. These uses are illustrated with examples. The paper ends with a discussion of potential problems associated with the sibling data being derived from retrospective fertility histories of mothers.
    Keywords: siblings, unobserved heterogeneity, retrospective fertility histories, state dependence, DHS, India.
    JEL: I12 O12 J10 C23 H31
    Date: 2008–10
  8. By: Sonia Bhalotra; Christine Valente; Arthur van Soest
    Abstract: Muslim children in India face substantially lower mortality risks than Hindu children. This is surprising because one would have expected just the opposite: Muslims have, on average, lower socio-economic status, higher fertility, shorter birth-spacing, and are a minority group in India that may be expected to live in areas that have relatively poor public provision. Although higher fertility amongst Muslims as compared with Hindus has excited considerable political and academic attention in India, higher mortality amongst Hindus has gone largely unnoticed. This paper considers this seeming puzzle in depth.
    Keywords: religion, child mortality, Muslim, Hindu, India
    JEL: I12 O12 J13
    Date: 2008–01
  9. By: Westlie, Lars (Ragnar Frisch Centre for Economic Research)
    Abstract: This paper investigates the effects of five different vocational rehabilitation (VR) programs on the hazard rates into employment, disability and temporarily withdrawals from the labor market for persons who face severe problems in re-entering the labor market, mostly due to medical problems. One of the main findings is that re-education into a new profession is an effective way to improve employability and prevent disability. Work training produces varying results and is more effective the more it resembles a real job. All programs, and in particular re-education, comes with a cost of increased VR duration. Finally, those with the worst initial employment prospects are the ones who benefit most from participation.
    Keywords: Vocational rehabilitation; program evaluation; disability; heterogeneous treatment effects; multivariate hazards
    JEL: C14 C15 C41 I21 J24 J64
    Date: 2008–09–01
  10. By: Gani Aldashev; Jean-Marie Baland
    Abstract: We present a simple political economy model that explains two major puzzles of government policies to combat HIV/AIDS epidemic: the lack of policy response in many countries where the epidemic is massive and the reversal of the downward trend in HIV prevalence in the countries that have adopted early agressive prevention campaigns. The model builds on the assumption that the unaware citizens impose a negative externality on the aware by increasing the risk of contagion. Prevention campaigns raise awareness of the current generation, which then partially transmit this awareness to the next generation, thus creating political support for the next-period awareness campaigns. The economy has two steady-state equilibria: the "good" one (with high awareness and low prevalence) and the "bad" one (low awareness, high prevalence). The "good" equilibrium is fragile, i.e. a sufficiently large exogenous drop in HIV prevalence undermines the next-generation political support for campaigns and makes the economy drift away towards the "bad" equilibrium.
    Keywords: HIV/AIDS, voting, overlapping generations, awareness
    JEL: I18 H51
    Date: 2008
  11. By: Wagstaff, Adam (The World Bank)
    Abstract: This paper exploits the transitions between tax-financed health care and social health insurance in the OECD countries over the period 1960-2006 to assess the effects of adopting social health insurance over tax finance on per capita health spending, amenable mortality, and labor market outcomes. The paper uses regression-based generalizations of difference-in-differences and instrumental variables to address the possible endogeneity of a country's health system. It finds that adopting social health insurance in preference to tax financing increases per capita health spending by 3-4 percent, reduces the formal sector share of employment by 8-10 percent, and reduces total employment by as much as 6 percent. For the most part, social health insurance adoption has no significant impact on amenable mortality, but for one cause--breast cancer among women--social health insurance systems perform significantly worse, with 5-6 percent more potential years of life lost.
    Keywords: Social health insurance; labor markets; health finance; health sector reform.
    Date: 2009–01–01
  12. By: Obermaier, Andreas J. (European Integration Research, Austrian Academy of Sciences)
    Abstract: This paper explores the structure of cross-border health purchasing between Austria and Hungary and determines the size of this phenomenon as well as the barriers to a further increase. Austrian patients may receive health care treatment in Hungary in three different ways. First, patients may receive benefits in the context of the European Community Regulations 1408/71 and 574/72 (Category I patients). Second, outside those regulatory structures, Austrian patients travel to Hungary to receive medical treatment, especially dental treatment, and then seek reimbursement from their Austrian insurance (Category II patients). Third, some patients receive medical treatment in Hungary outside both schemes (Category III patients). There are about 42,500 Category I patients per year; and 58,000 Category II patients world-wide per year. An unknown but supposedly greater number of patients travel to Hungary to receive mainly dental treatment and cosmetic surgery (Category III). Most health actors in both Austria and Hungary do not regard cross-border purchasing of health services as having cost-saving effects. They put forward major legal, institutional, political, and psychological barriers, which inhibit public and private Austrian providers, to facilitate trade in health care and which inhibit individual patients to realize cost savings through capitalizing on lower health care prices in Hungary. Therefore, for the time being, trade in health care and patient mobility between Austria and Hungary is a circumscribed phenomenon in terms of quantities, and it will most probably remain so in the near future.
    Keywords: access to health care; adequate resources; aid; beds; cataract surgery; clinics; Community hospitals; Consumer Protection; cost effectiveness; costs of treatment; dental care; dental treatment; dentists; Diagnosis; discrimination; disease; doctor; doctors; domestic law; employment; entitlement; expenditures; families; financial resources; fundamental principles; general practitioner; Health Affairs; health care; health care centers; health care costs; health care coverage; health care facilities; health care institutions; health care insurance; health care law; health care provider; health care providers; health care sector; health care services; health care standards; health care system; health care systems; Health Care Systems in Transition; health expenditure; health facilities; health insurance; health insurance companies; health insurance funds; health insurance system; health insurers; Health Organization; health organizations; health policy; health providers; health sector; health service; Health Services; health system; health systems; Health Systems in Transition; Healthcare; hospital care; hospital financing; Hospital Operator; hospital sector; hospital treatment; hospitals; hygiene; income; insurance; insurance coverage; insurance systems; Integration; judicial proceedings; legal provisions; marketing; Medical Association; medical associations; medical benefits; medical care; medical facilities; medical science; medical services; medical treatment; medicine; Migration; National Health; National Health Insurance; National Health Insurance Fund; national health policy; nurses; patient; patient care; patient treatment; patients; physician; physicians; Policy ReseaRch; Primary Care; private health insurance; private health insurers; private hospitals; private households; private insurance; private insurer; private insurers; private sector; provision of health care; provision of services; public health; public health care; public health insurance; public hospitals; public sector; quality control; quality of health; quality of health care; rehabilitation; reimbursement rates; right to health care; social health insurance; social insurance; Social Policy; social security; social security schemes; social security systems; surgery; therapy; treatments; Use of Health Care Services; visits; workers
    Date: 2009–01–01
  13. By: Wagstaff, Adam (The World Bank)
    Abstract: How can the impact of aid be estimated in the presence of fungibility? And how far does fungibility reduce its benefits? These questions are analyzed in a context where a donor wants to target its efforts on a specific sector and specific geographic areas. A traditional differences-in-differences method comparing the change in outcomes between the target and nontarget areas before and after the project risks misestimating the project's benefits. The paper develops an alternative estimation method in which intersectoral fungibility reduces project benefits insofar as government spending has a smaller impact in the sector to which the funds leak than in the target sector, while intrasectoral fungibility reduces benefits insofar as the donor is able to leverage productivity increases in government spending in the target areas. The methods are applied to two contemporaneous World Bank health projects that set out to target assistance on approximately one-half of Vietnam's provinces. Aid is not apparently fungible between Vietnam's health sector and other sectors, but is fungible across provinces within the health sector. Differences-in-differences yield an insignificant impact on infant mortality, while the use of the new method yields a statistically significant impact of around 4 per 1000 live births. The results, however, are ambiguous on the costs associated with intrasectoral fungibility.
    Keywords: foreign aid; fungibility; impact evaluation; child mortality
    Date: 2008–12–01
  14. By: Lokshin , Michael (The World Bank); Radyakin, Sergiy (The World Bank)
    Abstract: The authors use data from three waves of the India National Family Health Survey to explore the relationship between the month of birth and the health outcomes of young children in India. They find that children born during the monsoon months have lower anthropometric scores compared with children born during the fall and winter months. The authors propose and test four hypotheses that could explain such a correlation. The results emphasize the importance of seasonal variations in affecting environmental conditions at the time of birth and determining the health outcomes of young children in India. Policy interventions that affect these conditions could effectively impact the health and achievement of these children, in a manner similar to nutrition and micronutrient supplementation programs.
    Keywords: Nutrition; anthropometry; child health; seasonality; poverty; India
    JEL: I32 J12 O12
    Date: 2009–01–01
  15. By: Valerie Albouy (INSEE Institut national de la statistique et des études économiques); Laurent Davezies (INSEE Institut national de la statistique et des études économiques); Thierry Debrand (IRDES institut for research and information in health economics)
    Abstract: This study compares estimates of outpatient expenditure computed with different models. Our aim is to predict annual health expenditures. We use a French panel dataset over a six year period (2000-2006) for 7112 individuals. Our article is based on the estimations of five different models. The first model is a simple two part model estimated in cross section. The other models (models 2 to 5) are estimated with selection models (or generalized tobit models). Model 2 is a basic sample selection model in cross section. Model 3 is similar to model 2, but takes into account the panel dimension. It includes constant unobserved heterogeneity to deal with state dependency. Model 4 is a dynamic sample selection model (with lagged adjustement), while in model 5, we take into account the possible heteroskedasticity of residuals in the dynamic model. We find that all the models have the same properties in the cross section dimension (distribution, probability of health care use by gender and age, health expenditure by gender and age) but model 5 gives better results reflecting the temporal correlation with health expenditure. Indeed, the retransformation of predicted log transformed expenditures in homoscedastic models (models 1 to 4) generates very poor temporal correlation for " heavy consumers ", although the data show the contrary. Incorporation of heteroskedasticity gives better results in terms of temporal correlation.
    Keywords: Health econometrics, expenditures, panel data, selection models
    JEL: I0 C1 C5
    Date: 2009–01
  16. By: Arnaud Bourgain (CREA, Université du Luxembourg); Patrice Pieretti (CREA, Université du Luxembourg); Benteng Zou (CREA, Université du Luxembourg)
    Abstract: Substitution policies are strategies sometimes chosen in Sub-Saharan Africa for curtailing the shortage of health professionals especially caused by the outflow of medical personnel. The aim of our contribution is to propose a way to assess the merits and drawbacks of substitution policies by developing a simple growth model of healthcare productivity with medical brain drain. Within this framework, we use a medical care production function of the CES type which aggregates low and high specialized health workers. We then run simulations which compare scenarios with and without substitution strategies by using data from the Ghana’s medical sector.
    Keywords: medical shortage, healthcare policy, substitution policy
    JEL: I18 F22
    Date: 2008–10
  17. By: Titus Galama; Arie Kapteyn; Raquel Fonseca; Pierre-Carl Michaud
    Abstract: The authors formulate a stylized structural model of health, wealth accumulation and retirement decisions building on the human capital framework of health provided by Grossman. They explicitly assume a functional form of the utility function and carefully account for initial conditions, which allow them to derive analytic solutions for the time paths of consumption, health, health investment, savings and retirement. They argue that the Grossman literature has been unnecessarily restrictive in assuming that health is always at Grossman's "optimal" health level. Exploring the properties of corner solutions they find that advances in population health (health capital) can explain the paradox that while population health and mortality have continued to improve in the developed world, retirement ages have continued to fall with retirees pointing to deteriorating health as an important reason for early retirement. They find that improvements in population health decrease the retirement age, while at the same time individuals retire when their health has deteriorated. In their model, workers with higher human capital (say white collar workers) invest more in health and because they stay healthier retire later than those with lower human capital (say blue collar workers) whose health deteriorates faster. Plausibly, most individuals are endowed with an initial stock of health that is substantially greater than the level required to be economically productive.
    JEL: I10 I12 J00 J24 J26
    Date: 2008–12
  18. By: Jeremiah Hurely; Neil Buckley; Katherine Cuff; Mita Giacomini; David Cameron
    Abstract: Greater recognition by economists of the influential role that concern for distributional equity exerts on decision making in a variety of economic contexts has spurred interest in empirical research on the public judgments of fair distribution. Using a stated-preference experimental design, this paper contributes to the growing literature on fair division by investigating the empirical support for each of five distributional principles — equal division among recipients, Rawlsian maximin, total benefit maximization, equal benefit for recipients, and allocation according to relative need among recipients — in the division of a fixed bundle of a good across settings that differ with respect to the good being allocated (a health care good — pills, and non-health care but still health-affecting good — apples) and the way that alternative possible divisions of the good are described (quantitative information only, verbal information only, and both). It also offers new evidence on sample effects (university sample vs. community samples) and how the aggregate ranking of principles is affected by alternative vote-scoring methods. We find important information effects. When presented with quantitative information only, support for the division to equalize benefit across recipients is consistent with that found in previous research; changing to verbal descriptions causes a notable shift in support among principles, especially between equal division of the goods and total benefit maximization. The judgments made when presented with both quantitative and verbal information match more closely those made with quantitative-only descriptions rather than verbal-only descriptions, suggesting that the quantitative information dominates. The information effects we observe are consistent with a lack of understanding among participants as to the relationship between the principles and the associated quantitative allocations. We also find modest good effects in the expected direction: the fair division of pills is tied more closely to benefit-related criterion than is the fair division of apples (even though both produce health benefits). We find evidence of only small differences between the university and community samples and important sex-information interactions.
    Keywords: Distributive Justice; Equity; Resource Allocation; Health Care
    JEL: C9 D63 I1
    Date: 2009–01
  19. By: Isik U. Zeytinoglu; Margaret Denton; Sharon Davies; M. Bianca Seaton; Jennifer Millen
    Abstract: The home health care sector in Canada experienced major restructuring in the mid-1990s creating a variety of flexibilities for organizations and insecurities for workers. This paper examines the emotional and physical health consequences of employer flexibilities and worker insecurities on home health care workers. For emotional health the focus is on stress and for physical health the focus is on selfreported musculoskeletal disorders. Data come from our survey of home health care workers in a mid-sized city in Ontario, Canada. Data are analyzed separately for 990 visiting and 300 office workers. For visiting workers, results showed that none of the ‘objective’ flexibility/insecurity measures are associated with stress or musculoskeletal disorders controlling for other factors. However, ‘subjective’ flexibility/insecurity factors, i.e. feelings of job insecurity and labour market insecurity, are significantly and positively associated with stress. When stress is included in the analysis, for visiting workers stress mediates the effects of ‘subjective’ flexibility/insecurity with musculoskeletal disorders. For office workers, none of the objective flexibility/insecurity factors are associated with stress but subjective flexibility/insecurity factor of feelings of job insecurity is positively and significantly associated with stress. For office home care workers, work on call is negatively and significantly associated with musculoskeletal disorders. Feeling job insecurity is mediated through stress in affecting musculoskeletal disorders. Feeling labour market insecurity is significantly and positively associated with musculoskeletal disorders for office home care workers. Decision-makers in home care field are recommended to pay attention to insecurities felt by workers to reduce occupational health problems of stress and musculoskeletal disorders.
    Keywords: home health care workers, stress, worker insecurity
    JEL: I11 J28
    Date: 2009–01
  20. By: Ruben G. Mercado; K. Bruce Newbold
    Abstract: Most studies analyzed the impact of decreased mobility on health and social network status, but only a few have provided evidence to understand how these latter factors could affect travel decisions or outcomes. This paper examined the linkage between people’s car driving and public transit use in Canada and their personal, health and social network characteristics, with a focus on the elderly population. The study exploits Statistics Canada’s General Social Survey (GSS-19), a unique survey with a nationally representative sample that contains questions on health, social network and transportation situation. Multilevel binary logistic regression models were estimated for the two travel modes. Results showed that regardless of age, poor health discourages both car driving and public transit use. Physical limitations that constrain mobility were found to decrease the likelihood of using public transit, a finding that was expected. However, a very interesting finding of this study is that even in the presence of physical or mental situations, mobility is still made possible through car driving. Relatedly, the study showed how important license possession and car ownership are to personal mobility and to be less dependent on other modes of transport including public transit. <p>Findings from this study have also underlined that family network could play an important role in influencing both mobility decisions and provision. Car driving was found to be more likely when a person lives alone versus with one or more people in the household, a tendency that is stronger among the elderly than the non-elderly group. However, in the event of voluntary driving cessation, suspension of driving license, or when other means of transport would not be a convenient or feasible option, support from family members or caregivers could be critical given that, and as this study finding showed, elderly people are likely to continue to strive to maintain their driving skills even with a health condition, rather than prepare to stop driving. The size of close family networks did not show a considerable influence, but the quality of these ties (i.e. being close to family) was found relevant in public transit use. Results underlined implications to road safety, the development of alternative transport strategies and strengthening social support to help maintain mobility necessary for health and quality of life in later years.
    Keywords: elderly, transport, mode choice, Canada, health, social network
    JEL: I19 J14 O20 R42 R48
    Date: 2009–01
  21. By: Emmanuelle Pierard (Department of Economics, University of Waterloo)
    Abstract: We use data from the Canadian National Population Health Survey and the Canadian Institute for Health Information to estimate the relation- ship between per capita supply of physicians, both general practitioners and specialists, on health status. Measures of quality of life, self-assessed health status and the Health Utility Index are explored. The sample consists of all individuals who were age 18 or over at the beginning of the survey in 1994, and the sub-sample includes only individuals who were not diagnosed with a chronic condition for the first four years. Most previous studies of the effect of physician supply on health status used data only on individuals who had specific health problems, and many of them used outcomes related to the length of life of the patient. Random effects ordered probits are used to model self assessed health status and quantile regressions are used for the Health Utility Index. A higher supply of specialists is correlated with worse health outcomes, while a higher supply of general practitioners is correlated with better health outcomes as measured by both measures of health status.
    JEL: J22
    Date: 2009–01

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