nep-hea New Economics Papers
on Health Economics
Issue of 2017‒01‒01
twenty papers chosen by
Yong Yin
SUNY at Buffalo

  1. Does universalization of health work? Evidence from health systems restructuring and maternal and child health in Brazil By Bhalotra, Sonia; Rocha, Rudi; Soares, Rodigo R.
  2. Concordance of health states in couples. Analysis of self-reported, nurse administered and blood-based biomarker data in Understanding Society By Davillas, Apostolos; Pudney, Stephen
  3. The impact of food price shocks on weight loss: Evidence from the adult population of Tanzania By García-Germán, Sol; Romeo, Alessandro; Magrini, Emiliano; Balié, Jean
  4. Promoting Physical Activity among Low-Income Children in Colorado: Family Perspectives on Barriers and Opportunities By Daniel Finkelstein; Dana Petersen; Lisa Schottenfeld; Lauren Hula; Molly McGlone
  5. Bombs and Babies: US Navy Bombing Activity and Infant Health in Vieques, Puerto Rico By Gustavo J. Bobonis; Mark Stabile; Leonardo Tovar
  6. Can eating five fruit and veg a day really keep the doctor away? By Chitwan Lalji; Debayan Pakrashi; Russell Smyth
  7. Language, Health Outcomes and Health Inequality By Haining Wang; Zhiming Cheng; Russell Smyth
  8. Do Shocks Experienced in the Mother’s Uterus have Adverse Effects on Child Health, and Can Welfare Schemes Ameliorate such Effects?-Evidence from Andhra Pradesh, India By Salma Ahmed; Ranjan Ray
  9. How Does Technological Change Affect Quality-Adjusted Prices in Health Care? Systematic Evidence from Thousands of Innovations By Kristopher J. Hult; Sonia Jaffe; Tomas J. Philipson
  10. The Migrant Health Gap and the Role of Labour Market Status: Evidence from Switzerland By Sara Rellstab; Marco Pecoraro; Alberto Holly; Philippe Wanner; Karine Renard
  11. Learning For Life? The Effects of Schooling on Earnings and Health- Related Behavior Over the Life Cycle By Lång, Elisabeth; Nystedt, Paul
  12. A nonparametric analysis of the healthy immigrant effect By Antonio Fidalgo; Alberto Holly; Marco Pecoraro; Philippe Wanner
  13. How are health and life satisfaction related to education? By OECD
  14. The Effect of Mandatory Paid Sick Leave Laws on Labor Market Outcomes, Health Care Utilization, and Health Behaviors By Kevin Callison; Michael F. Pesko
  15. Effect of Particulate Air Pollution on Coronary Heart Disease in China: Evidence from Threshold GAM and Bayesian Hierarchical Model By Xiaoyu Chen;
  16. A Quantile Regression Approach to Panel Data Analysis of Health Care Expenditure in OECD Countries By Fengping Tian; Jiti Gao; Ke Yang
  17. Should there be a more active role of family care assistants in long-term care provision? – survey evidence on the view of German citizens By Ivo Bischoff; Nataliya Kusa
  18. Health Reform and Health Insurance Coverage of Early Retirees By Helen Levy; Thomas Buchmueller; Sayeh Nikpay
  19. New evidence about effects of reproductive variables on child mortality in sub-Saharan Africa By Kravdal, Øystein
  20. Effects of Increased Competition on Quality of Primary Care in Sweden By Dietrichson, Jens; Ellegård, Lina Maria; Kjellsson, Gustav

  1. By: Bhalotra, Sonia; Rocha, Rudi; Soares, Rodigo R.
    Abstract: We investigate restructuring of the health system in Brazil motivated to operationalize universal health coverage. Using administrative data from multiple sources and an event study approach that exploits the staggered rollout of programmatic changes across municipalities, we find large reductions in maternal, foetal, neonatal and postneonatal mortality, and fertility. We document increased prenatal care visits, hospital births and other maternal and child hospitalization, which suggest that the survival gains were supply-driven. We find no improvement in the quality of births, which may be explained by endogenous shifts in the composition of births towards higher-risk births.
    Date: 2016–12–12
  2. By: Davillas, Apostolos; Pudney, Stephen
    Abstract: We use a range of self-reported health measures, nurse-administered health measures and blood-based biomarkers to examine the concordance between the health states of partners in marital/cohabiting relationships. A lifecourse model of cumulative health exposures is used to interpret the empirical pattern of between-partner health correlation in relation to the elapsed duration of the relationship. This allows us to distinguish non-causal homogamy correlation arising from assortative mating, from potentially causal effects of shared lifestyle factors. We find important differences between the results for different health indicators, with strongest homogamy correlations observed for adiposity, associated biomarkers like blood pressure, heart rate, blood sugar and cholesterol, and also self-assessed general health. We find no evidence of a “dose-response relationship†for marriage duration, and show theoretically that this implies – perhaps counterintuitively – that shared lifestyle factors and homogamous partner selection make roughly equal contributions to the concordance we observe in most of the health measures we examine
    Date: 2016–12–12
  3. By: García-Germán, Sol; Romeo, Alessandro; Magrini, Emiliano; Balié, Jean
    Abstract: Undernourishment is still widespread in Tanzania, while obesity is becoming an issue of magnitude similar to undernutrition in the country. In this paper we examined the impact of an increase in maize prices on the nutritional status of Tanzania's adult population. We found that undernutrition increases as a result of increased prices, while the overweight and obese decrease their energy intake. The study presents evidences of the so called early stage of the nutritional transition that characterize developing countries. All in all, these findings are suggestive of the fact that food price shocks should be taken into consideration when designing policy and programmes aiming at addressing malnutrition in low income countries.
    Keywords: food price shocks,food demand models,malnutrition,Tanzania
    JEL: C31 D12 D13 I31 Q18
    Date: 2016
  4. By: Daniel Finkelstein; Dana Petersen; Lisa Schottenfeld; Lauren Hula; Molly McGlone
    Abstract: In this study of low-income families throughout Colorado, we learned that the majority of children are participating in some organized physical activities, and that most parents understand and value the benefits of regular physical activity for their children’s health and well-being. Parents identified a wide range of challenges that prevent their child from being physically active—such as the cost and availability of activities, difficulty scheduling activities or free play within work and family commitments, and concern for their children’s safety. Despite these challenges, many parents continue to try hard to identify opportunities for physical activity and had a wide range of recommendations for how communities could support their efforts.
    Keywords: youth, physical activity, health promotion
    JEL: I I0 I1
  5. By: Gustavo J. Bobonis; Mark Stabile; Leonardo Tovar
    Abstract: We study the relationship between in utero exposure to military exercises and children’s early-life health outcomes in a no-war zone. This allows us to document non-economic impacts of military activity on neonatal health outcomes. We combine monthly data on tonnage of ordnance in the context of naval exercises in Vieques, Puerto Rico, with the universe of births in Puerto Rico between 1990 and 2000; studying this setting is useful because these exercises have no negative consequences for local economic activity. We find that a one standard deviation increase in exposure to bombing activity leads to a three per thousand point (70 percent) increase in extremely premature births; a three to seven per thousand point – 34 to 77 percent – increase in the incidence of congenital anomalies; and a five per thousand point increase in low APGAR scores (38 percent). The evidence is generally consistent with the channel of environmental pollution. Given the well-documented relationship between neonatal health and later life outcomes, there is reason to believe that our substantial short-term effects may have longer-term consequences for this population.
    JEL: I1 O0
    Date: 2016–12
  6. By: Chitwan Lalji; Debayan Pakrashi; Russell Smyth
    Abstract: The ‘5-a-day’ fruit and vegetable campaign launched by the U.K government in 2003 laid emphasis on diet as an important determinant of population health. However, as of 2013, only 28% of women and 25% of men in Britain actually satisfied the recommended dietary intake of five portions of fruit and vegetables daily. Using data from the annual Health Survey for England, this paper estimates the association between daily intake of fruit and vegetables and various objective and subjective measures of health. We find that individuals who consume more portions of fruit daily report better overall health and have lower levels of cholesterol and blood pressure, compared to those who do not, while higher daily vegetable intake is associated with reduced risk of developing high blood pressure. Between fruit and vegetables, we find that consumption of fruit generally has stronger positive health outcomes. Our estimates, however, vary by gender, age and weight of the individual and exhibit considerable heterogeneity across different types of fruit and vegetables. We draw implications for diet promotional campaigns based on our results.
    Keywords: self-assessed health; mental health; blood pressure; cholesterol; diet.
    JEL: H51 I12 I18
    Date: 2016–11
  7. By: Haining Wang; Zhiming Cheng; Russell Smyth
    Abstract: We examine the health returns to proficiency in Mandarin in urban China using longitudinal data from the China Family Panel Studies. We find that greater proficiency in Mandarin improves self-reported health, mental health and capacity to perform activities of daily living. While we find that Mandarin proficiency increases incidence of chronic disease, Mandarin proficiency lagged two years is associated with reduced incidence of chronic disease. We also examine the relationship between Mandarin proficiency and health inequality and find that differences in Mandarin proficiency contribute to inequalities in health outcomes at the community level, district level and within a gender-age-education defined reference group. The decomposition results show that differences in Mandarin proficiency account for between 12 per cent and 28 per cent of health inequality, depending on the health indicator. Our results suggest that promoting ‘standard Mandarin’ can serve as a vehicle to improve health outcomes and reduce health inequality.
    Keywords: China; Mandarin proficiency; health outcomes; health inequalities; human capital
    JEL: I12 I14 I24 I26
    Date: 2016–11
  8. By: Salma Ahmed; Ranjan Ray
    Abstract: Indian children are among the most malnourished children in the world. The situation becomes desperate if the child suffers shocks in the mother’s uterus. This study on the YLS data from the Indian state of Andhra Pradesh provides evidence that uterus shocks experienced by the child have an adverse effect on her health. This study exploits an unique feature of the data set that allows distinction between different types of uterus shocks and reports that the adverse effect is the strongest in case of crop failure. Another distinguishing feature of this study is the comparison between the role of the Midday Meal Scheme (MDMS) and the National Rural Employment Guarantee Scheme (NREGS) in mitigating the adverse effect of uterus shocks. MDMS and NREGS were introduced around the same time, 2006. The study was conducted on panel data of children who were aged 6-18 months in 2002, 4-5 ½ years in 2007 and 7-8 ½ years in 2009. While the effectiveness of MDMS in mitigating the adverse effects on child health weakened between 2007 and 2009, the reverse was the case for NREGS. Though not explicitly designed to protect and promote child health, unlike MDMS, NREGS was in 2009 playing a role that was more effective than MDMS in acting as a buffer against uterus shocks to the child. In contrast, MDMS was more gender sensitive than NREGS in protecting the girl child’s heath in case of uterus shocks. The study points to the need for both schemes and for greater coordination between the two in delivery and coverage, especially in rural areas that have experienced crop failures. At a time when the NREGS is being curtailed, the fact that it has been playing a role that it was originally not designed to do is a result of much significance.
    Keywords: Child health; uterus shock; midday meals; NREGS; India
    Date: 2016–11
  9. By: Kristopher J. Hult; Sonia Jaffe; Tomas J. Philipson
    Abstract: Medical innovations have improved survival and treatment for many diseases but have simultaneously raised spending on health care. Many health economists believe that technological change is the major factor driving the growth of the heath care sector. Whether quality has increased as much as spending is a central question for both positive and normative analysis of this sector. This is a question of the impact of new innovations on quality-adjusted prices in health care. We perform a systematic analysis of the impact of technological change on quality-adjusted prices, with over six thousand comparisons of innovations to incumbent technologies. For each innovation in our dataset, we observe its price and quality, as well as the price and quality of an incumbent technology treating the same disease. Our main finding is that an innovation’s quality-adjusted prices is higher than the incumbent’s for about two-thirds (68%) of innovations. Despite this finding, we argue that quality-adjusted prices may fall or rise over time depending on how fast prices decline for a given treatment over time. We calibrate that price declines of 4% between the time when a treatment is a new innovation and the time when it has become the incumbent would be sufficient to offset the observed price difference between innovators and incumbents for a majority of indications. Using standard duopoly models of price competition for differentiated products, we analyze and assess empirically the conditions under which quality-adjusted prices will be higher for innovators than incumbents. We conclude by discussing the conditions particular to the health care industry that may result in less rapid declines, or even increases, in quality-adjusted prices over time.
    JEL: I1 O3
    Date: 2016–12
  10. By: Sara Rellstab (TI, Erasmus University Rotterdam); Marco Pecoraro (SFM, University of Neuchatel); Alberto Holly (IEMS, University of Lausanne); Philippe Wanner (I-Demo, University of Geneva); Karine Renard (SFM, University of Neuchatel)
    Abstract: With more than a fifth of the population being foreign citizens, Switzerland offers an ideal case to study the migrant health gap and the role of labour market status on the migrants' health. This paper examines the potential health gaps between Swiss nationals and different migrant groups (from the permanent foreign resident population), and how alternative types of labour market status affect health among each selected groups. Using a sample of working-age males from the Swiss Labour Force Survey for the years 2003-2009, we estimate a model with a dichotomic dependent variable and test the potential endogeneity of labour market status. Our empirical strategy avoids inconsistencies incurred by unobserved heterogeneity and simultaneity of the choice of labour market status. We observe a health gap in terms of chronic illness between Swiss nationals and all considered migrant groups. Compared to the Swiss, nationals from former Yugoslavia and Turkey have a worse health status whereas Germans have a lower prevalence of chronic illness. Our findings show a negative influence of part-time work, unemployment, and inactivity on health for all groups under study. Labour market status and standard individual characteristics (human capital, demographic attributes, etc.) explain the health disadvantage for migrants from Italy and Portugal/Spain entirely, whereas it does not for migrants from Turkey and former Yugoslavia. We provide insights on the unconditional health gap between migrants and Swiss nationals and estimate the causal effect of labour market status on chronic illness for different groups of the permanent resident population in Switzerland. The results show a negative correlation between non-employment (i.e. unemployment and inactivity) and health but this effect is reduced when taking into account the endogeneity of this variable. The same conclusion applies when labour market status is subdivided into three types: part-time work, unemployment, and inactivity.
    Keywords: Migration, Health, Labour Market, Latent Variable Models, Simultaneous Equation, Panel Data Analysis
    Date: 2016–12
  11. By: Lång, Elisabeth (Division of Economics, Department of Management and Engineering, Linköping University); Nystedt, Paul (Jönköping University)
    Abstract: We analyze how education is associated with earnings and health-related behaviors (HRBs) over the adult life cycle using a sample of 18,000 twins. The underlying motive is to improve the understanding of to what extent schooling may contribute to increased human welfare over time and age through the intermediaries of earnings and HRBs. We find that one additional year of schooling is associated with around 5-6 percent higher earnings at ages 35-75 and generally improved HRBs for both men and women. Much of the estimated relationships between schooling, earnings and HRBs can be traced back to genetic inheritance. Controlling for such inheritance, the remaining education-earnings premium is non-linear and increasing with educational level, and the education premium in HRBs is mainly concentrated to smoking habits.
    Keywords: Schooling; Education; Health-Related Behavior; Life-Cycle
    JEL: J01
    Date: 2016–12–15
  12. By: Antonio Fidalgo (SFM, University of Neuchatel and I-Demo, University of Geneva); Alberto Holly (IEMS, University of Lausanne); Marco Pecoraro (SFM, University of Neuchatel); Philippe Wanner (I-Demo, University of Geneva)
    Abstract: This paper uses data from the Swiss Labour Force Survey to evaluate the existence of the healthy immigrant effect (HIE) which would translate in i. a health advantage of immigrants upon their arrival in Switzerland compared to individuals with similar characteristics but Swiss-born and ii. an erosion of that advantage over the time of residence until convergence in the levels of health between these two groups. Our original contribution is to address this issue by taking a nonparametric approach in order overcome any potential danger of misspecification that would preclude valid inference. We find little empirical support for the HIE: i. no initial advantage and ii. no convergence but the health status of immigrants is shown to deteriorate more than Swiss-born individuals with similar characteristics. Significant differences appear when disaggregating among immigrants' country of origin. Interestingly, we show that a standard parametric approach, in contrast to our findings, would fully confirm the existence of the HIE with the same data set.
    Keywords: Migration, Health, Labour Market
    Date: 2016–12
  13. By: OECD
    Abstract: Since 2009, Education at a Glance (EAG) has included an indicator on education and social outcomes using data from different surveys. The OECD Programme for the International Assessment of Adult Competencies (PIAAC) develops and conducts the Survey of Adult Skills which measures adults’ proficiency in literacy, numeracy and problem solving in technology-rich environments. Data collected through the Survey of Adult Skills were used in various editions of EAG as it gathered rich information on various social outcomes. In EAG 2016, Indicator A8 (How are social outcomes related to education?) used this source to measure the association between educational attainment and self-reported health. This indicator also analysed data from the European Union Statistics on Income and Living Conditions (EU-SILC) on the prevalence of limitations that affect people’s ability to perform normal daily activities across the different educational attainment levels. Finally, it referred to the Gallup World Poll to analyse how life satisfaction varied across the different countries and educational attainment levels. The main findings are further developed in this paper.
    Date: 2016–12–20
  14. By: Kevin Callison (Grand Valley State University); Michael F. Pesko (Cornell University)
    Abstract: We evaluate the impact of paid sick leave (PSL) mandates on labor market outcomes, the utilization of health care services, and health behaviors for private sector workers in the United States. By exploiting geographic and temporal variation in PSL mandate adoption, we compare changes in outcomes for workers in counties affected by a PSL mandate to changes for those in counties with no mandate. Additionally, we rely on within-county variation in the propensity to gain PSL following a mandate to estimate policy effects for workers most likely to acquire coverage. Results indicate that PSL mandates lead to increased access to PSL benefits, especially for women without a college degree. We find that PSL laws reduce average weekly hours worked and private sector employment, but appear to have no effect on job tenure or labor force participation. PSL mandates are associated with sizable reductions in emergency department utilization and increases in general practitioner visits. Finally, we present suggestive evidence that PSL mandates lead to more days binge drinking.
    Keywords: Paid sick leave, labor market, health care, health behaviors
    JEL: I18 I12 J21 J23 J32
    Date: 2016–11
  15. By: Xiaoyu Chen;
    Abstract: There are few multicity studies to address the effect of short-term effect of particulate matter air pollution on daily Coronary Heart Disease (CHD) mortality in developing countries, much fewer to further discuss its threshold and seasonal effect. This study investigates the season-varying association between particulate matter less than or equal to 10 μm in aerodynamic diameter (PM10) and daily CHD mortality in seven cities of China. Time series threshold Poisson regression model is specified to estimate the health effect for four cities with the threshold effect, and conventional linear Poisson model is used to analyze the effect for three cities without threshold. We apply the Bayesian hierarchical model to pool the city-specific estimates into overall level. On average, a 10μg/m3 increase of the moving average concentrations of current-day and previous-day PM10 is associated with an increase of 0.81% (95% Posterior Interval, PI: -0.04%, 1.67%) in daily CHD mortality for all the cities as a whole. The associations are smaller than reported in developed countries or regions with lower polluted level, which is consistent to the findings in the literature. The hazardous effect are higher in hot summer and cold winter (1.15% and 0.89%) but lower in relative warm spring and fall (0.85% and 0.69%). In summary, we found significant associations between short-term exposure to PM10 and CHD mortality in China. The sensitivity analyses in the study support the robustness of our results.
    Date: 2016–12
  16. By: Fengping Tian; Jiti Gao; Ke Yang
    Abstract: This article investigates the variation in the effects of various determinants on the per capita health care expenditure. A total of 28 OECD countries are studied over the period 1990-2012, employing an instrumental variable quantile regression method for a dynamic panel model with fixed effects. The results show that the determinants of per capita health care expenditure do vary with the distribution of the health care expenditure growth, while the change patterns are dissimilar. Specifically, the lagged health spending growth has a significantly positive effect, with an effect that decreases towards the higher quantiles of growth of per capita health care expenditure. Per capita GDP has a significantly positive effect, both the short and long run income elasticities are smaller than one, and health care is a necessity. The density of physicians only has a significant negative effect at the lower tail of the distribution. The elderly population has the reverse effect at the lower and upper tails, and this shows an upward trend with the increase in health expenditure growth. Life expectancy has an effect similar to the proportion of the old. Variable representing Baumol’s model of “unbalanced growth†theory has a significantly positive effect, and the change pattern of its influence shows a marked upward trend. However, one component of “Baumol variable†, labor productivity, only shows significant effect in the low half of the distribution. More attention needs to be paid to the influence of determinants in health expenditure study.
    Keywords: health care expenditure, quantile regression, OECD countries, unbalanced growth
    JEL: C22 C23 I11
    Date: 2016
  17. By: Ivo Bischoff (University of Kassel); Nataliya Kusa (University of Kassel)
    Abstract: This paper deals with the public acceptance of policies that pave the way for a more active role of family care assistants in long-term care provision. Family care assistants, i.e. non-relatives providing homecare services in the own private home of the care recipient, provide valuable help for adult children organizing long-term care for their parents. However, their support comes at the price of transferring more family-owned wealth to non-relatives. Based on a survey among German citizens, we provide empirical evidence on the factors that drive the support for a more active role of family care assistants. We find support to be higher among subjects who gave long-term care personally. Monetary self-interest is found to matter. In addition, we find evidence of a clear line of conflict: Citizens with alive parents are more likely to support a more active role of family care assistants than citizens whose parents are dead.
    Keywords: long-term care, intergenerational transfers, citizens’ preferences, inheritance taxation, filial responsibility
    JEL: H27 D31 D72
    Date: 2016
  18. By: Helen Levy (University of Michigan); Thomas Buchmueller (University of Michigan); Sayeh Nikpay (Vanderbilt University)
    Abstract: This paper presents evidence of the dynamics of health insurance coverage between 2008 and 2014 among early retirees, defined as individuals ages 55 to 64 who are not in the labor force. We focus on three questions. First, how did insurance coverage change among early retirees in 2014, when the new ACA options became available, compared with trends in coverage from 2008 to 2013? Second, are there differences between states that did and did not implement the ACA’s Medicaid expansion in January 2014? Third, how did the income gradient in insurance coverage for early retirees change in 2014, both overall and in states with or without Medicaid expansion? We find that between 2013 and 2014, the fraction of early retirees without health insurance declined significantly from 14.7 percent to 11.2 percent, reversing a trend toward increasing uninsurance in recent years. This change was driven by increases in both Medicaid and private non-group coverage. Gains in coverage were larger in states that implemented the Affordable Care Act’s Medicaid expansion in January 2014 than in states that did not. The gains in coverage disproportionately benefited low-income early retirees, and therefore reduced the gradient in coverage with respect to income. There is no evidence of an acceleration of the decline in employer-sponsored coverage for early retirees, either overall or in states that expanded Medicaid. These results suggest that the major coverage provisions of the ACA have increased coverage among early retirees, with particularly large gains among those with very low income in states that expanded Medicaid.
    Date: 2016–09
  19. By: Kravdal, Øystein (Dept. of Economics, University of Oslo)
    Abstract: There is considerable uncertainty about how reproductive factors affect child mortality. Joint determinants are difficult to control adequately for, and the studies that have dealt with selection in the most advanced ways have given diverging results. According to very simple models estimated from DHS data from 28 countries in sub-Saharan Africa, mortality is highest for first-born children with a very young mother. Also some other groups of children with a young mother, or of high birth order, have high mortality. Net of such age and birth order differences, a short preceding birth interval is associated with high mortality. The pattern does not change much if a number of other observed characteristics are controlled for, but a different picture appears if time-invariant unobserved mother-level characteristics are taken into account in a multilevel-multiprocess model. According to the latter models, the mortality of a first child goes up as the mother’s age increases above 24, and younger siblings are adversely affected by the later start of childbearing as this means that their mother will be older when they are born. Avoiding a short birth interval reduces the chance that the next child dies, but this effect is weaker than suggested by the simpler models, and younger siblings have a disadvantage because their mothers are older than they otherwise would be. The conclusion is different if it is taken into account that a higher maternal age goes hand in hand with a later calendar period, which may reduce mortality. Assuming that the recent general mortality decline continues, the advice to a woman would be to avoid a very early first birth and short birth intervals. In addition to being an advantage in the short term, there are no disadvantages for the children she may have later. It is also discussed whether a woman’s next child will have lower mortality than her most recently born child. The statistical analysis is backed up by a simulation experiment.
    Keywords: birth interval; birth order; child; DHS; infant; maternal age; mortality; multilevel-multiprocess models; sub-Saharan Africa; reproductive variables; simulation
    JEL: C30 I10 J13
    Date: 2016–11–23
  20. By: Dietrichson, Jens (The Danish National Centre for Social Research (SFI)); Ellegård, Lina Maria (Department of Economics, Lund University); Kjellsson, Gustav (Department of Economics, University of Gothenburg)
    Abstract: In the last decades, many health systems have implemented policies to make care providers engage in quality competition. But care quality is a multi-dimensional concept, and competition may have different impacts on different dimensions of quality. The empirical evidence on competition and care quality is scarce, in particular regarding primary care. This paper adds evidence from recent reforms of Swedish primary care that affected competition in municipal markets differently depending on the pre- reform market structure. Using a difference-in-differences strategy, we demonstrate that the reforms led to substantially more entry of private care providers in municipalities where there were many patients per provider before the reforms. The effects on primary care quality in these municipalities are modest: we find small improvements in subjective measures of overall care quality, but no significant effects on the rate of avoidable hospitalizations or patients’ satisfaction with access to care. We find no indications of quality reductions.
    Keywords: Competition; Patient choice; Primary health care; Quality
    JEL: D04 H75 I11 I18
    Date: 2016–12–14

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