nep-hea New Economics Papers
on Health Economics
Issue of 2019‒07‒22
nineteen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. Pre- and Post-Birth Components of Intergenerational Persistence in Health and Longevity: Lessons from a Large Sample of Adoptees By Björkegren, Evelina; Lindahl, Mikael; Palme, Mårten; Simeonova, Emilia
  2. Private vs. Public Provision of Social Insurance: Evidence from Medicaid By Timothy J. Layton; Nicole Maestas; Daniel Prinz; Boris Vabson
  3. The Impact of Medicaid on Medical Utilization in a Vulnerable Population: Evidence from COFA Migrants By Timothy J. Halliday; Randall Q. Akee; Tetine Sentell; Megan Inada; Jill Miyamura
  4. Evaluation of Medical Technologies with Uncertain Benefits By Darius N. Lakdawalla; Charles E. Phelps
  5. The Remarkable Unresponsiveness of College Students to Nudging And What We Can Learn from It By Philip Oreopoulos; Uros Petronijevic
  6. Vaccination take-up and health: evidence from a flu vaccination program for the elderly. By Yleania Brilli; Claudio Lucifora; Antonio Russo; Marco Tonello
  7. Choice Architecture for Healthier Insurance Choices: Ordering and Partitioning Can Improve Decisions By Dellaert, B.G.C.; Johnson, E.J.; Baker, T.
  8. The Minimum Legal Drinking Age and Crime Victimization By Aaron Chalfin; Benjamin Hansen; Rachel Ryley
  9. Child Socio-Emotional Skills: The Role of Parental Inputs By Moroni, Gloria; Nicoletti, Cheti; Tominey, Emma
  10. Mental Health, Schooling Attainment and Polygenic Scores: Are There Significant Gene-Environment Associations? By Amin, Vikesh; Behrman, Jere R.; Fletcher, Jason M.; Flores, Carlos A.; Flores-Lagunes, Alfonso; Kohler, Hans-Peter
  11. Widening the High School Curriculum to Include Soft Skill Training: Impacts on Health, Behaviour, Emotional Wellbeing and Occupational Aspirations By Lordan, Grace; McGuire, Alistair
  12. Long Term Health Efect of Earned Income Tax Credit By Ze Sogn
  13. Does Stimulating Physical Activity Affect School Performance? By Golsteyn, Bart H.H.; Jansen, Maria W. J.; Van Kann, Dave H. H.; Verhagen, Annelore
  14. Air Pollution During Pregnancy and Birth Outcomes in Italy By Alessandro Palma; Inna Petrunyk; Daniela Vuri
  15. Effect of an Abrupt Change in Sexual and Reproductive Health Policy on Adolescent Birth Rates in Ecuador, 2008–2017 By Omar Galárraga; Jeffrey E. Harris
  16. Battling Antibiotic Resistance: Can Machine Learning Improve Prescribing? By Michael Allan Ribers; Hannes Ullrich
  17. Welfare Costs of Catastrophes: Lost Consumption and Lost Lives By Ian W.R. Martin; Robert S. Pindyck
  18. Questioning the stereotype of the "malingering bureaucrat" absence from work in the public and private sector in Germany By Prümer, Stephanie; Schnabel, Claus
  19. Implications of Increasing College Attainment for Aging in General Equilibrium By Conesa, Juan Carlos; Kehoe, Timothy J.; Nygard, Vegard; Raveendranathan, Gajendran

  1. By: Björkegren, Evelina (Uppsala University); Lindahl, Mikael (University of Gothenburg); Palme, Mårten (Stockholm University); Simeonova, Emilia (Johns Hopkins University)
    Abstract: We use data on a large sample of Swedish-born adoptees and their biological and adopting parents to decompose the persistence in health inequality across generations into pre-birth and post-birth components. We use three sets of measures for health outcomes in the second generation: mortality, measures based on data on hospitalization and, finally, measures using birth outcomes for the third generation. The results show that all of the persistence in mortality is transmitted solely via pre-birth factors, while the results for the hospitalization measures suggest that at least three quarters of the intergenerational persistence in health is attributable to the biological parents.
    Keywords: health inequality, intergenerational transmission, nature and nurture
    JEL: I10 I14
    Date: 2019–06
  2. By: Timothy J. Layton; Nicole Maestas; Daniel Prinz; Boris Vabson
    Abstract: Public health insurance benefits in the U.S. are increasingly provided by private firms, despite mixed evidence on welfare effects. We investigate the impact of privatization in Medicaid by exploiting the staggered introduction of county-level mandates in Texas that required disabled beneficiaries to switch from public to private plans. Compared to the public program, which used blunt rationing to control costs, we find privatization led to improvements in healthcare—including increased consumption of high-value drug treatments and fewer avoidable hospitalizations—but also higher Medicaid spending. We conclude that private provision can be beneficial when constraints in the public setting limit efficiency.
    JEL: H51 H53 H75 I13 I18
    Date: 2019–07
  3. By: Timothy J. Halliday; Randall Q. Akee; Tetine Sentell; Megan Inada; Jill Miyamura
    Abstract: In March 2015, the State of Hawaii stopped covering the vast majority of migrants from countries belonging to the Compact of Free Association (COFA) in the state Medicaid program. COFA migrants were instead required to obtain private insurance in the exchanges established under the Affordable Care Act. Using statewide administrative hospital discharge data, we show that Medicaid-funded hospitalizations and emergency room visits declined in this population by 69% and 42% after the expiration of Medicaid eligibility. This decrease occurred despite the fact that low-income COFA households were eligible for state-funded premium coverage for private insurance. Utilization funded by private insurance did increase, but not enough to offset the declines in Medicaid-funded utilization. Uninsured ER visits increased as a consequence of the expiration of Medicaid benefits. Paradoxically, we also find a substantial increase in Medicaid-funded ER visits by infants after the expiration of benefits.
    JEL: I10 I14 J61
    Date: 2019–07
  4. By: Darius N. Lakdawalla; Charles E. Phelps
    Abstract: Cost-effectiveness analysis (CEA) remains the de-facto method of choice to evaluate and compare medical interventions. Standard approaches to CEA use the average (mean) outcomes from clinical effectiveness studies such as randomized controlled trials. This paper generalizes standard methods to include uncertainty in clinical outcomes and proposes a generalized version of the quality-adjusted life-year (QALY), referred to as a quality- and risk-adjusted life-year (QRALY). Our approach requires new information from clinical studies – not only means and variances of health outcomes, but also skewness. With that added parameter, this paper shows how Taylor Series expansions of expected utility can account for two distinct effects of uncertainty: the “insurance value” of reducing overall risks to health, and the “value of hope” produced by the presence of positively skewed outcomes. Simulations demonstrate that stochastic terms are particularly important when baseline disease severity is high, and mean treatment effects are low. They also demonstrate that the variance-based term has the greatest importance among the stochastic terms, although skewness- and kurtosis-based terms can be significant in some situations.
    JEL: I1 I13 I18
    Date: 2019–07
  5. By: Philip Oreopoulos; Uros Petronijevic
    Abstract: We present results from a five-year effort to design promising online and text-message interventions to improve college achievement through several distinct channels. From a sample of nearly 25,000 students across three different campuses, we find some improvement from coaching-based interventions on mental health and study time, but none of the interventions we evaluate significantly influences academic outcomes (even for those students more at risk of dropping out). We interpret the results with our survey data and a model of student effort. Students study about five to eight hours fewer each week than they plan to, though our interventions do not alter this tendency. The coaching interventions make some students realize that more effort is needed to attain good grades but, rather than working harder, they settle by adjusting grade expectations downwards. Our study time impacts are not large enough for translating into significant academic benefits. More comprehensive but expensive programs appear more promising for helping college students outside the classroom.
    JEL: I2 J24
    Date: 2019–07
  6. By: Yleania Brilli; Claudio Lucifora (Università Cattolica del Sacro Cuore; Dipartimento di Economia e Finanza, Università Cattolica del Sacro Cuore); Antonio Russo; Marco Tonello
    Abstract: We analyze the effects of a vaccination program providing free flu vaccine to individuals aged 65 or more on take-up and hospitalization. By using linked patient-general practitioner (GP) data, we implement a regression discontinuity design around the threshold at age 65. We find that the program increases vaccination take-up by 6 percentage points, which corresponds to 75% of the take-up for non-eligible individuals, and reduces the probability of hospitalization by about 44%. We show that the effect on take-up is not entirely due to an income channel, and that the effect on health is mainly driven by patients with higher-quality GPs and emergency hospitalizations.
    Keywords: vaccination, influenza, public health, health prevention policies.
    JEL: I12 I18 J10
    Date: 2019–07
  7. By: Dellaert, B.G.C.; Johnson, E.J.; Baker, T.
    Abstract: Health insurance decisions are a challenge for many consumers and influence welfare, health outcomes, and longevity. Two choice architecture tools are examined that can improve these decisions: informed ordering of options (from best to worst) and choice set partitioning. It is hypothesized that these tools can improve choices by changing: (1) decision focus: the options in a set on which consumers focus their attention, and (2) decision strategy: how consumers integrate the different attributes that make up the options. The first experiment focuses on the mediating role of the hypothesized decision processes on consumer decision outcomes. The outcome results are validated further in a field study of over 40,000 consumers making actual health insurance choices and in two additional experiments. The results show that informed ordering and partitioning can reduce consumers’ mistakes by hundreds of dollars per year. They suggest that wise choice architecture interventions depend upon two factors: The quality of the user model possessed by the firm to predict consumers’ best choice and possible interactions among the ensemble of choice architecture tools.
    Keywords: choice architecture, decision-making, consumer decision process, health insurance choice, consumer welfare
    Date: 2019–07–01
  8. By: Aaron Chalfin; Benjamin Hansen; Rachel Ryley
    Abstract: For every crime there is a victim. However nearly all studies in the economics of crime have focused the causal determinants of criminality. We present novel evidence on the causal determinants of victimization, focusing on legal access to alcohol. The social costs of alcohol use and abuse are sizable and well-documented. We find criminal victimization for both violent and property crimes increases noticeably at age 21. Effects are not present at other birthdays and do not appear to be driven by a birth-day "celebration effect." The effects are particularly large for sexual assaults, especially those that occur in public locations. Our results suggest prior research which has focused on criminality has understated the true social costs associated with increased access to alcohol.
    JEL: D8 I1 I12 K42
    Date: 2019–07
  9. By: Moroni, Gloria (University of York); Nicoletti, Cheti (University of York); Tominey, Emma (University of York)
    Abstract: Informed by the psychological literature and our empirical evidence we provide new insights into the technology of socio-emotional skill formation in middle childhood. In line with economic evidence, increasing parental inputs that enrich the child home environment and reduce stress has larger returns for children with higher socio-emotional skills in early childhood (complementarity), but only for levels of inputs that are high. For low levels of inputs, i.e. levels implying a stressful home environment, an increase has a higher return for children with lower socio-emotional skills in early childhood (substitutability). Consequently, well targeted policies can reduce middle childhood socio-emotional gaps.
    Keywords: socio-emotional skills, complementarities, substitutabilities, parenting styles, mother's mental health, time investment, child behavioural disorders, diathesis-stress hypothesis
    JEL: J13 D10 I10 I31
    Date: 2019–06
  10. By: Amin, Vikesh (Central Michigan University); Behrman, Jere R. (University of Pennsylvania); Fletcher, Jason M. (University of Wisconsin-Madison); Flores, Carlos A. (California Polytechnic State University); Flores-Lagunes, Alfonso (Syracuse University); Kohler, Hans-Peter (University of Pennsylvania)
    Abstract: It is well-established that (1) there is a large genetic component to mental health, and (2) higher schooling attainment is associated with better mental health. Given these two observations, we test the hypothesis that schooling may attenuate the genetic predisposition to poor mental health. Specifically, we estimate associations between a polygenic score (PGS) for depressive symptoms, schooling attainment and gene-environment (GxE) interactions with mental health (depressive symptoms and depression), in two distinct United States datasets at different adult ages- 29 years old in the National Longitudinal Study of Adolescent Health (Add Health) and 54 years old in the Wisconsin Longitudinal Study (WLS). OLS results indicate that the association of the PGS with mental health is similar in Add Health and the WLS, but the association of schooling attainment is much larger in Add Health than in the WLS. There is some suggestive evidence that the association of the PGS with mental health is lower for more-schooled older individuals in the WLS, but there is no evidence of any significant GxE associations in Add Health. Quantile regression estimates also show that in the WLS the GxE associations are statistically significant only in the upper parts of the conditional depressive symptoms score distribution. We assess the robustness of the OLS results to omitted variable bias by using the siblings samples in both datasets to estimate sibling fixed-effect regressions. The sibling fixed-effect results must be qualified, in part due to low statistical power. However, the sibling fixed-effect estimates show that college education is associated with fewer depressive symptoms in both datasets.
    Keywords: schooling, mental health, genetics, gene-environment interactions
    JEL: I21 I10
    Date: 2019–06
  11. By: Lordan, Grace (London School of Economics); McGuire, Alistair (London School of Economics)
    Abstract: From 2020 Personal, Social, Health and Economic Education will be compulsory in UK schools for adolescents, however less is known about how it can be taught in a an effective manner. We examine, through a randomised trial, the impact of an evidenced based health related quality of life (HRQoL) curriculum called Healthy Minds that ran in 34 high schools in England over a four-year period. We find robust evidence that Healthy Minds positively augments many physical health domains of treated adolescents. We also find some evidence that Healthy Minds positively affects behaviour, but has no impact on emotional wellbeing. We find notable gender effects, strongly favouring boys. We also present evidence that Healthy Minds changes career aspirations, with those exposed to treatment being less likely to choose competitive work and more likely to choose work that involves "people-skills". Overall our work illustrates the potential for later childhood interventions to promote HRQoL and develop the career aspirations of adolescents.
    Keywords: soft skills, health related quality of life, character, high school curriculum, personal, social, health and economic education
    JEL: I18 I20
    Date: 2019–06
  12. By: Ze Sogn (Rutgers University)
    Abstract: Using decades of variation in the federal and state Earned Income Tax Credit (EITC) and the Panel Study of Income Dynamics (PSID) dataset, I examine the impact of exposure to EITC expansions in utero and during childhood on health outcomes in adulthood. In order to overcome the confounding relationship between family income and health outcomes, this study uses the maximum EITC benefit as the key variable. Reduced-form estimates show that EITC expansions had a positive impact on self-reported health status. Specific ally, a $1000 increase in the maximum EITC exposure from ages 13 to 18 corresponds with a 0.01 point increase in the reported health status during adulthood. In addition, being exposed to EITC expansions in utero increases reported health status by 0.05 point. Relative to the range of reported health of 1 to 5 and the standard deviation of 0.94, these are very small effects. Nonetheless, these health effects are consequential, associating with increases in both family income and maternal labor supply.
    Keywords: eitc, health
    JEL: I1 H2
    Date: 2019–06–28
  13. By: Golsteyn, Bart H.H. (Maastricht University); Jansen, Maria W. J. (Maastricht University); Van Kann, Dave H. H. (Fontys University of Applied Sciences); Verhagen, Annelore (Maastricht University)
    Abstract: This paper investigates whether encouraging children to become more physically active in their everyday life affects their primary school performance. We use data from a field quasi-experiment called the Active Living Program, which aimed to increase active modes of transportation to school and active play among 8- to 12-year-olds living in low socioeconomic status (SES) areas in the Netherlands. Difference-in-differences estimations reveal that while the interventions increase time spent on physical activity during school hours, they negatively affect school performance, especially among the worst-performing students. Further analyses reveal that increased restlessness during instruction time is a potential mechanism for this negative effect. Our results suggest that the commonly found positive effects of exercising or participating in sports on educational outcomes may not be generalizable to physical activity in everyday life. Policymakers and educators who seek to increase physical activity in everyday life need to weigh the health and well-being benefits against the probability of increasing inequality in school performance.
    Keywords: health behavior, field quasi-experiment, education, physical activity
    JEL: I12 C93 I20
    Date: 2019–06
  14. By: Alessandro Palma (University of Naples Parthenope & CEIS University of Rome "Tor Vergata"); Inna Petrunyk (Leuphana University Lueneburg); Daniela Vuri (CEIS & DEF University of Rome "Tor Vergata")
    Abstract: We investigate the impact of fetal exposure to air pollution on health outcomes at birth in Italy in the 2000s combining information on mother’s residential location from birth certificates with information on PM10 concentrations from air quality monitors. The potential endogeneity deriving from differential pollution exposure is addressed by exploiting as-good-as-random variation in rainfall shocks as an instrumental variable for air pollution concentrations. Our results show that both average levels of PM10 and days above the hazard limit have detrimental effects on birth weight, duration of gestation as well as overall health status at birth. These effects are mainly driven by pollution exposure during the third trimester of pregnancy and further differ in size with respect to the maternal socio-economic status, suggesting that babies born to socially disadvantaged mothers are more vulnerable. Given the non negligible effects of pollution on birth outcomes, further policy efforts are needed to fully protect fetuses from the adverse effects of air pollution and to mitigate the environmental inequality of health at birth.
    Keywords: pollution, particulate matter, birth weight, pre-term birth, environmental policies.
    JEL: I18 J13 Q53 Q58
    Date: 2019–07–12
  15. By: Omar Galárraga; Jeffrey E. Harris
    Abstract: In recent years, several countries have implemented restrictive, abstinence-only policies toward reproductive health, as opposed to comprehensive, adolescent-friendly health services. Little is known, however, about the effects of these restrictive policies on adolescent birth rates at the national level or their differential effects by race and ethnicity. The extant literature is even scarcer in low- and middle-income countries. We fill this knowledge gap by exploiting an unexpected policy change in Ecuador that abruptly reversed course for reproductive health services for adolescent women in 2014. In a difference-in-differences analysis of age-specific birth rates in Ecuador’s 221 cantons, we find that the abrupt policy change was associated with an increase in teen birth rates by 9 births per 1000 women. In a difference-in-difference-in-differences analysis, we find that the policy change was associated with an additional increase of 12 births per 1000 women among those cantons where at least 12 percent of the population is self-declared as indigenous. Our results are robust to changes in standard error clustering, population weighting, logarithmic model specification, adjustments for underreporting, and changes in the year when the new policy went into effect.
    JEL: I12 I18 J13 J18
    Date: 2019–07
  16. By: Michael Allan Ribers; Hannes Ullrich
    Abstract: Antibiotic resistance constitutes a major health threat. Predicting bacterial causes of infections is key to reducing antibiotic misuse, a leading driver of antibiotic resistance. We train a machine learning algorithm on administrative and microbiological laboratory data from Denmark to predict diagnostic test outcomes for urinary tract infections. Based on predictions, we develop policies to improve prescribing in primary care, highlighting the relevance of physician expertise and policy implementation when patient distributions vary over time. The proposed policies delay antibiotic prescriptions for some patients until test results are known and give them instantly to others. We find that machine learning can reduce antibiotic use by 7.42 percent without reducing the number of treated bacterial infections. As Denmark is one of the most conservative countries in terms of antibiotic use, this result is likely to be a lower bound of what can be achieved elsewhere.
    Date: 2019–06
  17. By: Ian W.R. Martin; Robert S. Pindyck
    Abstract: Most of the literature on the economics of catastrophes assumes that such events cause a reduction in the stream of consumption, as opposed to widespread fatalities. Here we show how to incorporate death in a model of catastrophe avoidance, and how a catastrophic loss of life can be expressed as a welfare-equivalent drop in wealth or consumption. We examine how potential fatalities affect the policy interdependence of catastrophic events and "willingness to pay" (WTP) to avoid them. Using estimates of the "value of a statistical life" (VSL), we find the WTP to avoid major pandemics, and show it is large (10% or more of annual consumption) and partly driven by the risk of macroeconomic contractions. Likewise, the risk of pandemics significantly increases the WTP to reduce consumption risk. Our work links the VSL and consumption disaster literatures.
    JEL: D81 H5 Q5 Q58
    Date: 2019–07
  18. By: Prümer, Stephanie; Schnabel, Claus
    Abstract: Public sector employees are often said to have excessive rates of absence from work. Using representative survey data for Germany, we indeed find absenteeism of employees to be higher in the public than the private sector. The differences in the incidence and days of absence showing up in descriptive statistics are substantially reduced and partly disappear in our estimates of hurdle regression models controlling for individuals' socio-demographic characteristics, health status, professional activities, and for many workplace-related factors. Nevertheless, the probability of staying home sick at least once a year is still 5.6 percentage points higher in the public sector, ceteris paribus. This finding refutes popular assertions that differences in absence rates between the sectors are mainly due to structural factors like different compositions of the workforce. We show that the same observable factors play a role for absenteeism in the public and private sector, but we cannot rule out that shirking may play a more important role in the public sector. Nevertheless, we conclude that the stereotype of the "malingering bureaucrat" seems to be an exaggeration, at least for Germany.
    Keywords: absenteeism,public sector,sick leave,Germany
    JEL: I19 J22 H8
    Date: 2019
  19. By: Conesa, Juan Carlos (Stony Brook University); Kehoe, Timothy J. (Federal Reserve Bank of Minneapolis); Nygard, Vegard (Federal Reserve Bank of Minneapolis); Raveendranathan, Gajendran (McMaster University)
    Abstract: We develop and calibrate an overlapping generations general equilibrium model of the U.S. economy with heterogeneous consumers who face idiosyncratic earnings and health risk to study the implications of exogenous trends in increasing college attainment, decreasing fertility, and increasing longevity between 2005 and 2100. While all three trends contribute to a higher old age dependency ratio, increasing college attainment has different macroeconomic implications because it increases labor productivity. Decreasing fertility and increasing longevity require the government to increase the average labor tax rate from 32.0 to 44.4 percent. Increasing college attainment lowers the required tax increase by 10.1 percentage points. The required tax increase is higher under general equilibrium than in a small open economy with a constant interest rate because the reduction in the interest rate lowers capital income tax revenues.
    Keywords: College attainment; Aging; Health care; Taxation; General equilibrium
    JEL: H20 H51 H55 I13 J11
    Date: 2019–05–08

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