nep-hea New Economics Papers
on Health Economics
Issue of 2011‒09‒16
twenty-two papers chosen by
Yong Yin
SUNY at Buffalo, USA

  1. Medicaid and Wealth: An Examination Using the NLSY79 By Maury Gittleman
  2. Comparing the Predicitive Power of Subjective and Objective Health Indicators: Changes in Hand Grip Strength and Overall Satisfaction with Life as Predictors of Mortality By Jens Ambrasat; Jürgen Schupp; Gert G. Wagner
  3. The Causal Effect of Education on Health: What is the Role of Health Behaviors? By Brunello, Giorgio; Fort, Margherita; Schneeweis, Nicole; Winter-Ebmer, Rudolf
  4. Health Insurance without Single Crossing: Why Healthy People have High Coverage By Boone, J.; Schottmuller, C.
  5. Impacts of parental health on children's development of personality traits and problem behavior: Evidence from parental health shocks By Morefield, Brant; Mühlenweg, Andrea M.; Westermaier, Franz
  6. Epidemic trade By Börner, Lars; Severgnini, Battista
  7. Does expanding health insurance beyond formal-sector workers encourage informality ? measuring the impact of Mexico's Seguro Popular By Aterido, Reyes; Hallward-Driemeier, Mary; Pages, Carmen
  8. The Effect of Vaccination on Children's Physical and Cognitive Development in the Philippines By David E. Bloom; David Canning; Erica Seigner
  9. Population Aging: Facts, Challenges, and Responses By David E. Bloom; Axel Boersch-Supan; Patrick McGee; Atsushi Seike
  10. Long-Run Trends of Human Aging and Longevity By Holger Strulik; Sebastian Vollmer
  11. The Economic Effects of Malaria Eradication: Evidence from an Intervention in Uganda By Jeremy Barofsky; Claire Chase; Tobenna Anekwe; Farshad Farzadfar
  12. Implications of Population Aging for Economic Growth By David E. Bloom; David Canning; Günther Fink
  13. Population aging and endogenous economic growth By Klaus Prettner
  14. Essays on Labor Force Participation, Aging, Income and Health. By Knoef, M.G.
  15. Why Does Population Aging Matter So Much for Asia? Population Aging, Economic Security and Economic Growth in Asia By Sang-Hyop LEE; Andrew MASON; Donghyun PARK
  16. How can infrastructures reduce child malnutrition and health inequalities? Evidence from Guatemala By Thomas Poder; Jie He
  17. Does Better Disease Management in Primary Care Reduce Hospital Costs? By Mark Dusheiko; Hugh Gravelle; Stephen Martin; Nigel Rice; Peter C Smith
  18. Impact of Swarnajayanti Gram Swarojgar Yojona on health, education and women empowerment By Kundu, Amit; Mukherjee, Arghya Kusum
  19. Patient Mobility, Health Care Quality and Welfare By Brekke, Kurt Richard; Levaggi, Rosella; Siciliani, Luigi; Straume, Odd Rune
  20. Exercise, Physical Activity, and Exertion over the Business Cycle By Gregory J. Colman; Dhaval M. Dave
  21. Racial, Ethnic and Gender Differences in Physical Activity By Henry Saffer; Dhaval M. Dave; Michael Grossman
  22. The Impact of Therapeutic Procedure Innovation on Hospital Patient Longevity: Evidence from Western Australia, 2000-2007 By Frank R. Lichtenberg

  1. By: Maury Gittleman (U.S. Bureau of Labor Statistics)
    Abstract: Do public insurance programs crowd out private savings? I examine the relationship between Medicaid and wealth and make a contribution to the literature on this issue in three primary ways. First, I apply the instrumental-variables approach developed by Gruber and Yelowitz (1999) to a different dataset, the National Longitudinal Survey of Youth, 1979 (NLSY79), while at the same time examining an alternative instrument. The results turn out to differ depending on the instrument and, for one of the instruments, to be sensitive to assumptions needed to identify Medicaid’s effects. Second, using the longitudinal data in the NLSY79, I am able to observe families before and after becoming eligible for Medicaid, and use fixed-effects to control for family-specific unobservable factors that are correlated with both Medicaid eligibility and wealth accumulation. It turns out, however, that assessment of the impact of Medicaid by means of fixed effects has its limitations as well. Third, I make use of the SIPP data used by Gruber and Yelowitz themselves, and examine the sensitivity of their conclusions to omitted factors that may be related to both Medicaid eligibility and to wealth accumulation. While more robust than the results using the NLSY79, the SIPP estimates are found to depend on the sample used and on certain specification restrictions. Taken together, the results suggest caution in making inferences about the impact of Medicaid on wealth.
    Keywords: Medicaid, Wealth
    JEL: I18 I38 D3
    Date: 2011–09
  2. By: Jens Ambrasat; Jürgen Schupp; Gert G. Wagner
    Abstract: Self-reported measures of health are generally treated as weak measures of respondents’ objective health status. On the other hand, most surveys use self-reported health to measure health status and to determine the effects of a range of other socio-economic characteristics of the local environment on individual health. It is therefore of interest to the public health research community to verify the validity of self-reported health data. We do this by analyzing data from a longitudinal household panel survey: the German Socio-Economic Panel Study (SOEP). In 2006, and again in 2008, hand grip strength was measured as part of the SOEP. The hand grip data can be compared with other indicators of health and well-being from the SOEP survey. In a first step, we examine short-term mortality outcomes predicted by changes in hand grip strength. Then we compare the predictive power of the results with those of a subjective indicator of well-being: overall life satisfaction. We find that both measures are related to mortality risk. However, the effects are quite independent. Thus we argue that changes in hand grip strength and overall life satisfaction capture two different aspects of health status and its changes. We therefore test this hypothesis by correlating the indicators with other survey-based health measures that were also taken in the SOEP in 2006 and 2008.
    Keywords: grip strength, subjective health status measures, mortality, subjective well-being, SOEP
    JEL: C81 I12 J14
    Date: 2011
  3. By: Brunello, Giorgio (University of Padova); Fort, Margherita (University of Bologna); Schneeweis, Nicole (University of Linz); Winter-Ebmer, Rudolf (University of Linz)
    Abstract: In this paper we investigate the contribution of health related behaviors to the education gradient, using an empirical approach that addresses the endogeneity of both education and behaviors in the health production function. We apply this approach to a multi-country data set, which includes 12 European countries and has information on education, health and health behaviors for a sample of individuals aged 50+. Focusing on self reported poor health as our health outcome, we find that education has a protective role both for males and females. When evaluated at the sample mean of the dependent variable, one additional year of education reduces self-reported poor health by 7.1% for females and by 3.1% for males. Health behaviors – measured by smoking, drinking, exercising and the body mass index – contribute to explaining the gradient. We find that the effects of education on smoking, drinking, exercising and eating a proper diet account for at most 23% to 45% of the entire effect of education on health, depending on gender.
    Keywords: health, education, health behaviors, Europe
    JEL: J1 I12 I21
    Date: 2011–08
  4. By: Boone, J.; Schottmuller, C. (Tilburg University, Center for Economic Research)
    Abstract: Standard insurance models predict that people with high (health) risks have high insurance coverage. It is empirically documented that people with high income have lower health risks and are better insured. We show that income differences between risk types lead to a violation of single crossing in the standard insurance model. If insurers have some market power, this can explain the empirically observed outcome. This observation has also policy implications: While risk adjustment is traditionally viewed as an intervention which increases efficiency and raises the utility of low health agents, we show that with a violation of single crossing a trade off between efficiency and solidarity emerges.
    Keywords: Health insurance;single crossing;risk adjustment.
    JEL: D82 I11
    Date: 2011
  5. By: Morefield, Brant; Mühlenweg, Andrea M.; Westermaier, Franz
    Abstract: In this paper, we examine how parental health affects children's development of personality traits and problem behavior. Based on a German mother-and-child data base, we draw on observed parental health shocks as a more exogenous source of health variation to identify these effects and control for child and family characteristics including variables reflecting initial endowments observed at birth. At the age of six, we observe that maternal health shocks in early childhood have significant impacts on children's emotional symptoms, hyperactivity and neuroticism. Paternal health seems to be less relevant for the development of these non-cognitive characteristics. However, we observe that paternal health shocks cause children to be more extraverted. --
    Keywords: Human capital,health,personality traits,non-cognitive skills
    JEL: I00 J24 I10
    Date: 2011
  6. By: Börner, Lars; Severgnini, Battista
    Abstract: This paper studies the spread of the Black Death as a proxy for the ow of medieval trade between 1346 and 1351. The Black Death struck most areas of Europe and the wider Mediterranean. Based on a modified version of the gravity model, we estimate the speed (in kilometers per day) of transmission of the disease between the transmitting and the receiving cities. We find that the speed depends on distance, political borders, and on the political importance of a city. Furthermore, variables related to the means of transportation like rivers and the sea, religious seasons such as Lent and Advent, and geographical position are of substantial significance. These results are the first to enable us to identify and quantify key variables of medieval trade ows based on an empirical trade model. These results shed new light on many qualitative debates on the importance and causes of medieval trade. --
    Keywords: Trade,Middle Ages,Black Death,Gravity model,Poisson regression
    JEL: F10 F15 N13
    Date: 2011
  7. By: Aterido, Reyes; Hallward-Driemeier, Mary; Pages, Carmen
    Abstract: Seguro Popular was introduced in 2002 to provide health insurance to the 50 million Mexicans without Social Security. This paper tests whether the program has had unintended consequences, distorting workers'incentives to operate in the informal sector. The analysis examines the impact of Seguro Popular on disaggregated labor market decisions, taking into account that program coverage depends not only on the individual's employment status, but also that of other household members. The identification strategy relies on the variation in Seguro Popular's rollout across municipalities and time, with the difference-in-difference estimation controlling for household fixed effects. The paper finds that Seguro Popular lowers formality by 0.4-0.7 percentage points, with adjustments largely occurring within a few years of the program's introduction. Rather than encouraging exit from the formal sector, Seguro Popular is associated with a 3.1 percentage point reduction (a 20 percent decline) in the inflow of workers into formality. Income effects are also apparent, with significantly decreased flows out of unemployment and lower labor force participation. The impact is larger for those with less education, in larger households, and with someone else in the household guaranteeing Social Security coverage. However, workers pay for part of these benefits with lower wages in the informal sector.
    Keywords: Health Monitoring&Evaluation,Labor Markets,Labor Policies,Housing&Human Habitats,Population Policies
    Date: 2011–08–01
  8. By: David E. Bloom (Harvard School of Public Health); David Canning (Harvard School of Public Health); Erica Seigner
    Abstract: We use data from the Cebu Longitudinal Health and Nutrition Survey in the Philippines to link vaccination in the first two years of life with later physical and cognitive development in children. We use propensity score matching to estimate the causal effect of vaccination on child development. We find no effect of vaccination on later height or weight, but full childhood vaccination for measles, polio, TB, and DPT significantly increases cognitive test scores relative to matched children who received no vaccinations. The size of the effect is large, raising test scores, on average, by about half a standard deviation.
    Keywords: vaccination, Phiippines, cognitive development
    Date: 2011–04
  9. By: David E. Bloom (Harvard School of Public Health); Axel Boersch-Supan (Mannheim Research Institute for the Economics of Aging); Patrick McGee; Atsushi Seike
    Abstract: The world’s population is growing older, leading us into uncharted demographic waters. There will be higher absolute numbers of elderly people, a larger share of elderly, longer healthy life expectancies, and relatively fewer numbers of working-age people. There are alarmist views – both popular and serious – in circulation regarding what these changes might mean for business and economic performance. But the effects of population aging are not straightforward to predict. Population aging does raise some formidable and fundamentally new challenges, but they are not insurmountable. These changes also bring some new opportunities, because people have longer, healthier lives, resulting in extended working years, and different capacities and needs. The key is adaptation on all levels: individual, organizational, and societal. This article explores some potentially useful responses from government and business to the challenges posed by aging.
    Keywords: population, aging, longevity, fertility
    Date: 2011–05
  10. By: Holger Strulik; Sebastian Vollmer (Harvard Center for Population and Development Studies)
    Abstract: Over the last 200 years humans experienced a huge increase of life expectancy. These advances were largely driven by extrinsic improvements of their environment (for example, the available diet, disease prevalence, vaccination, and the state of hygiene and sanitation). In this paper we ask whether future improvements of life-expectancy will be bounded from above by human life-span. Life-span, in contrast to life-expectancy, is conceptualized as a biological measure of longevity driven by the intrinsic rate of bodily deterioration. In order to pursue our question we first present a modern theory of aging and show that immutable life-span would put an upper limit on life-expectancy. We then show for a sample of developed countries that human life-span thus defined was indeed constant until the 1950s but increased since then by about eight years in sync with life-expectancy. In other words, we find evidence for manufactured life-span.
    Keywords: human life-span, life-expectancy, aging, compression of mortality, life-span extension
    Date: 2011–08
  11. By: Jeremy Barofsky (Harvard School of Public Health); Claire Chase (Harvard School of Public Health); Tobenna Anekwe; Farshad Farzadfar
    Abstract: This study evaluates the economic consequences of a malaria eradication campaign in the southwestern Ugandan district of Kigezi. The project was a joint venture between the WHO and Uganda's Ministry of Health, designed to test for the first time the feasibility of malaria eradication in a sub-Saharan African country. During the years of 1959 and 1960, eradication efforts employing DDT spraying and mass distribution of anti-malarials were implemented, beginning in northern Kigezi. Follow-up studies reported a drop in overall parasite rates from 22.7 to 0.5% in hyperendemic areas and from 12.5 to 0% in mesoendemic areas. We use this campaign as a plausibly exogenous health shock to explore changes in human-capital formation and income. We employ a difference-in-difference methodology to show that eradication produced differential improvements in Kigezi compare to the rest of Uganda in years of schooling, literacy, and primary school completion. In addition, we find suggestive evidence that eradication increased income levels.
    Keywords: human capital, malaria, economic development and health
    Date: 2011–05
  12. By: David E. Bloom (Harvard School of Public Health); David Canning (Harvard School of Public Health); Günther Fink (Harvard School of Public Health)
    Abstract: Between 2005 and 2050, the share of the population aged 60 and over is projected to increase in nearly every country in the world. Insofar as this shift will tend to lower both labor force participation and savings rates, it raises bona fide concerns about a future slowing of economic growth. These concerns apply to both developed and developing countries. An examination of past decades' data for OECD countries reveals that life expectancy has increased much faster than the legal age of retirement. Indications are similar in developing countries, which face the additional challenge of getting "old" before they get "rich". This paper analyses the implications of population aging for economic growth. Our main conclusion is that population aging poses challenges that are formidable, but not insurmountable.
    Keywords: population aging, economic growth, economic policy, labor force participation, life expectancy, retirement age
    Date: 2011–01
  13. By: Klaus Prettner (Harvard Center for Population and Development Studies)
    Abstract: This article investigates the consequences of population aging for long-run economic growth perspectives. We introduce age specific heterogeneity of households into a model of research and development (R&D) based technological change. We show that the framework incorporates two standard specifications as special cases: endogenous growth models with scale eects and semi-endogenous growth models without scale effects. The introduction of an age structured population implies that aggregate laws of motion for capital and consumption have to be obtained by integrating over different cohorts. It is analytically shown that these laws of motion depend on the underlying demographic assumptions. Our results are that (i) increases in longevity have positive effects on per capita output growth, (ii) decreases in fertility have negative effects on per capita output growth, (iii) the longevity effect dominates the fertility eect in case of endogenous growth models and (iv) population aging fosters long-run growth in endogenous growth models, while the converse holds true in semiendogenous growth frameworks.
    Keywords: population aging, endogenous technological change, longrun economic growth
    Date: 2011–07
  14. By: Knoef, M.G. (Universiteit van Tilburg)
    Date: 2011
  15. By: Sang-Hyop LEE (Sang-Hyop LEE East West Center and University of Hawaii at Manoa, USA); Andrew MASON (Andrew MASON East West Center and University of Hawaii at Manoa, USA); Donghyun PARK (Donghyun PARK Economics and Research Department, Asian Development Bank, Philippines)
    Abstract: Asia as a whole is experiencing a rapid demographic transition toward older population structures. Within this broader region-wide trend, there is considerable heterogeneity, with different countries at different stages of the demographic transition. In this paper, we document Asia’s population aging, describe the region’s old-age support systems, and draw out the regional socioeconomic implications of population aging and old-age support systems. Population aging gives rise to two fundamental challenges for the region – (1) developing socioeconomic systems that can provide economic security to the growing number of elderly and (2) sustaining strong growth in the face of aging over the next few decades. Successfully addressing those two challenges will be vital for ensuring Asia’s continued economic success in the medium and long term.
    Date: 2011–08–01
  16. By: Thomas Poder (UETMIS - CHU de Sherbrooke, GREDI - Université de Sherbrooke); Jie He (University of Sherbrooke, GREDI)
    Abstract: With the propensity score matching method, we carried out an average benefit incidence analysis that helps disclose those who really benefited from the sanitary services in Guatemala. Specifically, we tested the role of income, maternal education and social capital on how sanitary infrastructures affect child health. Results indicated that the child health benefits from infrastructure increase (decrease) with the household’s socioeconomic status when the infrastructure is a complement (substitute) of the private inputs provided by the household, and that the role of the infrastructure (complement or substitute) itself depends on the household’s socioeconomic status. Finally, results revealed that the battle against child malnutrition and health inequalities could be improved by combining sanitary infrastructure investments with effective public promotion of maternal education, social trust, and poverty reduction.
    Keywords: Malnutrition, infrastructure, health inequality, Guatemala
    Date: 2011–08
  17. By: Mark Dusheiko (Centre for Health Economics, University of York, UK); Hugh Gravelle (Centre for Health Economics, University of York, UK); Stephen Martin (Department of Economics, University of York, UK); Nigel Rice (Centre for Health Economics, University of York, UK); Peter C Smith (Imperial College Buisiness School, UK)
    Abstract: We apply cross-sectional and panel data methods to a database of 5 million patients in 8,000 English general practices to examine whether better primary care management of 10 chronic diseases is associated with reduced hospital costs. We find that only primary care performance in stroke care is associated with lower hospital costs. Our results suggest that the 10% improvement in the general practice quality of stroke care between 2004/5 and 2007/8 reduced 2007/8 hospital expenditure by about £130 million in England. The cost savings are due mainly to reductions in emergency admissions and outpatient visits, rather than to lower costs for patients treated in hospital or to reductions in elective admissions.
    Keywords: Quality; disease management; primary care; hospital costs; ambulatory care sensitive conditions; preventative care.
    JEL: I12 I18
    Date: 2011–08
  18. By: Kundu, Amit; Mukherjee, Arghya Kusum
    Abstract: Swarna Jayanti Gram Swarojgar Yojona (SGSY), a government sponsored micro credit programme of India, has been designed to ameliorate income poverty among the rural poor, particularly women, through human capital development and strengthening female agency. In this backdrop the basic objectives of the paper are to see: (a) whether the programme has any impact on health of the programme participants across Socio Religious Communities (SRCs)(b) Whether the programme has any significant role in improving education across SRCs. (c) Whether SGSY programme has been able to enhance female agency irrespective of caste and community affiliation. The District of Murshidabad, West Bengal, has been chosen as the field of study. All the selected SHG members were two years old. The initial sampling was done in 2006 to know about the pre-SHG participation socio economic condition. The resurvey was conducted in 2008. The study shows that from 2004 to 2008, the programme has significant impact on female agency across all SRCs except Muslims, but the role of the programme in forming human capital is insignificant irrespective of SRCs. If household specific unobserved heterogeneity is removed, then significant impact of the programme on female agency becomes insignificant across all SRCs except UCs.
    Keywords: Microfinance ; SGSY Scheme of the Government of India; Unobserved heterogeneity; Fixed effects
    JEL: C23 I38 J16 G21
    Date: 2011–01–10
  19. By: Brekke, Kurt Richard; Levaggi, Rosella; Siciliani, Luigi; Straume, Odd Rune
    Abstract: Patient mobility is a key issue in the EU who recently passed a new law on patients' right to EU-wide provider choice. In this paper we use a Hotelling model with two regions that differ in technology to study the impact of patient mobility on health care quality, health care financing and welfare. A decentralised solution without patient mobility leads to too low (high) quality and too few (many) patients being treated in the high-skill (low-skill) region. A centralised solution with patient mobility implements the first best, but the low-skill region would not be willing to transfer authority as its welfare is lower than without mobility. In a decentralised solution, the effects of patient mobility depend on the transfer payment. If the payment is below marginal cost, mobility leads to a `race-to-the-bottom' in quality and lower welfare in both regions. If the payment is equal to marginal cost, quality and welfare remain unchanged in the high-skill region, but the low-skill region benefits. For a socially optimal payment, which is higher than marginal cost, quality levels in the two regions are closer to (but not at) the first best, but welfare is lower in the low-skill region. Thus, patient mobility can have adverse effects on quality provision and welfare unless an appropriate transfer payment scheme is implemented.
    Keywords: health care quality; patient mobility; regional and global welfare
    JEL: H51 H73 I11 I18
    Date: 2011–09
  20. By: Gregory J. Colman; Dhaval M. Dave
    Abstract: As economic recessions reduce employment and wages, associated shifts in time and income constraints would be expected to also impact individuals’ health behaviors. Prior work has focused exclusively on recreational exercise, which typically represents only about 4% of total daily physical exertion. The general presumption in these studies is that, because exercise improves health, if unemployment increases exercise it must also improve health. Yet a person may be laid off from a physically demanding job, exercise more, and still be less physically active than when employed. Thus the relevant question is whether unemployment leads persons to become more physically active. We study this question with the American Time Use Survey (2003-2010), exploring the impact of the business cycle (and specifically the Great Recession) on individuals’ exercise, other uses of time, and physical activity during the day. We also utilize more precise measures of exercise (and all other physical activities), which reflect information on the duration as well as intensity of each component activity, than has been employed in past studies. Using within-state variation in employment and unemployment, we find that recreational exercise tends to increase as employment decreases. In addition, we also find that individuals substitute into television watching, sleeping, childcare, and housework. However, this increase in exercise as well as other activities does not compensate for the decrease in work-related exertion due to job-loss. Thus total physical exertion, which prior studies have not analyzed, declines. These behavioral effects are strongest among low-educated males, which is validating given that the Great Recession led to some of the largest layoffs within the manufacturing, mining, and construction sectors. Due to the concentration of low-educated workers in boom-and-bust industries, the drop in total physical activity during recessions is especially problematic for vulnerable populations and may play a role in exacerbating the SES-health gradient during recessions. We also find some evidence of intra-household spillover effects, wherein individuals respond to shifts in spousal employment conditional on their own labor supply.
    JEL: D01 D1 I1 J1 J22
    Date: 2011–09
  21. By: Henry Saffer; Dhaval M. Dave; Michael Grossman
    Abstract: This study examines racial, ethnic and gender differentials in physical activity. Individuals engage in physical activity during leisure-time and also during in many other activities such as walking to work, home maintenance, shopping and child care. Physical activity also occurs on the job is this is referred to as work physical activity. Prior studies have shown that non-work physical activity has a positive impact on health while work physical activity has a negative impact on health. Many prior studies have relied primarily on leisure-time physical activity, which typically constitutes only about 10% of non-work physical activity and does not capture specific information on the intensity or duration of the activity. This study addresses these limitations by constructing measures of physical activity from the American Time Use Surveys, which are all-inclusive and capture the duration of each activity combined with its intensity based on the Metabolic Equivalent of Task (MET). Non-work physical activity tends to be significantly lower for Blacks, Hispanics, other racial groups than for Whites and lower for males than for females. These adjusted differentials are consistent with racial, ethnic and gender differentials in health. About 25-46% of the differentials in non-work physical activity can be attributed to differences in education, socio-economic status, proxies for time constraints, and locational attributes.
    JEL: I12
    Date: 2011–09
  22. By: Frank R. Lichtenberg
    Abstract: We investigate the effect of therapeutic procedure innovation in general on the longevity of all hospital patients, i.e. patients with a variety of medical conditions. The analysis is based on data on over one million discharges from public and private hospitals in Western Australia (WA) during the period 2000-2007. We can measure survival for a period as long as 8 years after admission, and we know the date each procedure was added to the Medicare Benefits Schedule. Estimates based on patient-level data indicate that therapeutic procedure innovation increased the life expectancy of WA hospital patients by almost 3 months between 2000 and 2007, controlling for the patient’s age, sex, Diagnosis Related Group (DRG, over 600 categories), Aboriginal status, marital status, insurance coverage (whether or not the patient had private insurance), postcode (over 400 postcodes), year of hospital admission, and number of procedures performed.. Estimates based on longitudinal DRG-level data also indicate that therapeutic procedure innovation increased the life expectancy of WA hospital patients, but the implied increase may be smaller—about 2 months. In either case, therapeutic procedure innovation in WA hospitals appears to have been remarkably cost-effective, because it increased the cost of medical procedures by a negligible amount.
    JEL: I12 J11 O33
    Date: 2011–09

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