nep-hea New Economics Papers
on Health Economics
Issue of 2019‒05‒20
nineteen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. Nonparametric Estimates of Demand in the California Health Insurance Exchange By Pietro Tebaldi; Alexander Torgovitsky; Hanbin Yang
  2. The Role of Neonatal Health in the Incidence of Childhood Disability By Todd Elder; David N. Figlio; Scott A. Imberman; Claudia Persico
  3. Unemployed or Disabled? Disability Screening and Labor Market Outcomes of Youths By Schreiner, Ragnhild C.
  4. Emotional responses to behavioral economic incentives for health behavior change By van der Swaluw, K.; Lambooij, M.S.; Mathijssen, J.J.P.; Prast, H.M.; Zeelenberg, M.; Polder, J.J.
  5. Commitment lotteries promote physical activity among overweight adults : A cluster randomized trial By van der Swaluw, K.; Lambooij, M.S.; Mathijssen, J.J.P.; Schipper, M.; Zeelenberg, M.; Berkhout, S.; Polder, J.J.; Prast, H.M.
  6. Individual labor market effects of local public expenditures on sports By Pawlowski, Tim; Steckenleiter, Carina; Wallrafen, Tim; Lechner, Michael
  7. Paid Family Leave and Breastfeeding: Evidence from California By Jessica Pac; Ann P. Bartel; Christopher Ruhm; Jane Waldfogel
  8. A novel supply-side measure to combat abuse of addictive prescription drugs By Alexander Ahammer
  9. Mindfulness, preferences and well-being: Mindfulness predicts adolescents' field behaviour By Lima de Miranda, Katharina
  10. The Impact of CEOs in the Public Sector: Evidence from the English NHS By Janke, Katharina; Propper, Carol; Sadun, Raffaella
  11. Demand and Welfare Analysis in Discrete Choice Models with Social Interactions By Debopam Bhattacharya; Pascaline Dupas; Shin Kanaya
  12. Who is willing to stay sick for the collective? – Individual characteristics, experience, and trust By Carlsson, Fredrik; Jacobsson, Gunnar; Jagers, Sverker C.; Lampi, Elina; Robertsson, Felicia; Rönnerstrand, Björn
  13. The Effect of Education on Health: Evidence from the 1997 Compulsory Schooling Reform in Turkey By Baltagi, Badi H.; Flores-Lagunes, Alfonso; Karatas, Haci M.
  14. Inequality during the nutritional transition: Hospital diets in Mediterranean Spain (Valencia, 1853-1923) By Francisco J. Medina-Albaladejo; Salvador Calatayud
  15. Associations of childhood health and financial situation with quality of life after retirement: Regional variation across Europe By Börnhorst, Claudia; Heger, Dörte; Mensen, Anne
  16. The Competitive Impact of Branded Generic Medicine in a Developing Country By Roberto Álvarez; Aldo González; Sebastian Fernández
  17. Length of maternal schooling and child’s risk of malaria infection in Uganda: evidence from a natural experiment By Masuda, Kazuya
  18. Fifty years of Asian experience in the spread of education and healthcare By Mundle Sudipto
  19. Impact of Development aid on infant mortality : Micro-level evidence from Cote d’Ivoire By Didier Wayoro; Leonce Ndikumana

  1. By: Pietro Tebaldi; Alexander Torgovitsky; Hanbin Yang
    Abstract: We estimate the demand for health insurance in the California Affordable Care Act marketplace (Covered California) without using parametric assumptions about the unobserved components of utility. To do this, we develop a computational method for constructing sharp identified sets in a nonparametric discrete choice model. The model allows for endogeneity in prices (premiums) and for the use of instrumental variables to address this endogeneity. We use the method to estimate bounds on the effects of changing premium subsidies on coverage choices, consumer surplus, and government spending. We find that a $10 decrease in monthly premium subsidies would cause between a 1.6% and 7.0% decline in the proportion of low-income adults with coverage. The reduction in total annual consumer surplus would be between $63 and $78 million, while the savings in yearly subsidy outlays would be between $238 and $604 million. Comparable logit models yield price sensitivity estimates towards the lower end of the bounds.
    JEL: C14 C3 C5 I13
    Date: 2019–05
  2. By: Todd Elder; David N. Figlio; Scott A. Imberman; Claudia Persico
    Abstract: We use linked birth and education records for all children born in Florida between 1992 and 2002 to assess the effects of neonatal health on the identification of childhood disabilities. We find that several measures of neonatal health are associated with disability incidence, although birthweight plays the most empirically relevant role. Using large samples of siblings and twins, we find that infant health influences multiple measures of disability and grade repetition in school. The association between birthweight and disability holds throughout the distribution of birthweight and across a range of socioeconomic characteristics, including maternal education and race.
    JEL: I10 I21
    Date: 2019–05
  3. By: Schreiner, Ragnhild C. (Dept. of Economics, University of Oslo)
    Abstract: This paper examines the effect of being granted temporary disability insurance (TDI), as opposed to a non-health related benefit, on later labor market outcomes of youths who are seeking temporary income support from the state. In Norway, there has been a development over time towards a more lenient screening to TDI, and this development has been more pronounced in some municipalities than in others. Using local screening leniency as an instrument for TDI receipt, I find that being granted TDI benefits significantly reduces later labor market attachment of youths whose benefit receipt would differ according to their municipality of residence, and the year of entry to the benefit system.
    Keywords: Social insurance; disability screening; youth unemployment; program evaluation
    JEL: C21 C26 H55 I18
    Date: 2019–05–03
  4. By: van der Swaluw, K. (Tilburg University, School of Economics and Management); Lambooij, M.S.; Mathijssen, J.J.P. (Tilburg University, School of Economics and Management); Prast, H.M. (Tilburg University, School of Economics and Management); Zeelenberg, M. (Tilburg University, School of Economics and Management); Polder, J.J. (Tilburg University, School of Economics and Management)
    Abstract: Many people aim to change their lifestyle, but have trouble acting on their intentions. Behavioral economic incentives and related emotions can support commitment to personal health goals, but the related emotions remain unexplored. In a regret lottery, winners who do not attain their health goals do not get their prize but receive feedback on what their forgone earnings would have been. This counterfactual feedback should provoke anticipated regret and increase commitment to health goals. We explored which emotions were actually expected upon missing out on a prize due to unsuccessful weight loss and which incentive-characteristics influence their likelihood and intensity. Participants reported their expected emotional response after missing out on a prize in one of 12 randomly presented incentive-scenarios, which varied in incentive type, incentive size and deadline distance. Participants primarily reported feeling disappointment, followed by regret. Regret was expected most when losing a lottery prize (vs. a fixed incentive) and intensified with prize size. Multiple features of the participant and the lottery incentive increase the occurrence and intensity of regret. As such, our findings can be helpful in designing behavioral economic incentives that leverage emotions to support health behavior change.
    Date: 2018
  5. By: van der Swaluw, K. (Tilburg University, School of Economics and Management); Lambooij, M.S.; Mathijssen, J.J.P. (Tilburg University, School of Economics and Management); Schipper, M.; Zeelenberg, M. (Tilburg University, School of Economics and Management); Berkhout, S.; Polder, J.J. (Tilburg University, School of Economics and Management); Prast, H.M. (Tilburg University, School of Economics and Management)
    Abstract: Background: The World Health Organization has identified physical inactivity as the fourth leading risk factor for global mortality. People often intend to engage in physical activity on a regular basis, but have trouble doing so. To realize their health goals, people can voluntarily accept deadlines with consequences that restrict undesired future behaviors (i.e., commitment devices). Purpose: We examined if lottery-based deadlines that leverage regret aversion would help overweight individuals in attaining their goal of attending their gym twice per week. At each deadline a lottery winner was drawn from all participants. The winners were only eligible for their prize if they attained their gym-attendance goals. Importantly, nonattending lottery winners were informed about their forgone prize. The promise of this counterfactual feedback was designed to evoke anticipated regret and emphasize the deadlines. Methods: Six corporate gyms with a total of 163 overweight participants were randomized to one of three arms. We compared (i) weekly short-term lotteries for 13 weeks; (ii) the same short-term lotteries in combination with an additional long-term lottery after 26 weeks; and (iii) a control arm without lotteries. Results: After 13 weeks, participants in the lottery arms attained their attendance goals more often than participants in the control arm. After 26 weeks, we observe a decline in goal attainment in the short-term lottery arm and the highest goal attainment in the long-term lottery arm. Conclusions: With novel applications, the current research adds to a growing body of research that demonstrates the effectiveness of commitment devices in closing the gap between health goals and behavior.
    Date: 2018
  6. By: Pawlowski, Tim; Steckenleiter, Carina; Wallrafen, Tim; Lechner, Michael
    Abstract: By merging administrative data on public finances of all municipalities in Germany with individual data from the German Socio-Economic Panel, we explore whether local public expenditures on sports facilities influences individual labor market outcomes. Our identification strategy follows a selection-on-observables approach and exploits the panel structure of the data covering 12 years between 2001 and 2012. The results of our matching estimations suggest that both women and men living in municipalities with high expenditure levels benefit, exhibiting approximately 7 percent of additional household net income on average. However, this income effect is fully captured by earning gains for men rather than women living in the household. Additional analysis suggests, that these gender differences, which can also be observed in terms of working time, hourly wage and employment status, appear plausible since women in the age cohort under consideration are less likely than men to engage in sports in general and in any of the publicly funded sports facilities in particular. Moreover, improved well-being and health are possible mechanisms that determine how the positive labor market effects for men may unfold.
    Keywords: Labor market effects, public expenditures, sports, health, well-being
    JEL: H72 H75 J31
    Date: 2019–04
  7. By: Jessica Pac (Columbia University); Ann P. Bartel (Columbia University); Christopher Ruhm (University of Virginia Frank Batten School of Leadership and Public Policy); Jane Waldfogel (Columbia University)
    Abstract: This paper evaluates the effect of Paid Family Leave (PFL) on breastfeeding, which we identify using California’s enactment of a 2004 PFL policy that ensured mothers up to six weeks of leave at a 55 percent wage replacement rate. We employ synthetic control models for a large, representative sample of over 270,000 children born between 2000 and 2012 drawn from the restricted-use versions of the 2003 – 2014 National Immunization Surveys. Our estimates indicate that PFL increases the overall duration of breastfeeding by nearly 18 days, and the likelihood of breastfeeding for at least six months by 5 percentage points. We find substantially larger effects of PFL on breastfeeding duration for some disadvantaged mothers.
    Keywords: paid family leave, maternity leave, child health, breastfeeding
    JEL: I12 I18 J13 J18
    Date: 2019–05
  8. By: Alexander Ahammer
    Abstract: In the United States, 115 people die each day due to overdose, and a third of overdoses involve the concurrent use of opioids and a class of sedatives called benzodiazepines. Facing a similar problem in 2012, Austria responded by installing public health officers (PHOs) as third-party institutions overseeing prescriptions of the most potent and commonly abused benzodiazepine, flunitrazepam. Since December 15, 2012, every single flunitrazepam prescription must be authorized and countersigned by a PHO, prescriptions were restricted to a month’s supply of the drug, and doses must be dispensed daily, under supervision, in a pharmacy. I identify a sample of opioids addicts in administrative social security data and study their response to this reform. Event studies suggest a persistent decline in flunitrazepam prescriptions but substitution to less potent benzodiazepines following the reform. To examine subsequent health, labor market, and drug abuse-related outcomes, I additionally exploit regional variation in PHO strictness affecting the likelihood that addicts opt to quit the drug due to the reform. I find that addicts who quit after encountering a strict PHO have better health and labor market outcomes, have fewer opioid overdoses, and are less likely to take antidepressants or weak opioids. I discuss how these findings translate to the US setting, and whether a similar policy can help curb its opioid epidemic.
    Keywords: Opioid epidemic, addictive drugs, supply-control, prescription regulations
    JEL: I18 I12 H12
    Date: 2019–04
  9. By: Lima de Miranda, Katharina
    Abstract: Mindfulness could influence economic and health related behaviour by bringing about increased and unbiased attention to the present moment, for example to a decision making process. This study explores the relationship between mindfulness and economic preferences, and consequently well-being, of adolescents. Comprehensive data of 525 German secondary school students were elicited and show no evidence for a strong linear or non-linear correlation between mindfulness and economic preferences. However, both mindfulness and preferences have explanatory power for adolescents' field behaviour and thus contribute to explaining variation in behaviour that may translate into serious health and economic consequences. In this regard, my findings indicate that the two concepts play rather complementary than substitutable roles, which implies that an integration of economic preferences and personality traits such as mindfulness may improve the analysis of potential sources of variation in life outcomes. As mindfulness reflects on a healthier lifestyle (less smoking and smaller BMI) and higher life satisfaction, the findings furthermore point into the direction that the development of mindfulness skills might help students to grow social-emotional capacities and increase physical and psychological well-being.
    Keywords: time preference,risk preferences,mindfulness,personality,experiments with adolescents,subjective well-being
    JEL: C93 D81 D90 I12 I20
    Date: 2019
  10. By: Janke, Katharina; Propper, Carol; Sadun, Raffaella
    Abstract: We investigate whether top managers affect the performance of large and complex public sector organizations, using as a case study CEOs of English public hospitals (large, complex organizations with multi-million turnover). We study the extent to which CEOs are differentiated in terms of their pay, as well as a wide range of hospital production measures including inputs, intermediate operational outcomes and clinical outcomes. Pay differentials suggest that the market perceives CEOs to be differentiated. However, we find little evidence of CEOs' impact on hospital production. These results question the effectiveness of leadership changes to improve performance in the public sector.
    Keywords: CEOs; Hospitals; NHS; Public sector; style
    JEL: H51 I11 L32 M12
    Date: 2019–05
  11. By: Debopam Bhattacharya (University of Cambridge); Pascaline Dupas (Stanford University); Shin Kanaya (University of Aarhus and CREATES)
    Abstract: Many real-life settings of consumer-choice involve social interactions, causing targeted policies to have spillover-effects. This paper develops novel empirical tools for analyzing demand and welfare-effects of policy-interventions in binary choice settings with social interactions. Examples include subsidies for healthproduct adoption and vouchers for attending a high-achieving school. We establish the connection between econometrics of large games and Brock-Durlauf-type interaction models, under both I.I.D. and spatially correlated unobservables. We develop new convergence results for associated beliefs and estimates of preference-parameters under increasing-domain spatial asymptotics. Next, we show that even with fully parametric specifications and unique equilibrium, choice data, that are sufficient for counterfactual demand - prediction under interactions, are insufficient for welfare-calculations. This is because distinct underlying mechanisms producing the same interaction coefficient can imply different welfare-effects and deadweightloss from a policy-intervention. Standard index-restrictions imply distribution-free bounds on welfare. We illustrate our results using experimental data on mosquito-net adoption in rural Kenya.
    Keywords: Policy targeting, welfare analysis, social interaction, spillover, externality, convergence of Bayesian-Nash equilibria, spatial dependence, Kenya
    JEL: C01 H23 H4 H51 I38 O1
    Date: 2019–04–26
  12. By: Carlsson, Fredrik (Department of Economics, School of Business, Economics and Law, Göteborg University); Jacobsson, Gunnar (Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden); Jagers, Sverker C. (Centre for Collective Action Research (CeCAR), University of Gothenburg, Gothenburg, Sweden); Lampi, Elina (Department of Economics, School of Business, Economics and Law, Göteborg University); Robertsson, Felicia (Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden); Rönnerstrand, Björn (Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden)
    Abstract: This paper deals with the collective action dilemma of antibiotic resistance. Despite the collective threat posed by antibiotic resistance, there are limited incentives for individuals to consider the contribution of their decisions to use antibiotics to the spread of resistance. Drawing on a novel survey of Swedish citizens (n=1,906), we study factors linked to i) willingness to accept a physician’s decision not to prescribe antibiotics and ii) willingness to limit personal use of antibiotics voluntary. In our study, 53 percent of the respondents stated that they would be willing to accept the physician’s decision despite disagreeing with it, and trust in the healthcare sector is significantly associated with acceptance. When it comes to people’s willingness to voluntarily abstain from using antibiotics, a majority stated that they are willing or very willing not to take antibiotics. The variation in willingness is best explained by concerns about antibiotic resistance and experience of antibiotic therapy, especially if a respondent has been denied antibiotics. Generalized trust seems to be unrelated to willingness to abstain, but the perception that other people limit their personal use of antibiotics is linked to respondents’ own willingness to do so. Few of the individual characteristics can explain the variation in that decision.
    Keywords: collective action; antibiotics use; antibiotic resistance; willingness to abstain
    JEL: D90 I12
    Date: 2019–05
  13. By: Baltagi, Badi H.; Flores-Lagunes, Alfonso; Karatas, Haci M.
    Abstract: This paper analyzes the relationship between education and health outcomes using a natural experiment in Turkey. The compulsory schooling increased from 5 to 8 years in 1997. This increase was accompanied by a massive construction of classrooms and recruitment of teachers in a differential rate across regions. As in previous studies, we confirm that the 1997 reform substantially increased education in Turkey. Using the number of new middle school class openings per 1000 children as an intensity measure for the 1997 reform, we find that, on average, one additional middle school class increases the probability of completion of 8 years or more of schooling by about 7.1 percentage points. We use this exogenous increase in the educational attainment to investigate the impact of education on body mass index, obesity, smoking behavior, and self-rated health, as well as the effect of maternal education on the infant’s well-being. Using ordinary least squares, we find that there is a statistically significant favorable effect of education on health outcomes and behavior. However, this relationship becomes insignificant when we account for the endogeneity of education and health by instrumenting education with exogenous variations generated by the 1997 reform and the accompanying middle school class openings. The insignificance of the health effect may be due to lack of statistical power in our data, or to the fact that this policy affects only relatively low levels of schooling and the health effects of education need to be examined at higher levels of schooling.
    Keywords: health,education,compulsory schooling,body mass index,obesity,smoking,selfrated health,maternal education,infant’s well-being,Turkey
    JEL: C26 I12 I21 I28
    Date: 2019
  14. By: Francisco J. Medina-Albaladejo (Universidad de Valencia, Spain); Salvador Calatayud (Universidad de Valencia, Spain)
    Abstract: Unequal access to food is one of the main issues in nutritional history, but scarcity of sources has hampered the quantification of this phenomenon. This work proposes using hospital diets to address this gap. We have used records from 1853 to 1923 concerning hospital diets in the psychiatric section of the Hospital General de Valencia (Spain) and we have inferred the actual intake of nutrients for six groups of patients and members of staff. The results reveal considerable differences in terms of diet and nutrition. While the most-favoured group (nuns and well-off patients) had by 1853 reduced their relative intake of cereals and increased that of meat, in line with the general trend of the nutritional transition, the poor and orphans were still behind the trend by 1923. On the other hand, hospital staff were on a high-calorie diet that was adequate for undertaking heavy tasks, yet still suffered from a significant deficit in nutrient intake. These inequalities indicate that the nutritional transition was an uneven and non-linear process, with substantial differences according to social groups.
    Keywords: Nutritional Transition, Inequality, Hospital Diets, Nutrient Intake, Spain
    JEL: N33 N34 I12 I31
    Date: 2019–05
  15. By: Börnhorst, Claudia; Heger, Dörte; Mensen, Anne
    Abstract: Many studies have shown that childhood circumstances can have long term consequences that persist until old age. To better understand the transmission of early life circumstances, this paper analyses the effects of health and financial situation during childhood on quality of life after retirement as well as the mediating role of later life health, educational level, and income in this association. Moreover, this study is the first to compare these pathways across European regions. The analyses are based on data of 13,092 retirees aged > 60 and
    Keywords: early life circumstances,life course epidemiology,retirement phase,quality of life,path analysis
    JEL: H75 I31 J14
    Date: 2019
  16. By: Roberto Álvarez; Aldo González; Sebastian Fernández
    Abstract: This paper studies the effect of the entry of branded generic medications — representing 47 molecules — between January 2002 and July 2017 in the Chilean retail pharmaceutical market. Using a differences-in-differences approach, we measure the impact on prices and quantities on the market after the entry of branded generic pharmaceuticals, following the patent expiration of innovator drugs. The results show that in a period of 48 months from the first entry, the quantities sold in the retail market increased by 148.1%. This is explained by the lower prices of the branded generics, as the gross average price is 33% cheaper than the innovator alternatives. Finally, no statistically significant effect is observed on prices and quantities for innovators, suggesting that the segmented market theory might apply to the Chilean pharmaceutical market.
    Date: 2019–05
  17. By: Masuda, Kazuya
    Abstract: Background: An estimated 216 million cases of malaria occurred worldwide every year. Cross sectional studies have reported negative association between maternal education and child malaria risks, but no randomized trial has confirmed a causal relationship between these two factors. I utilized the free primary education reform in Uganda to assess the causal effects of maternal schooling on the child’s risk of malaria infection.Methods: Malaria biomarkers of children aged
    Date: 2019–03
  18. By: Mundle Sudipto
    Abstract: This paper analyses the dramatic spread of education and healthcare in Asia and also the large variations in that spread across and within countries over 50 years.Apart from differences in initial conditions and income levels, the nature of the state has also been an important determinant of these variations. This is because social development has typically been led by the state.But in most countries, public resource constraints and the growing dependence on private provision and private spending have generated a pattern of nested disparities in the access to education and healthcare between rich and poor regions, between rural and urban areas within regions, and between rich and poor households within these areas.However, as the better-off regions, areas, and households approach the upper limits of achievable education and health standards, a process of convergence is also underway as those left behind begin to catch up.
    Keywords: Healthcare,Inequality,State,Education
    Date: 2018
  19. By: Didier Wayoro (Department of Economics, Indiana State University Terre Haute); Leonce Ndikumana (Department of Economics, University of Massachusetts Amherst)
    Abstract: The empirical literature has failed to reach consensus on the impact of aid on development outcomes based on aggregate cross-country analysis. This study follows the current trend in the literature on the effectiveness of aid to examine the impact of local-level aid on health outcomes. We combine data on World Bank’s geo-located aid projects with three rounds of Demographic Health Surveys from Cote d’Ivoire and use difference-in-difference estimation techniques to explore the effects of aid on infant mortality. We find that proximity to development aid projects is associated with reduced infant mortality. Our results are robust to mother fixed-effects estimations as well as water and sanitation projects. The evidence suggests that access to prenatal and postnatal health care are possible mechanisms through which aid may affect infant mortality.
    Keywords: Aid, infant mortality, Cote d’Ivoire
    JEL: F35 I15 O55
    Date: 2019

This nep-hea issue is ©2019 by Nicolas R. Ziebarth. It is provided as is without any express or implied warranty. It may be freely redistributed in whole or in part for any purpose. If distributed in part, please include this notice.
General information on the NEP project can be found at For comments please write to the director of NEP, Marco Novarese at <>. Put “NEP” in the subject, otherwise your mail may be rejected.
NEP’s infrastructure is sponsored by the School of Economics and Finance of Massey University in New Zealand.