nep-hea New Economics Papers
on Health Economics
Issue of 2014‒11‒01
sixteen papers chosen by
Yong Yin
SUNY at Buffalo

  1. A Bayesian Analysis of Sibling Correlations in Health By Timothy Halliday; Bhashkar Mazumder
  2. A comprehensive review of empirical and modeled HIV incidence trends (1990-2012) By Taaffe, Jessica; Fraser-Hurt, Nicole; Gorgens, Marelize; Harimurti, Pandu
  3. A Population Level Study of the Effects of Early Intervention for Autism By Janet Currie; David Figlio; Joshua Goodman; Claudia Persico
  4. An Empirical Model of Health Care Demand under Non-linear Pricing By Rainer Winkelmann
  5. Analyzing Disparities Trends for Health Care Insurance Coverage Among Non-Elderly Adults in the US: Evidence from the Behavioral Risk Factor Surveillance System, 1993-2009 By Shireen Assaf; Stefano Campostrini; Cinzia Di Novi; Fang Xu; Carol Gotway Crawford Author-X-Name- Carol
  6. Contracting for Primary Health Care in Brazil: The Cases of Bahia and Rio de Janeiro By Edson Araujo; Luciana Cavalini; Sabado Girardi; Megan Ireland; Magnus Lindelow
  7. Disabled children's cognitive development in the early years By Samantha Parsons; Lucinda Platt
  8. Dropping out of Ethiopia’s Community Based Health Insurance scheme By Mebratie, A.D.; Sparrow, R.A.; Debebe, Z.Y.; Alemu, G.; Bedi, A.S.
  9. Foreign nurse importation to the United States and the supply of native registered nurses By Cortes, Patricia; Pan, Jessica
  10. Medical Insurance and Free Choice of Physician Shape Patient Overtreatment. A Laboratory Experiment By Steffen Huck; Gabriele Lünser; Florian Spitzer; Jean-Robert Tyran
  11. Medical Manpower Planning in Australia: Taking stock for the eighties Creation Date: 1983 By P.T. Ganderton
  12. Sickness Absence and Works Councils: Evidence from German Individual and Linked Employer-Employee Data By Daniel Arnold; Tobias Brändle; Laszlo Goerke
  13. The Health Costs of Ethnic Distance: Evidence from Sub-Saharan Africa By Gomes, Joseph
  14. The impact of Ethiopia’s pilot community based health insurance scheme on healthcare utilization and cost of care By Mebratie, A.D.; Sparrow, R.A.; Debebe, Z.Y.; Abebaw Ejigie, D.; Alemu, G.; Bedi, A.S.
  15. The Political Sustainability of a Basic Income Scheme and Social Health Insurance By Kifmann, Mathias; Roeder, Kerstin
  16. Tobacco Control in California, 2007-2014: A Resurgent Tobacco Industry While Inflation Erodes the California Tobacco Control Program   By Cox, Elizabeth; Barry, Rachel; Glantz, Stanton A.; Barnes, Richard L.

  1. By: Timothy Halliday (University of Hawaii at Manoa and UH Economic Research Organization); Bhashkar Mazumder (Federal Reserve Bank of Chicago)
    Abstract: We estimate sibling correlations in health status using the Panel Study of Income Dynamics. We use Bayesian methods to estimate the covariance structure of a system of latent variable equations. Across a battery of outcomes, we estimate that between 50% and 60% of health status can be attributed to familial or neighborhood characteristics. Taking the principal component across all outcomes, we obtain a slightly lower sibling correlation of about 45%. These estimates, which are larger than previous estimates of sibling correlations in health that rely on linear models, are more in-line with sibling correlations in income and suggest that health status, like other measures of socioeconomic success, is strongly influenced by family background. Therefore, efforts to improve the circumstances of families and communities may potentially lead to improved childhood health today and also reduce future health disparities.
    Keywords: Sibling correlations, Intergenerational mobility, Health
    JEL: I0 I12 J0 D3 J62
    Date: 2014–10
  2. By: Taaffe, Jessica; Fraser-Hurt, Nicole; Gorgens, Marelize; Harimurti, Pandu
    Abstract: An accurate measurement of HIV incidence is a key for policy makers and HIV program managers directing national HIV response. However, there is no perfect method to measure or estimate the rate at which new HIV infections occur in a population. This review compiles and triangulates longitudinal HIV incidence and prevalence data from published studies and trials, national reports and surveys, and the Joint United Nations Programme on HIV/AIDS estimates from the Spectrum model, focusing on 20 countries in Sub-Saharan Africa with generalized HIV epidemics. Three main points can be taken from this analysis of HIV incidence trends. First, modeled HIV incidence and nationally reported HIV prevalence levels in young females suggest that national HIV incidence has declined since 2000 in all except three countries analyzed (stable estimated HIV trends in Burkina Faso, Burundi, and Uganda), but trial and survey data suggest that in some demographics, HIV incidence remains critically high. Second, all modeled national HIV incidence curves and most empirically observed trends commenced a downward trajectory prior to the introduction of anti-retroviral therapy programs around 2004, suggesting the contribution of other factors, such as HIV prevention programs and natural epidemic dynamics, to this decline. Third, modeled HIV incidence estimates, including the incidence peaks in the past, exhibit much variation between Spectrum model versions and when new data are added, emphasizing the uncertainty of model outputs and the need to use incidence estimates with caution.
    Keywords: Disease Control&Prevention,Population Policies,HIV AIDS,HIV AIDS and Business,Gender and Health
    Date: 2014–09–01
  3. By: Janet Currie; David Figlio; Joshua Goodman; Claudia Persico
    Abstract: Billions of dollars are spent each year on early diagnosis and intervention programs for autism. However, there is little reliable evidence about the effectiveness of these programs. Few studies that evaluate early interventions for autism use random assignment or quasi-experimental designs, and studies of the effects of early intervention programs have relied on small, selected samples that lacked power to detect even moderate associations. A recent meta-analysis by Spreckley and Boyd (2009) on the efficacy of applied behavior intervention in preschool children with autism found that compared with standard care, applied behavior interventions did not significantly improve the cognitive outcomes of the children in these programs. Using population-level data of all children with autism spectrum disorders who were born in the state of Florida between 1994-2002, we evaluate the effects of a free, statewide early diagnosis and intervention program for autism called Early Steps. Families can receive autism diagnoses from one of 18 Early Steps centers located around the state; we make use of distance to the nearest Early Steps center as an instrument for receipt of autism services prior to a child’s fourth birthday. The first stage is very strong: Children living in the same community as an Early Steps center at the time of birth are nearly twice as likely to receive early services as those In communities more than 30 miles away from a center. We use instrumental variables methods to determine whether early diagnosis and intervention impacts (1) short term outcomes, such as kindergarten readiness scores and attending kindergarten on time, (2) grade repetition, (3) significant behavioral problems, and (4) longer term cognitive outcomes, including elementary school test scores. Preliminary results show strong, significant effects of early intervention for autism by age four on attending kindergarten on time, and on third and fourth grade FCAT (Florida’s Comprehensive Assessment Test)�scores. In addition, children who have had early intervention for autism by age four via Early Steps are significantly less likely to have a behavioral incident at school or to be suspended, and have fewer days of suspension than children with later diagnoses of autism. This study is the first population-level study of the effects of early intervention on autism. In addition, this is the first evaluation of a statewide free early diagnosis and intervention program for autism.� Finally, this is the first study to examine the effects of early intervention for autism on school-based cognitive and behavioral outcomes. Thus, this study will hopefully lend insight into how policies that provide free treatment for autistic individuals can lead to a variety of positive developmental outcomes for these children.
    Date: 2014–06
  4. By: Rainer Winkelmann
    Abstract: In 2004, the German Social Health Insurance introduced a co-payment for the first doctor visit in a calendar quarter. I combine a structural model of health care demand and a difference-in-differences strategy to estimate the effect of that reform on the number of visits. In the model, the implied incentive to delay a first visit also affects subsequent visits, as the expected remaining time to the end of quarter is reduced. This effect has been ignored by the prior literature using standard hurdle count models. Data are from the German Socio-Economic Panel. Results show no statistically significant reduction in visits due to the reform.
    Keywords: Count data, Poisson process, co-payment, hurdle model
    JEL: C25 I10
    Date: 2014
  5. By: Shireen Assaf (Department of Statistical Sciences, University Of Padua); Stefano Campostrini (Department of Economics, University Of Venice Cà Foscari); Cinzia Di Novi (Department of Economics, University Of Venice Cà Foscari); Fang Xu (Northrop Grumman Information Systems); Carol Gotway Crawford Author-X-Name- Carol (Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University)
    Abstract: Access to health care in the United States remains greatly disproportionate across socioeconomic groups. It is not known, however, whether the disparities between the socioeconomic categories are increasing or decreasing. This analysis used a well-established non-parametric technique, employing time-varying coefficient models applied to data from the 1993 to 2009 US Behavioral Risk Factor Surveillance System (BRFSS). The analysis was able to show the changes in the odds ratios of having no health insurance plan for variables of interest over time, therefore highlighting the changes in the disparities between the categories of a variable over time. While other studies have attempted to show the changes in health insurance coverage by socioeconomic groups in different time periods, there is no study to date that has shown these changes as a smooth function with time, therefore providing a clearer picture of the changes in these disparities. The results of this analysis show, for instance, that when compared with individuals with a college education or greater, those with less than a high school education showed a steady increase in the odds ratios for having no health insurance. The same trend seems applicable although in a less-clear way to Hispanics and Non-Hispanic black race-ethnicities, compared with non-Hispanic whites (the reference race category). As measures of the Affordable Care Act are being gradually implemented, studies are needed to provide baseline information about health care access disparity, in order to gauge any changes in health care access over time; BRFSS can be a useful data source in accomplishing this task.
    Keywords: USA, big data, disparities, health plan, health surveillance data, P-splines, temporal trends, varying coefficient model.
    JEL: I14
  6. By: Edson Araujo; Luciana Cavalini; Sabado Girardi; Megan Ireland; Magnus Lindelow
    Abstract: This study presents two case studies, each on a current initiative of contracting for primary health services in Brazil, one for the state of Bahia, the other for the city of Rio de Janeiro. The two initiatives are not linked and their implementation has independently sprung from a search for more effective ways of delivering public primary health care. The two models differ considerably in context, needs, modalities, and outcomes. This paper identifies their strengths and weaknesses, initially by providing a background to universal primary health care in Brazil, paying particular attention to the family health strategy, the driver of the basic health care model. It then outlines the history of contracting for health care within Brazil, before analyzing the two studies. The state of Bahia sought to expand coverage of the family health strategy and increase the quality of services, but had difficulty in attracting and retaining qualified health professionals. Rigidities in the process of public hiring led to a number of isolated contracting initiatives at the municipal level and diverse, often unstable employment contracts. The state and municipalities decided to centralize the hiring of health professionals in order to offer stable positions with career plans and mobility within the state, and chose to create a state foundation, acting under private law to manage and oversee this process. Results have been mixed as lower than expected municipal involvement resulted in relatively high administrative costs and consequent default on municipal financial contributions. The state foundation is undergoing a governance reform and has now diversified beyond hiring for primary care. The municipality of Rio de Janeiro, which until recently relied on an expansive hospital network for health care delivery, sought in particular to expand primary health services. The public health networks suffered from inefficiency and poor quality, and it was therefore decided to contract privately owned and managed, not-for-profit, social organizations to provide primary care services. The move has succeeded in attracting considerable increases in funding for primary health and coverage has increased significantly. Performance initiatives, however, still need fine-tuning and reliable information systems must be implanted in order to evaluate the system.
    Keywords: administrative costs, administrative rules, aged, ambulatory services, antenatal care, basic health care, birth control, block grants, Bulletin, Care Performance, chronic ... See More + disease, cities, civil society organizations, Clinics, community health, complications, contractual arrangements, deaths, decentralization, delivery of health services, developing countries, diabetes, diseases, drugs, economic inequality, Economic Policy, Economics, economies of scale, emergency care, emergency rooms, employment, equipment, essential medicines, families, Family Health, financial contributions, financial incentives, financial resources, Government capacity, Health Affairs, health care delivery, health care facilities, health care needs, health care provision, health care workers, Health Clinics, Health Coverage, health education, health facilities, health indicators, Health Inequalities, Health Information, Health Information System, Health Information Systems, health infrastructure, Health Organization, health planning, Health Policy, health professionals, health professions, health promotion, health providers, health risks, HEALTH SECTOR, health service, health service delivery, health services, health spending, Health Strategy, Health System, health system performance, Health System Reform, health systems, health workers, Healthy Life, home care, hospital, hospital management, hospital sector, hospital services, hospital system, hospitals, human resource management, human resources, human right, hypertension, illness, income, income countries, income inequality, infant, infant mortality, information asymmetry, integration, international organizations, IUD, labor market, laboratories, large populations, laws, leprosy, Life expectancy, Life expectancy at birth, live births, local governments, low birth weight, management of health, management of patients, maternal mortality, maternal mortality ratio, medical care, medical doctors, medical education, medical procedures, medical residents, Medical School, medical staff, medicines, Millennium Development Goal, Ministry of Health, morbidity, mortality, national level, nongovernmental organizations, nurse, nurses, Nutrition, oral health, outreach activities, patient, patients, Physician, pocket payments, policy decisions, policy makers, political decision, poor quality care, population density, pregnancy, pregnant women, prenatal care, primary care, PRIMARY HEALTH CARE, primary health care facilities, primary health care services, primary health facilities, primary health services, primary health system, private sector, progress, provision of care, provision of health services, public administration, public contract, public health, public health system, public policy, PUBLIC SECTOR, public services, quality improvement, quality of care, quality of services, respect, school health, Secretary of Health, service providers, service provision, social action, social participation, social security, social security benefits, social services, socioeconomic development, state policy, State University, strategic priorities, Sustainable Development, tuberculosis, universal access, universities, urban areas, vaccination, woman, workers, workforce, World Health Organization
    Date: 2014–09
  7. By: Samantha Parsons (Department of Quantitative Social Science, Institute of Education); Lucinda Platt (Department of Social Policy, London School of Economics and Political Science)
    Abstract: Disabled children are known to fare worse in terms of educational attainment during their school years, with subsequent consequences for their later transitions and adult outcomes. But despite the acknowledged importance of the early years in children's later outcomes, we know relatively little about when disabled children's educational problems emerge or how they develop in young childhood. In this paper, we use a nationally representative longitudinal survey of UK children to address the following questions: do disabled children in England have lower cognitive skills prior to school entry? How do educational attainment and cognitive skills develop over the early school years relative to their non-disabled peer group? What role do background and environmental factors play in accounting for patterns of disabled children's progress? Using multiple measures of educational and cognitive attainment, and controlling for a number of key child, family and environmental factors, we investigate educational progress across two measures of disability. We find that disabled children have poorer cognitive skills at age 3, and that this is not accounted for by differences in home context. We also find that they make less progress over the early years than their non-disabled peers with similar levels of cognitive skills. Our findings are robust to a series of alternative specifications. Implications are discussed.
    Keywords: Disability, children, educational progress, Millennium Cohort Study, Special Educational Needs, Longstanding Limiting Illness, school, Key Stage 1, England
    JEL: I21 I24 J13 J14
    Date: 2014–10–07
  8. By: Mebratie, A.D.; Sparrow, R.A.; Debebe, Z.Y.; Alemu, G.; Bedi, A.S.
    Abstract: Low contract renewal rates have been identified as one of the challenges facing the development of community based health insurance schemes (CBHI). This paper uses longitudinal household survey data to examine dropout in the case of Ethiopia’s pilot CBHI scheme, which saw enrolment increases from 41 percent one year after inception to 48 percent a year later. An impressive 82 percent of those who enrolled in the first year renew their subscriptions, while 25 percent who had not enrolled join the scheme. The analysis shows that socio-economic status, a greater understanding of health insurance, and experience with and knowledge of the CBHI scheme reduce dropout. While there are concerns about the quality of care and the treatment meted out to the insured by providers, the overall picture is that returns from the scheme are overwhelmingly positive. For the bulk of households, premiums do not seem to be onerous, basic understanding of health insurance is high and almost all those who are currently enrolled signal their desire to renew contracts.
    Date: 2014–09–29
  9. By: Cortes, Patricia (Boston University); Pan, Jessica (National University of Singapore)
    Abstract: Importing foreign nurses has been used as a strategy to ease nursing shortages in the United States. The effectiveness of this policy critically depends on the long-run response of native-born nurses. We examine how the immigration of foreign-born registered nurses (RNs) affects the occupational choice and long-run employment decisions of native RNs. Using a variety of empirical strategies that exploit the geographical distribution of immigrant nurses across U.S. cities, we find evidence of large displacement effects—over a 10-year period, for every foreign nurse that migrates to a city, between one and two fewer native nurses are employed in that city. We find similar results at the state level using data on individuals taking the nursing board exam—an increase in the flow of foreign nurses significantly reduces the number of natives sitting for licensure exams in the states that are more dependent on foreign-born nurses compared to those states that are less dependent on foreign nurses. Using data on self-reported workplace satisfaction among a sample of California nurses, we find evidence suggesting that some of the displacement effects could be driven by a decline in the perceived quality of the workplace environment.
    JEL: J44 J61
    Date: 2014–07–31
  10. By: Steffen Huck (Wissenschaftszentrum Berlin für Sozialforschung (WZB)); Gabriele Lünser (University College London - Centre for Economic Learning and Social Evolution (ELSE)); Florian Spitzer (Department of Economics, Vienna Center for Experimental Economics (VCEE), University of Vienna); Jean-Robert Tyran (Department of Economics, Copenhagen University)
    Abstract: In a laboratory experiment designed to capture key aspects of the interaction between physicians and patients in a stylized way, we study the effects of medical insurance and competition in the guise of free choice of physician. Medical treatment is an example of a credence good: only the physician (but not the patient) knows the appropriate treatment, and even after consulting, the patient is not sure whether he got proper treatment or got an unnecessary treatment, i.e. was overtreated. We find that with insurance, moral hazard looms on both sides of the market: patients consult more often and physicians overtreat more often than in the baseline condition. Competition decreases overtreatment compared to the baseline and patients therefore consult more often. When the two institutions are combined, competition is found to partially offset the adverse effects of insurance: most patients seek treatment, but overtreatment is moderated.
    Keywords: Credence good, Patient, Physician, Overtreatment, Competition, Insurance, Moral hazard
    JEL: C91 I11 I13
    Date: 2014–09–30
  11. By: P.T. Ganderton
  12. By: Daniel Arnold; Tobias Brändle; Laszlo Goerke
    Abstract: Using both household and linked employer-employee data for Germany, we assess the effects of non-union representation in the form of works councils on (1) individual sickness absence rates and (2) a subjective measure of personnel problems due to sickness absence as perceived by a firm's management. We find that the existence of a works council is positively correlated with the incidence and the annual duration of absence. We observe a more pronounced correlation in western Germany which can also be interpreted causally. Further, personnel problems due to absence are more likely to occur in plants with a works council.
    Keywords: Absenteeism, LIAB, personnel problems, sickness absence, SOEP, works councils
    JEL: J53 I18 M54
    Date: 2014
  13. By: Gomes, Joseph
    Abstract: We show that ethnic distances can explain the ethnic inequalities in child mortality rates in Africa. Using individual level micro data from DHS surveys for fourteen Sub-Saharan African countries combined with a novel high resolution dataset on the spatial distribution of ethnic groups we show that children whose mothers have a higher linguistic distance from their neighbours have a higher probability of dying. Fractionalization reduces the probability of child death. We argue that fractionalization re ects a higher stock of knowledge and information leading to better health outcomes. Knowledge does not ow smoothly to linguistically distant groups. Linguistically distant mothers also have a lower probability of knowing about the oral rehydration product (ORS) for treating children with diarrhoea.
    Date: 2014–10–17
  14. By: Mebratie, A.D.; Sparrow, R.A.; Debebe, Z.Y.; Abebaw Ejigie, D.; Alemu, G.; Bedi, A.S.
    Abstract: In recent years there has been a proliferation of Community Based Health Insurance (CBHI) schemes designed to enhance access to modern health care services and provide financial protection to workers in the informal and rural sectors. In June 2011, the Government of Ethiopia introduced a pilot CBHI scheme in rural parts of the country. This paper assesses the impact of the scheme on utilization of modern health care and the cost of accessing health care. It adds to the relatively small body of work that provides a rigorous evaluation of CBHI schemes. We find that enrolment leads to a 30 to 41 percent increase in utilization of outpatient care at public facilities, a 45 to 64 percent increase in the frequency of visits to public facilities and at least a 56 percent decline in the cost per visit to public facilities. The effects of the scheme on out-of-pocket spending are not as clear. The impact on utilization and costs combined with a high uptake rate of almost 50 percent within two years of scheme establishment, suggests that this scheme has the potential to meet the goal of universal access to health care.
    Keywords: community based health insurance, outpatient healthcare utilization, out-of-pocket expenditure, Ethiopia
    Date: 2014–10–16
  15. By: Kifmann, Mathias; Roeder, Kerstin
    Abstract: This paper studies how society votes on the payroll taxes of a basic income and a social health insurance scheme. Individuals differ along the two most important dimensions when it comes to the design of the two welfare schemes, namely, income and risk. Even though the introduction of a basic income scheme opens up the possibility for additional redistribution, it also crowds out social health insurance. We show that when both welfare schemes are open for debate, the political equilibrium is such that only the basic income scheme prevails. At the constitutional stage we determine which welfare scheme society agrees to implement behind the veil of ignorance and with a Rawlsian objective. Since social health insurance not only redistributes income from rich to poor but also from low-risk to high-risk agents, the doubly disadvantaged in society – low-income and high-risk agents – may lose out in the political process when a basic income scheme is in place. Depending on the amount of health care expenditure and the inequalities in income and risk, it may well be that a society will find it optimal to set up an institutional framework for a social health insurance scheme only.
    Keywords: Basic Income; Social Health Insurance; Income Taxation; Political Support
    JEL: D6 D7 H1 H2 H5
    Date: 2014–09–06
  16. By: Cox, Elizabeth; Barry, Rachel; Glantz, Stanton A.; Barnes, Richard L.
    Keywords: Medicine and Health Sciences
    Date: 2014–10–23

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