nep-hea New Economics Papers
on Health Economics
Issue of 2019‒03‒11
ten papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. The Roots of Health Inequality and The Value of Intra-Family Expertise By Yiqun Chen; Petra Persson; Maria Polyakova
  2. Socialized Healthcare and Women’s Fertility Decisions By Resul Cesur; Pinar Mine Gunes; Erdal Tekin; Aydogan Ulker
  3. Measuring Multivariate Risk Preferences in the Health Domain By Arthur Attema; Olivier L’haridon; Gijs Van de Kuilen
  4. The Intergenerational Transmission of Health in the United States: A Latent Variables Analysis By Ashley Wong; Bhashkar Mazumder; Timothy J Halliday
  5. A generalized counterfactual approach to decomposing differences between populations By Nikkil Sudharsanan; Maarten J. Bijlsma
  6. The influence of threatening visual warnings on tobacco packaging: Measuring the impact of threat level, image size, and type of pack through psychophysiological and self-report methods By Olivier Droulers; Karine Gallopel-Morvan; Sophie Lacoste-Badie; Mathieu Lajante
  7. Soda tax incidence and design under monopoly By Helmuth Cremer; Catarina Goulão; Jean-Marie Lozachmeur
  8. Working Paper 312 - Quality Homes for Sustainable Malaria Prevention in Africa By Tiguéné Nabassaga; El-Hadj Bah; Issa Faye
  9. The Impact of Community Based Health Insurance Schemes on Out-of-Pocket Healthcare Spending: Evidence from Rwanda By Andinet Woldemichael; Daniel Gurara; Abebe Shimeles
  10. Short-Run Health Consequences of Retirement and Pension Benefits: Evidence from China By Nikolov, Plamen; Adelman, Alan

  1. By: Yiqun Chen; Petra Persson; Maria Polyakova
    Abstract: Mounting evidence documents a stark correlation between income and health, yet the causal mechanisms behind this gradient are poorly understood. This paper examines the impact of access to expertise on health, and whether unequal access to expertise contributes to the health-income gradient. Our empirical setting, Sweden, allows us to shut down inequality in formal access to health care; we first document that strong socioeconomic gradients nonetheless persist. Second, we study the effect of access to health-related expertise – captured by the presence of a health professional in the extended family – on health. Exploiting “admissions lotteries” into medical schools and variation in the timing of degrees, we show that access to intra-family medical expertise has far-reaching health consequences, at all ages: It raises longevity, improves drug adherence and reduces the occurrence of lifestyle-related disease in adulthood, raises vaccination rates in adolescence, and reduces tobacco exposure in utero. Third, we show that the effects of expertise are larger at the lower end of the income distribution – precisely where access to expertise is scarcer. Unequal access to health-related expertise can account for as much as 18% of the health-SES gradient, and may thus play a significant role in sustaining health inequality.
    JEL: D12 D83 G22 H1 H4 I13 I14
    Date: 2019–02
  2. By: Resul Cesur; Pinar Mine Gunes; Erdal Tekin; Aydogan Ulker
    Abstract: This paper examines the effect of a nationwide healthcare reform implemented in Turkey on women’s fertility decisions. The Family Medicine Program (FMP), introduced in 2005, provided a wide-range of primary healthcare services, free of charge, and achieved universal access by matching each citizen to a specific family physician, who operates at neighborhood clinics, called Family Health Centers, on a walk-in basis. Although reducing fertility was not specified among the goals of the reform, reproductive-health and family-planning services have been covered under the FMP. To establish causality, we exploit the staggered rollout of the FMP implementation across Turkish provinces over time using a difference-in-differences estimation strategy. Our estimates indicate that the FMP significantly reduced childbearing among both teenagers and women ages 20-29. These results can be explained by increased access to and reduced cost of reproductive-health and family-planning services. However, the patterns in which the program effect has evolved over time differs between the two groups of women in a way that provides additional insights about the mechanisms. For teenagers, the FMP had a direct effect on childbearing, reflected by an immediate and rapidly-increasing pattern, which is not surprising given the broad agreement about the negative consequences of teenage childbearing among government and public health officials, including those in Turkey. For women ages 20-29, however, the program had a gradual and slowly-increasing effect, which is consistent with an empowerment channel. This should be interpreted as an unintended consequence of the program because, if anything, Turkey is a country where the government’s position is to encourage fertility behavior and discourage birth control practices among women at prime childbearing ages.
    JEL: I10 I12 I13 I18 J13
    Date: 2019–02
  3. By: Arthur Attema (Erasmus School of Economics - Erasmus University Rotterdam); Olivier L’haridon (CREM - Centre de recherche en économie et management - UNICAEN - Université de Caen Normandie - NU - Normandie Université - UR1 - Université de Rennes 1 - UNIV-RENNES - Université de Rennes - CNRS - Centre National de la Recherche Scientifique); Gijs Van de Kuilen (TiSEM - Tilburg School of Economics and Management - Tilburg University [Netherlands])
    Abstract: We investigate univariate and multivariate risk preferences for health (longevity) and wealth. We measure attitudes toward correlation and attitudes toward higher order dependence structures such as cross-prudence and cross-temperance, making use of the risk apportionment technique proposed by Eeckhoudt et al. (2007). For multivariate gains, we find correlation aversion and cross-prudence in longevity and wealth. For losses, we observe correlation seeking and cross-imprudence. We do not find clear evidence for cross-temperance. Our results indicate that longevity and wealth are considered to be substitutes for gains, but not for losses. Second, univariate (higher order) risk preferences are comparable for longevity and wealth, although somewhat closer to linearity for wealth. Third, we find evidence that attitudes toward dependence structures in the health domain are sign-dependent.
    Keywords: multivariate risk attitudes,health,prudence,temperance
    Date: 2019–03
  4. By: Ashley Wong (Northwestern University); Bhashkar Mazumder (Federal Reserve Bank of Chicago); Timothy J Halliday (University of Hawaii at Manoa)
    Abstract: Social scientists have long documented that many components of socioeconomic status such as income and education have strong ties across generations. However, health status, arguably a more critical component of welfare, has largely been ignored. We fill this void by providing the first estimates of the Intergenerational Health Association (IHA) that are explicitly based on a non-linear latent variable model. Adjusting for only age and gender, we estimate an IHA of 0.3 indicating that about one third of a parent's health status gets transmitted to their children. Once we add additional mediators to the model, we show that education, and particularly children's education, is an important transmission channel in that it reduces the IHA by one third. Finally, we show that estimates of the IHA from non-linear models are only moderately higher than those from linear models, while rank-based mobility estimates are identical.
    Keywords: Health, Mobility, Latent Variable, Inequality
    JEL: I1 I14
    Date: 2019–02
  5. By: Nikkil Sudharsanan; Maarten J. Bijlsma (Max Planck Institute for Demographic Research, Rostock, Germany)
    Abstract: One central aim of the population sciences is to understand why one population has different levels of health and well-being compared to another. Various methods, such as the Oaxaca-Blinder and Kitagawa decompositions, have been used to decompose population-differences in a wide range of outcomes. We provide a way of implementing an alternative decomposition method that, under certain assumptions, adds a causal interpretation to the decomposition by building upon counterfactual-driven estimation methods. In addition, the approach has the advantage of flexibility to accommodate different types of outcome and explanatory variables and any population contrast. By using Monte Carlo methods, our approach does not rely on closed-form approximate solutions and can be applied to any parametric model without having to derive any decomposition equations. We demonstrate our approach through two motivating examples using data from the Mexican Health and Aging Study and the 1970 British Birth Cohort Study. The first example uses a cross-sectional binary outcome (disability), a contrast of prevalence rates, and considers a binary mediator (stroke), while the second example uses a count outcome (age at first birth), a contrast of median ages, and considers a count mediator (women’s own years of education). Together, our two examples outline how to implement a very generalized decomposition procedure that is theoretically grounded in counterfactual theory but still easy to apply to a wide range of situations. We provide example R-code and an R-function [package in development].
    Keywords: methods of analysis
    JEL: J1 Z0
    Date: 2019–02
  6. By: Olivier Droulers (CREM - Centre de recherche en économie et management - UNICAEN - Université de Caen Normandie - NU - Normandie Université - UR1 - Université de Rennes 1 - UNIV-RENNES - Université de Rennes - CNRS - Centre National de la Recherche Scientifique); Karine Gallopel-Morvan (EHESP - École des Hautes Études en Santé Publique [EHESP]); Sophie Lacoste-Badie (CREM - Centre de recherche en économie et management - UNICAEN - Université de Caen Normandie - NU - Normandie Université - UR1 - Université de Rennes 1 - UNIV-RENNES - Université de Rennes - CNRS - Centre National de la Recherche Scientifique); Mathieu Lajante (CREM - Centre de recherche en économie et management - UNICAEN - Université de Caen Normandie - NU - Normandie Université - UR1 - Université de Rennes 1 - UNIV-RENNES - Université de Rennes - CNRS - Centre National de la Recherche Scientifique)
    Abstract: The first aim of this research was to assess the effectiveness, in terms of emotional and behavioral reactions, of moderately vs. highly TVWs (Threatening Visual Warnings) displayed on tobacco packs. Given the key role that emotional reactions play in explaining the effect of TVWs on behaviors, psychophysiological and self-report methods were used–for the first time in this context–to measure the emotions provoked by TVWs. The second aim of this research was to determine whether increasing the size of warnings, and their display on plain packaging (compared with branded packaging) would improve their effectiveness. A within-subjects experiment was conducted. Three variables were manipulated: health warning threat level (high vs. moderate), image size (40% vs. 75%) and pack type (plain vs. branded). A convenience sample of 48 French daily smokers participated. They were exposed to eight different packs of cigarettes in a research lab at the University of Rennes. Smokers' emotions and behavioral intentions were recorded through self-reports. Emotions were also evaluated using psychophysiological measurements: electrodermal activity and facial electromyography. The results revealed that TVWs with a high threat level are the most effective in increasing negative emotions (fear, disgust, valence, arousal) and behavioral intentions conducive to public health (desire to quit, etc.). They also highlight the appeal of increasing the size of the warnings and displaying them on plain packs, because this influences emotions, which is the first step toward behavioral change. Increasing the threat level of TVWs from moderate to high seems beneficial for public health. Our results also confirm the relevance of recent governmental decisions to adopt plain packaging and larger TVWs (in the UK, France, Ireland, Canada, New Zealand, Hungary, etc.).
    Keywords: Electromyography,Face,Public and occupational health,Emotions,Behavior,Smoking habits,Fear,Electrophysiology
    Date: 2017–09–14
  7. By: Helmuth Cremer; Catarina Goulão; Jean-Marie Lozachmeur
    Abstract: We consider an unhealthy good, such as a sugar-sweetened beverage, the health damages of which are misperceived by consumers. The sugar content is endogenous. We first study the solution under “pseudo” perfect competition. In that case a simple Pigouvian tax levied per unit of output but proportional to the sugar content is sufficient to achieve a first best solution. Then we consider a monopoly. Market power affects both output and sugar content, possibly in opposite directions, and these effects have to be balanced against Pigouvian considerations. We show that, nevertheless, a tax per unit of output achieves an efficient solution, but it must be an affine function of the sugar content; taxing “grams of sugar” is no longer sufficient. Interestingly, both the total tax as well as its sugar component can be positive as well as negative.
    Keywords: sin tax, tax incidence, misperception, monopoly
    JEL: H22 I12 D42
    Date: 2019
  8. By: Tiguéné Nabassaga (African Development Bank); El-Hadj Bah (African Development Bank); Issa Faye (African Development Bank)
    Abstract: Using the Demographic and Health Surveys (DHS) data from 8 African countries, among the top 10 countries with the highest malaria cases, accounting for 87% of malaria incidence cases in Africa, we analyze the impact of housing quality and the usual malaria prevention measures on malaria incidence among children under 5 years old. First, we investigate the potential correlation between malaria incidence and the quality of housing materials. Secondly, using OLS, two-stage least squares and Poisson regression, we estimate the marginal effects of housing quality on the incidence of malaria. The results can be summarized in four points. (i) The statistical analysis results show a substantial correlation between housing quality and the incidence of malaria. We found 8 percentage points lower rate of incidence among children living in houses constructed with improved materials than those in houses with poor quality materials. (ii) We also found that it is not only the physical characteristic of homes that matters, having good sanitation is associate with lower malaria incidence, with a total difference of 10 and 4 percentage points compared to those with less improved toilet facility and poor-quality drinking water respectively. (iii) An improvement in the overall housing quality leads to a significant reduction in the incidence of malaria among children under 5 years old. Explicitly, an improvement from the first percentile measure of housing quality to the 50th percentile leads to a 32% reduction in the number of malaria cases among children under age-five. In other words, if one improves the housing quality of poorer households to the national average, and keeping other factors constant, the number of malaria cases will drop by 50%. (iv) For both groups of households, those that use mosquito bed nets and those who use insecticide as means of preventing malaria, the results show that improved housing quality complements bed nets and insecticides. As housing quality improves, the role of the two preventives become smaller and smaller. Keywords: Malaria, Housing quality, indoor intervention, IV regression, marginal plot. JEL classification: I18; P25; B23
    Date: 2019–02–22
  9. By: Andinet Woldemichael; Daniel Gurara; Abebe Shimeles
    Abstract: Achieving universal health coverage, including financial risk protection and access to quality essential health-care services, is one of the main Sustainable Development Goals. In low-income countries, innovative and affordable health financing systems are key to realize these goals. This paper assesses the impacts of Community-Based Health Insurance Scheme in Rwanda on health-related financial risks using a nationally representative household survey data collected over a ten-year period. We find that the scheme significantly reduce annual per capita out-of-pocket spending by about 3,600 Rwandan Franc (about US$12) or about 83 percent of average per capita healthcare expenditure compared to the baseline level in 2000.The impacts however favor the rich as compared to the poor. The program also reduces the incidence of catastrophic healthcare spending significantly.
    Date: 2019–02–22
  10. By: Nikolov, Plamen; Adelman, Alan
    Abstract: This paper examines the impact of the New Rural Pension Scheme (NRPS) in China. Exploiting the staggered implementation of an NRPS policy expansion that began in 2009, we used a difference-in-difference approach to study the effects of the introduction of pension benefits on the health status, health behaviors, and healthcare utilization of rural Chinese adults age 60 and above. The results point to three main conclusions. First, in addition to improvements in self-reported health, older adults with access to the pension program experienced significant improvements in several important measures of health, including mobility, self-care, usual activities, and vision. Second, regarding the functional domains of mobility and self-care, we found that the females in the study group led in improvements over their male counterparts. Third, in our search for the mechanisms that drive positive retirement program results, we find evidence that changes in individual health behaviors, such as a reduction in drinking and smoking, and improved sleep habits, play an important role. Our findings point to the potential benefits of retirement programs resulting from social spillover effects. In addition, these programs may lessen the morbidity burden among the retired population. (JEL H55, H75, I10, I12, I19, J26)
    Keywords: life-cycle, retirement, pension, health, aging, developing countries, China.
    JEL: H55 H75 I10 I12 I15 I19 J26 J32 O11
    Date: 2018–11–30

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