nep-hea New Economics Papers
on Health Economics
Issue of 2011‒06‒18
fifteen papers chosen by
Yong Yin
SUNY at Buffalo, USA

  1. Electronic Health Records: Delivering the Right Information to the Right Health Care Providers at the Right Time By William M. Tierney
  2. Maternal age and offspring adult health: evidence from the Health And Retirement Study By Mikko Myrskylä; Andrew T. Fenelon
  3. Labor Complementarities and Health in the Agricultural Household By Achyuta Adhvaryu; Anant Nyshadham
  4. Healthcare Choices, Information and Health Outcomes By Achyuta Adhvaryu; Anant Nyshadham
  5. Labor Supply, Schooling and the Returns to Healthcare in Tanzania By Achyuta Adhvaryu; Anant Nyshadham
  6. Patients Whose GP Knows Complementary Medicine Tend to Have Lower Costs and Live Longer By Kooreman, Peter; Baars, Erik W.
  7. Health Information and Health Outcomes: An Application of the Regression Discontinuity Design to the 1995 UK Contraceptive Pill Scare Case By Emilia Del Bono; Marco Francesconi; Nicky Best
  8. Schooling and youth mortality : learning from a mass military exemption By Cipollone, Piero; Rosolia, Alfonso
  9. The Demand for Health Insurance among Uninsured Americans: Results of a Survey Experiment and Implications for Policy By Alan B. Krueger; Ilyana Kuziemko
  10. Explaining gender-specific racial differences in obesity using biased self-reports of food intake By Mary A. Burke; Frank W. Heiland
  11. Physical Activity and Health Outcome: Evidence from Canada By Humphreys, Brad; McLeod, Logan; Ruseski, Jane
  12. In brief: Hospital performance: the impact of good management By Nicholas Bloom; Stephen Dorgan; Rebecca Homkes; Dennis Layton; Raffaella Sadun; John Van Reenen
  13. Statistical analysis of accidents at work in the international context By FRENDA, ANTONIO
  14. Disability in Belgium: There is More than Meets the Eye By Alain Jousten; Mathieu Lefebvre; Sergio Perelman
  15. A Few More Laps to Go: Tobacco Industry Political Influence, Public Health Advocacy and Tobacco Control Policy Making in Indiana By Rosenbaum, Daniel J. BA; Barnes, Ricahrd L JD; Glantz, Stanton A. PhD

  1. By: William M. Tierney (Regenstrief Institute, Inc., 410 West 10th Street, Suite 2000, Indianapolis, IN 46202-3012)
    Abstract: In 1993 I wrote "Communication and information management consume as much as 40 percent of all inpatient costs, yet errors still occur at an unacceptable rate. The Institute of medicine has suggested that electronic medical records (EMRs) will help lower health care costs, maintain quality of care, and provide physicians with better information" (Tierney et al. 1993, 379). Nearly 20 years later I'm here to tell you how far we've come toward implementing EHRs nationwide, and what we've learned from our experience at the Regenstrief Institute in Indiana University. Most of us consider health care to be a service business, because we think in terms of a patient who goes to the doctor to get some thing: advice, medication, devices, surgery, or physical therapy. I'm going to argue that what patients really get, and health care practitioners really provide, is information. Ninety-eight percent of what we who practice medicine do is not the end result, the end service, but the overall process of getting there.
    Keywords: electronic medical records, EMRs, EHRs
    JEL: H51 I12
    Date: 2011–03
  2. By: Mikko Myrskylä (Max Planck Institute for Demographic Research, Rostock, Germany); Andrew T. Fenelon (Max Planck Institute for Demographic Research, Rostock, Germany)
    Abstract: Advanced maternal age is associated with negative offspring health outcomes. The interpretation often relies on physiological processes related to aging, such as decreasing oocyte quality. We use a large population-based sample of American adults to analyze how selection and lifespan overlap between generations influence the maternal age-offspring adult health association. We find that offspring born to mothers below age 25 or above 35 have worse outcomes with respect to mortality, self-rated health, height, obesity and the number of diagnosed conditions than those born to mothers aged 25-34. Controls for maternal education and age at which the child lost the mother eliminate the effect for advanced maternal age up to age 45. The association between young maternal age and negative offspring outcomes is robust to these controls. Our findings suggest that the advanced maternal age-offspring adult health association reflects selection and factors related to lifespan overlap. These may include shared frailty or parental investment, but are not directly related to the physiological health of the mother during conception, fetal development, or birth. The results for young maternal age add to the evidence suggesting that children born to young mothers might be better off if the parents waited a few years.
    JEL: J1 Z0
    Date: 2011–06
  3. By: Achyuta Adhvaryu (MEPH Health Policy and Administration, Yale University); Anant Nyshadham (Department of Economics, Yale University)
    Abstract: Models of the agricultural household have traditionally relied on assumptions regarding the complementarity or substitutability of family labor inputs. We show how data on time allocations, health shocks and corresponding treatment choices can be used to test these assumptions. Data from Tanzania provide evidence that complementarities exist and can explain the pattern of labor supply adjustments across household members and productive activities following acute sickness. In particular, we find that sick and healthy household members both shift labor away from self-employment and into farming when the sick recover more quickly. Infra-marginal adjustments within farming activity types provide further evidence of farm-specific complementarities.
    Keywords: intra-household allocation, health shocks, complementarity
    JEL: I10 J22 J43 O12
    Date: 2011–03
  4. By: Achyuta Adhvaryu (MEPH Health Policy and Administration, Yale University); Anant Nyshadham (Department of Economics, Yale University)
    Abstract: Self-selection into healthcare options on the basis of severity likely biases estimates of the effects of healthcare choice on health outcomes. Using an instrumental variables strategy which exploits exogenous variation in the cost of formal-sector care, we show that using such care to treat acute sickness decreases the incidence of fever and malaria in young children in Tanzania. Compared to the instrumental variables estimates, ordinary least squares estimates significantly understate the effects of formal-sector healthcare use on health outcomes. Improved information and more timely treatment, rather than greater access to medicines, seem to be the primary mechanisms for this effect.
    Keywords: healthcare, information, child health, Tanzania
    JEL: I10 I18 O10 O12
    Date: 2011–03
  5. By: Achyuta Adhvaryu (MEPH Health Policy and Administration, Yale University); Anant Nyshadham (Department of Economics, Yale University)
    Abstract: We estimate the effects of higher quality healthcare usage on health, labor supply and schooling outcomes for sick individuals in Tanzania. Using exogenous variation in the cost of formal sector healthcare to predict treatment choice, we show that using better quality care improves health outcomes and changes the allocation of time amongst productive activities. In particular, sick adults who receive better quality care reallocate time from non-farm to farm labor, leaving total labor hours unchanged. Among sick children, school attendance significantly increases as a result of receiving higher quality healthcare, but labor allocations are unaffected. We interpret these results as evidence that healthcare has heterogeneous effects on marginal productivity across productive activities and household members.
    Keywords: labor supply, health shocks, schooling, Tanzania
    JEL: I10 J22 J43 O12
    Date: 2011–03
  6. By: Kooreman, Peter (Tilburg University); Baars, Erik W. (Louis Bolk Institute)
    Abstract: Health economists have largely ignored complementary and alternative medicine (CAM) as an area of research, although both clinical experiences and several empirical studies suggest cost-effectiveness of CAM. The objective of this paper is to explore the cost-effectiveness of CAM compared to conventional medicine. A data set from a Dutch health insurer was used containing quarterly information on healthcare costs (care by general practitioner (GP), hospital care, pharmaceutical care, and paramedic care), dates of birth and death, gender and 6-digit postcode of all approximately 150,000 insurees, for the years 2006-2009. Data from 1913 conventional GPs were compared to data from 79 GPs with additional CAM training in acupuncture (25), homeopathy (28) and anthroposophic medicine (26). Patients whose GP has additional CAM training have 0 to 30 percent lower healthcare costs and mortality rates, depending on age groups and type of CAM. The lower costs result from fewer hospital stays and fewer prescription drugs. Since the differences are obtained while controlling for confounders including neighborhood specific fixed effects at a highly detailed level, the lower costs and longer lives are unlikely to be related to differences in socio-economic status. Possible explanations include selection (e.g. people with a low taste for medical interventions might be more likely to choose CAM) and better practices (e.g. less overtreatment, more focus on preventive and curative health promotion) by GPs with knowledge of complementary medicine. More controlled studies (replication studies, research based on more comprehensive data, cost-effectiveness studies on CAM for specific diagnostic categories) are indicated.
    Keywords: healthcare costs, life expectancy, complementary medicine
    JEL: I11 I12
    Date: 2011–05
  7. By: Emilia Del Bono; Marco Francesconi; Nicky Best
    Abstract: This paper provides a general formulation of the regression discontinuity (RD) design and shows its general applicability to many epidemiological problems. It then applies the RD method to estimate the e®ects of the 1995 pill scare in the UK, using individual birth records and aggregate monthly statistics. The results show that, following the announce- ment of the health warning on the \third generation" pill, conception rates increased by about 7%, with a 9% increase in abortion rates and a 6-7% rise in birth rates. No e®ect was found on still births, very low birth weight, sex ratios, or average birth weight. There is evidence of a slight increase in the rates of low birth weight births and multiple births and of a considerable reduction in the rate of births with congenital anomalies. Hetero- geneity by mother's age and social class is very pronounced, with most of the e®ects being experienced by women aged less than 25 and of lower socioeconomic status.
    Date: 2011–06–09
  8. By: Cipollone, Piero; Rosolia, Alfonso
    Abstract: This paper examines the relationship between education and mortality in a young population of Italian males. In 1981 several cohorts of young men from specific southern towns were unexpectedly exempted from compulsory military service after a major quake hit the region. Comparisons of exempt cohorts from the least damaged towns on the border of the quake region with similar ones from neighbouring non-exempt towns just outside the region show that, by 1991, the cohorts exempted while still in high school display significantly higher graduation rates. The probability of dying over the decade 1991-2001 was also significantly lower. Several robustness checks confirm that the findings do not reflect omitted quake-related confounding factors, such as the ensuing compensatory interventions. Moreover, cohorts exempted soon after high school age do not display higher schooling or lower mortality rates, thus excluding that the main findings reflect direct effects of military service on subsequent mortality rather than a causal effect of schooling. The authors conclude that increasing the proportion of high school graduates by 1 percentage point leads to 0.1-0.2 percentage points lower mortality rates between the ages of 25 and 35.
    Keywords: Population Policies,Health Monitoring&Evaluation,Labor Policies,Demographics,Education For All
    Date: 2011–06–01
  9. By: Alan B. Krueger (Princeton University); Ilyana Kuziemko (Princeton University)
    Abstract: Most existing work on the price elasticity of demand for health insurance focuses on employees' decisions to enroll in employer-provided plans. Yet any attempt to achieve universal coverage must focus on the uninsured, the vast majority of whom are not offered employer-sponsored insurance. In the summer of 2008, we conducted a survey experiment to assess the willingness to pay for a health plan among a large sample of uninsured Americans. The experiment yields price elasticities substantially greater than those found in most previous studies. We use these results to estimate coverage expansion under the Affordable Care Act, with and without an individual mandate. We estimate that 39 million uninsured individuals would gain coverage and find limited evidence of adverse selection.
    Keywords: health insurance, universal coverage, Affordable Care Act, price elasticity of demand
    JEL: D19 H75 I18 J32
    Date: 2011–04
  10. By: Mary A. Burke; Frank W. Heiland
    Abstract: Policymakers have an interest in identifying the differences in behavior patterns - namely, habitual caloric intake and physical activity levels - that contribute to demographic variation in body mass index (BMI) and obesity risk. While disparities in mean BMI and obesity rates between whites (non-Hispanic) and African-Americans (non-Hispanic) are well-documented, the behavioral differences that underlie these gaps have not been carefully identified. Moreover, the female-specificity of the black-white obesity gap has received relatively little attention. In the National Health and Nutrition Examination Surveys (NHANES) data, we initially observe a very weak relationship between self-reported measures of caloric intake and physical activity and either BMI or obesity risk, and these behaviors appear to explain only a small fraction of the black-white BMI gap (or obesity gap) among women. These unadjusted estimates echo previous findings from large survey datasets such as the NHANES. Using an innovative method to mitigate the widely recognized problem of measurement error in self-reported behaviors - proxying for measurement errors using the ratio of reported caloric intake to estimated true caloric needs - we obtain much stronger relationships between behaviors and BMI (or obesity risk). Behaviors can in fact account for a significant share of the BMI gap (and the obesity gap) between black women and white women and are consistent with the presence of much smaller gaps between black men and white men. The analysis also shows that the effects smoking has on BMI and obesity risk are small-to-negligible when measurement error is properly controlled.
    Keywords: Obesity
    Date: 2011
  11. By: Humphreys, Brad (University of Alberta, Department of Economics); McLeod, Logan (University of Alberta, Department of Public Health Sciences); Ruseski, Jane (University of Alberta, Department of Economics)
    Abstract: Health production models include participation in physical activity as an input. We investigate the relationship between participation in physical activity and health using a bivariate probit model. Participation is identifi ed with an exclusion restriction on a variable reflecting sense of belonging to the community. Estimates based on data from Cycle 3.1 of the Canadian Community Health Survey indicate that participation in physical activity reduces the reported incidence of diabetes, high blood pressure, heart disease, asthma, and arthritis as well as being in fair or poor health. Increasing the intensity and frequency of participation in physical activity appears to have a diminishing marginal impact on adverse health outcomes above the moderate level.
    Keywords: health production; physical activity; lifestyle choices; bivariate probit
    JEL: I12 I18
    Date: 2011–05–01
  12. By: Nicholas Bloom; Stephen Dorgan; Rebecca Homkes; Dennis Layton; Raffaella Sadun; John Van Reenen
    Abstract: CEP research highlights the potential role of improving the quality of hospital management for raising productivity in the UK healthcare sector
    Keywords: health
    JEL: I10 I18
    Date: 2011–03
    Abstract: This research describes safety at work as an issue to be addressed in terms of legislation, with due statistical knowledge of the phenomenon. Through the application of multiple indicators while investigating the rate of homogeneity and non-homogeneity of available data, especially at international level, the concept at study can be analyzed using specific scientific methods.
    Keywords: Accident risk; Standardized Attendance Rates ESAW (European Statistics on Accidents at Work); Underground Economy.
    JEL: A12
    Date: 2010–12–28
  14. By: Alain Jousten; Mathieu Lefebvre; Sergio Perelman
    Abstract: The paper provides a perspective on the development of the Belgian disability insurance system. Using both survey and administrative data, it sketches a picture of the (changing) factors leading towards disability, as well as the outcomes in terms of program participation. The paper shows the key role of integrating other forms of early retirement programs into the analysis. The main findings are an unspectacular trend in the number of DI beneficiaries over time combined with a strong expansion of (early-) retirement schemes.
    JEL: H55 J14 J21 J26
    Date: 2011–06
  15. By: Rosenbaum, Daniel J. BA; Barnes, Ricahrd L JD; Glantz, Stanton A. PhD
    Abstract: Tobacco policy has been an issue in Indiana since 1893, when the legislature passed a law prohibiting selling tobacco to people under 16. Beginning as early as 1969, Indiana General Assembly members and tobacco control advocates launched uncoordinated efforts to pass a law restricting smoking in government buildings. The tobacco industry responded with a well-financed and well-connected network of lobbyists, campaign contributions and third-party allies which's lobbyists that defeated every statewide clean indoor air proposal from 1969 to 1986. In 1986, tobacco control advocates formed the Indiana Campaign for a Tobacco-Free Society and, in 1987, successfully advocated for Indiana's first clean indoor air law that created nonsmoking areas in government-owned buildings. Participating in the National Cancer Institute's American Stop Smoking Intervention Study (ASSIST; 1991 to 1999) provided Indiana with its first funded tobacco control local infrastructure, which laid the foundation for future progress. In 1997, despite opposition from tobacco control advocates, the Tobacco Institute, the tobacco industry's lobbying organization, convinced the Indiana Legislature to preempt local governments from regulating the sale, distribution or display of tobacco products. Between 2000 and 2009, the tobacco industry spent over $4 million on lobbying. From 1994 to 2008, the tobacco industry contributed $560,884 to elected officials. Nine of the 10 officials who accepted the highest amounts of money held high-ranking leadership positions. Industry contributions were associated with more pro-industry behavior by legislators. Tobacco Industry campaign contributions peaked during 1999-2000, when legislators were considering how to spend money from the Master Settlement Agreement (MSA), and during 2003-2004, when legislators cut the state tobacco control budget by 70 percent. In 2000, the Legislature created the Indiana Tobacco Use Prevention and Cessation (ITPC) Agency as an independent agency governed by an Executive Board with $35 million of MSA money for FY 2001, meeting the US Centers for Disease Control and Prevention's minimum funding recommendation. The ITPC Executive Board created the Hoosier Model, an adaptation of CDC's Best Practices for Comprehensive Tobacco Control Programs, with a particularly strong emphasis on community programs. In 2002, with active support from tobacco control advocates and ITPC, the Governor proposed and the Legislature enacted a 40¢/pack cigarette tax increase, the first increase since 1987. None of the money went to tobacco control. In 2007, again with support from the health advocates and ITPC, the Legislature enacted Governor Mitch Daniels' (R) Healthy Indiana Plan financed by a 44¢/pack cigarette tax increase (to 99.5¢). Only $1.2 million of the new tax revenues were allocated to ITPC, and even this small amount ended after just one year. As of 2010, Indiana's cigarette tax was still 45.5¢ below the national average. Bloomington passed Indiana's first comprehensive smokefree ordinance in 2003 which prohibited smoking in public places and enclosed workplaces, followed by bars in 2005. Indianapolis-Marion County passed an ordinance in 2005 prohibiting smoking in public places and enclosed workplaces, except for bars and private clubs. Thirty-five local ordinances passed after the Indianapolis-Marion County ordinance, 21 of which exempted bars and 28 exempted private clubs, mirroring the Indianapolis-Marion County ordinance. In 2006, tobacco control advocates adopted statewide “deal breaker†agreements establishing a minimum standard for comprehensive local smokefree ordinances without exemptions. These agreements resulted in fewer but stronger ordinances: from 2003 through 2006, only 5 of 28 ordinances included bars; between 2007 and 2009, 6 of 10 ordinances included bars. Decreases in ITPC funding to local communities has made it difficult for local coalitions to maintain staff levels and program efficacy. Advocates have been too focused on strengthening the 2005 Indianapolis-Marion County clean indoor air ordinance; advocates should reinvigorate local activity throughout the state to pass comprehensive ordinances in smaller communities. In 2009, statewide tobacco control advocates made a strategic error in not actively supporting a non-preemptive clean indoor air bill covering everything but casinos. In 2010, in an arrangement with House Speaker B. Patrick Bauer, Representative Charlie Brown (D-Gary) introduced essentially the same bill that the advocates passed on in 2009, which again failed without their support. Tobacco control advocates were divided which weakened their coalition. ITPC's funding was never secure; between FY 2001 and FY 2004, legislators cut ITPC's funding by 70%. ITPC received $10.9 million for FY 2010, just 14% of Best Practices. Despite the cuts, ITPC's programs decreased youth smoking. From 2000 to 2008, smoking prevalence decreased among high school students by 42 percent, from 31.6 percent to 18.3 percent and among middle school students by 58 percent, from 9.8 percent to 4.1 percent. During this period adult smoking prevalence remained stable, while per capita consumption dropped, indicating that smokers were smoking fewer cigarettes. The continuing decline in youth smoking while adult prevalence stagnated probably reflected the ITPC Executive Board's decision to give priority to reducing youth smoking in response to cuts in total funding available. State policy makers were correct to establish ITPC as an independent agency and to fund it at CDC-recommended levels. In 2010, tobacco control advocates defeated a proposal from Governor Mitch Daniels and Senator Luke Kenley (R-Noblesville) to dissolve the ITPC Executive Board and transfer the Agency's functions to the Indiana State Department of Health (ISDH). States that have dissolved or transferred their independent tobacco control programs into state health departments have historically raided funds and been left with ineffective programs. In 2011, advocates again fought a similar last minute amendment to the state budget bill to dismantle ITPC introduced by Sen. Kenley, but were unsuccessful in part. ITPC was dissolved and the program's budget transferred to ISDH and reduced by 25 percent. However, the public outcry generated by ITPC supporters influenced ISDH to create a new, high level division reporting directly to the State Commissioner of Health focused solely on tobacco prevention and cessation and to make a commitment to maintaining ITPC‟s effective program focus. If advocates can successfully transition ITPC's programs into ISDH, broaden its program focus to reintegrate adults, and restore full funding, it will likely yield rapid decreases in health care costs and other economic losses stemming from tobacco-related illnesses and so contribute not only to the physical health of Hoosiers, but also the fiscal health of their government and businesses.
    Keywords: Political Science, Public Affairs, Public Policy and Public Administration
    Date: 2011–06–01

This nep-hea issue is ©2011 by Yong Yin. It is provided as is without any express or implied warranty. It may be freely redistributed in whole or in part for any purpose. If distributed in part, please include this notice.
General information on the NEP project can be found at For comments please write to the director of NEP, Marco Novarese at <>. Put “NEP” in the subject, otherwise your mail may be rejected.
NEP’s infrastructure is sponsored by the School of Economics and Finance of Massey University in New Zealand.