nep-hea New Economics Papers
on Health Economics
Issue of 2019‒10‒21
nineteen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. Does Medicare Coverage Improve Cancer Detection and Mortality Outcomes? By Rebecca Myerson; Reginald Tucker-Seeley; Dana Goldman; Darius Lakdawalla
  2. Facilitating Healthy Dietary Habits: An Experiment with a Low Income Population By Belot, Michèle; James, Jonathan; Spiteri, Jonathan
  3. What Difference Does a Diagnosis Make? Evidence from Marginal Patients By Mattan Alalouf; Sarah Miller; Laura R. Wherry
  4. All Medicaid Expansions Are Not Created Equal: The Geography and Targeting of the Affordable Care Act By Craig Garthwaite; John A. Graves; Tal Gross; Zeynal Karaca; Victoria R. Marone; Matthew J. Notowidigdo
  5. The Effects of the Affordable Care Act Medicaid Expansion on Subjective Well-being By Kim, Seonghoon; Koh, Kanghyock
  6. Treatment responses of mental health care providers after a demand shock By Rudy Douven; Minke Remmerswaal; Tobias Vervliet
  7. Can Diffuse Delivery System Reforms Improve Population Health? A Study of the State Innovation Models Initiative By Partha Deb; Anjelica Gangaram; Hoda Khajavi
  8. Subsidy Targeting with Market Power By Maria Polyakova; Stephen P. Ryan
  9. Weight Gains from Trade in Foods: Evidence from Mexico By Giuntella, Osea; Rieger, Matthias; Rotunno, Lorenzo
  10. Stress and Food Preferences: A Lab Experiment with Low-SES Mothers By Belot, Michèle; James, Jonathan; Vecchi, Martina; Vitt, Nicolai
  11. Beauty and Adolescent Risky Behaviours By Colin Green; Luke Wilson; Anwen Zhang
  12. Marriage Equality Laws and Youth Suicidal Behaviors By D. Mark Anderson; Kyutaro Matsuzawa; Joseph J. Sabia
  13. It is Time to Kill the Economic Theory of Suicide By Smith, Gary
  14. Maternal Stress and Birth Outcomes: Evidence from an Unexpected Earthquake Swarm By Kutinova Menclova, Andrea; Stillman, Steven
  15. Validation of the Danish Birth Registration By Jens Kristensen
  16. The influence of health in early adulthood on male fertility By Kieron J. Barclay; Martin Kolk
  17. Educational, Labor-market and Intergenerational Consequences of Poor Childhood Health By Krzysztof Karbownik; Anthony Wray
  18. A Fresh Look at the Health-Wealth Correlation: A Case Study of European Countries By García-Muñoz, Teresa; Neuman, Shoshana; Neuman, Tzahi
  19. Transition from Plan to Market, Height and Well-Being By Adsera, Alicia; Dalla Pozza, Francesca; Guriev, Sergei; Kleine-Rueschkamp, Lukas; Nikolova, Elena

  1. By: Rebecca Myerson; Reginald Tucker-Seeley; Dana Goldman; Darius Lakdawalla
    Abstract: Medicare is the largest government insurance program in the United States, providing coverage for over 60 million people in 2018. This paper analyzes the effects of Medicare insurance on health for a group of people in urgent need of medical care – people with cancer. We used a regression discontinuity design to assess impacts of near-universal Medicare insurance at age 65 on cancer detection and outcomes, using population-based cancer registries and vital statistics data. Our analysis focused on the three tumor sites with recommended screening before and after age 65: breast, colorectal, and lung cancer. At age 65, cancer detection increased by 72 per 100,000 population among women and 33 per 100,000 population among men; cancer mortality also decreased by 9 per 100,000 population for women but did not significantly change for men. In a placebo check, we found no comparable changes at age 65 in Canada. This study provides the first evidence to our knowledge that near-universal access to Medicare at age 65 is associated with improvements in population-level cancer mortality, and provides new evidence on the differences in the impact of health insurance by gender.
    Keywords: cancer detection, Medicare, mortality
    JEL: I10 I13 J16
    Date: 2019–10
  2. By: Belot, Michèle (European University Institute); James, Jonathan (University of Bath); Spiteri, Jonathan (University of Malta)
    Abstract: This paper tests an intervention aimed at facilitating (cognitively) the adoption of healthy dietary habits. We provide easy-to-understand information about the risks of developing diabetes or heart diseases and give easy-to-follow dietary recommendations to minimize these risks. We implement two variations, one consisting of generic information, the other consisting of information tailored to the individual, the latter resembling newly developed on-line health assessment tools. On top of the information treatment, we implement a second experimental variation nudging people into spending more time thinking about their dietary choices. We find evidence that the information intervention leads to healthier choices in the short run, but mostly in the generic treatment. Surprisingly, we find that people are on average pessimistic about their health, and therefore receive good news on average when the information is tailored to them. We find no evidence that increasing the time available to make choices leads to healthier choices, and find no evidence of long-term changes in habits. These results do not support a bounded rationality explanation for poor dietary choices.
    Keywords: health risks, dietary habits, bounded rationality, heuristics, information, time availability, laboratory experiments
    JEL: I12 I18 H51 D83
    Date: 2019–10
  3. By: Mattan Alalouf; Sarah Miller; Laura R. Wherry
    Abstract: Over the past 30 years, the criteria used to diagnose many illnesses have been relaxed, resulting in millions more relatively healthy individuals receiving treatment. This paper explores the impact of receiving a diagnosis of a common disease among such “marginally ill” patients. We apply a regression discontinuity design to the cutoff in blood sugar levels used to classify patients as having diabetes. We find that a marginally diagnosed patient with diabetes spends $1,097 more on drugs and diabetes-related care annually after diagnosis, but find no corresponding changes in self-reported health or healthy behaviors. These increases in spending persist over the 6-year period we observe the patients. These marginally diagnosed patients experience improved blood sugar after the first year of diagnosis, but this improvement does not persist in subsequent years. Other clinical measures of health, such as BMI, blood pressure, cholesterol, and mortality show no improvement. The diagnosis rates for preventable disease-related conditions such as diabetic retinopathy, neuropathy, and kidney disease increase following a diagnosis, likely due to more intensive screening. Our results imply that a small relaxation in the diagnosis cutoff would increase total spending on diabetes-related care by about $2.4 billion annually and minimally impact patient health.
    JEL: I1 I12
    Date: 2019–10
  4. By: Craig Garthwaite; John A. Graves; Tal Gross; Zeynal Karaca; Victoria R. Marone; Matthew J. Notowidigdo
    Abstract: We use comprehensive patient-level discharge data to study the effect of Medicaid on the use of hospital services. Our analysis relies on cross-state variation in the Affordable Care Act’s Medicaid expansion, along with within-state variation across ZIP Codes in exposure to the expansion. We find that the Medicaid expansion increased Medicaid visits and decreased uninsured visits. The net effect is positive for all visits, suggesting that those who gain coverage through Medicaid consume more hospital services than they would if they remained uninsured. The increase in emergency department visits is largely accounted for by “deferrable” medical conditions. Those who gained coverage under the Medicaid expansion appear to be those who had relatively high need for hospital services, suggesting that the expansion was well targeted. Lastly, we find significant heterogeneity across Medicaid-expansion states in the effects of the expansion, with some states experiencing a large increase in total utilization and other states experiencing little change. Increases in hospital utilization were larger in Medicaid-expansion states that had more residents gaining coverage and lower pre-expansion levels of hospital uncompensated care costs.
    JEL: H51 H75 I13
    Date: 2019–09
  5. By: Kim, Seonghoon (Singapore Management University); Koh, Kanghyock (Korea University)
    Abstract: This study analyzes the effects of the 2014 Affordable Care Act (ACA) Medicaid expansion on the subjective well-being of individuals in the United States. Using data from the Panel Study of Income Dynamics, we find that the expansion has significantly improved the overall life satisfaction of low-income non-elderly adults. Various sensitivity checks and falsification tests confirm the internal validity. Our findings imply that, without considering psychological benefits, the actual benefits of the ACA Medicaid expansion may be underemphasized.
    Keywords: Affordable Care Act Medicaid Expansion, health insurance, subjective well-being, life satisfaction, happiness
    JEL: I13 I18 I31
    Date: 2019–09
  6. By: Rudy Douven (CPB Netherlands Bureau for Economic Policy Analysis); Minke Remmerswaal (CPB Netherlands Bureau for Economic Policy Analysis); Tobias Vervliet (CPB Netherlands Bureau for Economic Policy Analysis)
    Abstract: This paper investigates how two different groups of Dutch mental health care providers responded to an exogenous 20% drop in the number of patients in 2012. Providers that operated under a budget increase treatment duration on average by 8%. We fi nd suggestive evidence for over-treatment as the longer treatments did not result in better patient outcomes, i.e. general assessment of functioning scores. Both professional uncertainty and income effects may explain the results. For the group of self-employed providers, paid by a stepwise fee-for-service function, we find only a small signi cant increase in treatment duration for the least altruistic providers, which we relate to an income effect.
    JEL: H51 I11 I12 J22 J31 J33
    Date: 2019–09
  7. By: Partha Deb; Anjelica Gangaram; Hoda Khajavi
    Abstract: We examine the effects of the State Innovation Models (SIM) on population-level health status. The SIM initiative provided $250 million to six states in 2013 for delivery system reforms. We use data from the Behavioral Risk Factor Surveillance System for the years 2010 -- 2016 to compare health of the populations in 6 SIM states to 15 states that were not involved in any aspects of SIM. We examine changes in health using an event study design. We develop a Latent Class Profile model that takes multiple measures of latent health into a common, latent health status to study the effect of the intervention. Such models can yield informative estimates where separate estimation of measures do not. We find that individuals in states that implemented SIM saw significant improvements in health across a number policy-relevant subpopulations.
    JEL: I1 I18
    Date: 2019–10
  8. By: Maria Polyakova; Stephen P. Ryan
    Abstract: In-kind public transfers are commonly targeted based on observable characteristics of potential recipients. This paper argues that when the subsidized good is provided by imperfectly-competitive firms, targeting can give rise to a “demographic externality,” creating unintended redistribution of surplus and distorting efficiency. We illustrate this mechanism empirically in the context of means-tested subsidies for privately-provided health insurance plans under the Affordable Care Act (ACA). Using a structural model of supply and demand, we show that market power increases the welfare loss from subsidy targeting, vis-a-vis income-invariant subsidies, by 33 percent.
    JEL: H0 H2 H20 H21 H22 H23 H31 H41 H5 H51 I1 I10 I11 I13 I18 I38 L0
    Date: 2019–10
  9. By: Giuntella, Osea (University of Pittsburgh); Rieger, Matthias (ISS, Erasmus University Rotterdam); Rotunno, Lorenzo (Aix-Marseille University)
    Abstract: In this paper, we investigate the effects of trade in foods on obesity in Mexico. To do so, we match data on Mexican food imports from the U.S. with anthropometric and food expenditure data. Our findings suggest that exposure to food imports from the U.S. can explain up to twenty percent of the rise in obesity prevalence among Mexican women between 1988 and 2012. Pro-obesity effects are driven by areas more exposed to unhealthy food imports. We also find evidence in favour of a price mechanism. By linking trade flows to obesity, the paper sheds light on an important channel through which globalisation may affect health.
    Keywords: trade, obesity, nutrition transition, Mexico
    JEL: I10 I12
    Date: 2019–10
  10. By: Belot, Michèle (European University Institute); James, Jonathan (University of Bath); Vecchi, Martina (University of Bath); Vitt, Nicolai (Pennsylvania State University)
    Abstract: We investigate whether short-term everyday stressors leads to unhealthier dietary choices among low socioeconomic status mothers. We propose a novel stress protocol that aims to mimic everyday stressors experienced by this population, involving time and financial pressure. We evaluate the impact of stress on immediate and planned food choices, comparing a group exposed to our stress protocol relative to a control group. Immediate consumption is measured with in-laboratory consumption of low calorie and high calorie snacks; planned consumption is measured with an incentivized food shopping task. The stressfulness of the stress protocol is evaluated using subjective assessments, as well as physiological measurements (heart rate and salivary cortisol levels). We find no evidence of an effect of stress on the nutritional content of immediate or planned food consumption, thus no support for the hypothesis that everyday stressors are a likely explanation for unhealthy food choices.
    Keywords: diet, acute stress, everyday stressors, lab experiment
    JEL: I12 D91
    Date: 2019–10
  11. By: Colin Green (Department of Economics, Norwegian University of Science and Technology); Luke Wilson (University of Sheffield); Anwen Zhang (University of Glasgow)
    Abstract: A growing body of research demonstrates marked labour market bene?ts from physical attractiveness. Yet, how physical attractiveness in?uences earlier consequential decisions is not well understood. This paper estimates the effect of attractiveness in adolescence on one set of consequential outcomes, engagement in risky behaviours. We ?nd robust evidence of marked effects of teenage attractiveness across a range of risky behaviours, including underage drinking, smoking, substance abuse and teenage sexual activity. More attractive individuals are more likely to engage in underage drinking, but markedly less likely to smoke or to be sexual active. Mediation analysis reveals that popularity, self-esteem, and personality attractiveness are likely underlying mechanisms. Our ?ndings suggest physical attractiveness in adolescence carries long-lasting consequences over the life course.
    Keywords: beauty, risky behaviours, adolescent development
    JEL: I12 J10
    Date: 2019–10–15
  12. By: D. Mark Anderson; Kyutaro Matsuzawa; Joseph J. Sabia
    Abstract: Since the landmark ruling in Goodridge v. Department of Public Health in 2004, the legalization of same-sex marriage (SSM) has proliferated throughout the United States via either legislative action or court order. Advocates of SSM laws argue that marriage equality will generate important health benefits not only for adult same-sex couples, but also for LGBQ-identifying youths. Using data from the State Youth Risk Behavior Surveys, we explore the relationship between marriage equality and suicidal behaviors among LGBQ-identifying youths. Despite previous research suggesting otherwise, we find little evidence that SSM laws have reduced suicide attempts among teen sexual minorities, nor have they decreased the likelihood of suicide planning, suicide ideation, or depression. Instead, we find some evidence that SSM legalization via judicial mandate is associated with worse mental health for these individuals, consistent with a story of social backlash.
    JEL: I1 I12 J12
    Date: 2019–10
  13. By: Smith, Gary (Pomona College)
    Abstract: A seminal paper by Hamermesh and Soss modeled suicide as a rational economic decision based on a comparison of the financial costs and benefits of staying alive. Their model is fundamentally flawed and their prediction that suicide rates increase with age is wrong.
    Keywords: suicides, health, depression, economic sociology
    Date: 2019–01–01
  14. By: Kutinova Menclova, Andrea (University of Canterbury); Stillman, Steven (Free University of Bozen/Bolzano)
    Abstract: We examine the impact of a major earthquake that unexpectedly affected the Canterbury region of New Zealand on a wide-range of birth outcomes, including birth weight, gestational age and an indicator of general newborn health. We control for observed and unobserved differences between pregnant women in the area affected by the earthquake and other pregnant women by including mother fixed effects in all of our regression models. We extend the previous literature by comparing the impact of the initial unexpected earthquake to the impacts of thousands of aftershocks that occurred in the same region over the 18 months following the initial earthquake. We find that exposure to these earthquakes reduced gestational age, increased the likelihood of having a late birth and negatively affected newborn health - with the largest effects for earthquakes that occurred in the first and third trimesters of pregnancy. Our estimates are similar when we focus on just the impact of the initial earthquake or, in contrast, on all earthquakes controlling for endogenous location decisions using an instrumental variables approach. This suggests that the previous estimates in the literature that use this approach are likely unbiased and that treatment effects are homogenous in the population. We present supporting evidence that the likely channel for these adverse effects is maternal stress.
    Keywords: maternal stress, pregnancy, earthquakes, birth weight, Apgar score
    JEL: I12 J13 I31
    Date: 2019–09
  15. By: Jens Kristensen (University of Copenhagen)
    Abstract: We assessed validity and reliability of data on four serious pregnancy complications and gestational age in two national registers, the Medical Birth Register (MBR) and the National Register of Hospital Discharges (NRHD). From a cohort of all women in Denmark who gave birth to their first and second singleton infant in 1982-1987, a review was made of a selected sample of 1662 medical records. Regarding registration of pregnancy complications, there was good agreement (kappa above 0.6) between medical records and the registers, and between the registers. However, there was a tendency toward understatement evidenced by low sensitivity of three of four pregnancy complications. The level of agreement (43%) for length of gestation was disappointing. The number of systematic and nonsystematic errors indicate that there was about 52% more singleton preterm deliveries in Denmark in 1982 than previously reported (6.9% instead of 4.5%). It is concluded that the validity of the Danish birth registers should be improved by explicit definitions, increased use of raw data, and data collection by motivated professionals at birth.
    Keywords: Epidemiologi, preterm, registerstudy
    Date: 2019–10
  16. By: Kieron J. Barclay (Max Planck Institute for Demographic Research, Rostock, Germany); Martin Kolk
    Abstract: Despite the large literature examining socioeconomic predictors of fertility and the influence of reproductive history on post-reproductive mortality, previous research has not offered a population-level perspective on how male health in early adulthood is related to subsequent fertility. Using Swedish population registers and military conscription data, we study how body mass index (BMI), physical fitness and height are associated with total fertility and parity transitions by 2012 amongst 405,427 Swedish men born 1965-1972, meaning we observe fertility up to age 40 or older. Applying linear regression as well as sibling fixed effects, we find that our anthropometric measures are strong predictors of later fertility, even after accounting for educational attainment and cumulative income up to age 40. Men with a 'normal' BMI and in the highest decile of physical fitness have the most children by the end of our follow-up period. Men who were already obese at ages 17-20 had a relative probability of childlessness almost twice as high as men who had a 'normal' BMI at ages 17-20, and men in the bottom decile of physical fitness had a relatively probability of childlessness almost 50% higher than men in the top decile of physical fitness. These patterns were at least as strong in our models applying the sibling fixed effects design. We find that the association between male height and fertility is curvilinear in models estimated without sibling fixed effects, but only men in the lowest decile of height have lower fertility in sibling comparison models. Further analyses show that the strong associations between our anthropometric measures and male fertility persist even amongst men who married. We discuss the implications of our findings for fertility in high-income countries in light of secular increases in the prevalence of overweight/obesity.
    Keywords: Sweden, anthropometry, body height, body weight, cohort fertility, fertility, health, population registers, siblings
    JEL: J1 Z0
    Date: 2019–10
  17. By: Krzysztof Karbownik; Anthony Wray
    Abstract: We study whether childhood health capital affects school attendance, long-run occupational outcomes, and intergenerational mobility. We address this question in the context of London, England during the late-nineteenth century using the inpatient admission records of three large hospitals linked to population census records, from which we identify household characteristics and the patients’ siblings. Sibling fixed effects estimates indicate that boys with health deficiencies were 14.9 percent less likely to work in white collar occupations as adults and 13.9 percent more likely to experience downward occupational mobility relative to their fathers, in comparison to their brothers. This negative effect offsets 16.2 percent of the benefit of having a father in a high status occupation. We also explore medium-run mechanisms for both boys and girls, and find that poor childhood health reduced the likelihood of attending school by 2.5 and 4.1 percent, respectively.
    JEL: I14 J62 N33
    Date: 2019–10
  18. By: García-Muñoz, Teresa (Universidad de Granada); Neuman, Shoshana (Bar-Ilan University); Neuman, Tzahi (Hebrew University, Jerusalem)
    Abstract: This paper contributes to the development-health literature by studying the correlation between development measures (see below) and health measures - one subjective ('self-assessed-health-status'), and the other one objective (the individual's 'number of chronic diseases'). Correlations are examined for 29 European countries, using the SHARE data set, and country-level development measures. Specifically, we examine whether country fixed-effects in regressions of health measures, controlling for individual socio-demographic variables, are significantly correlated with country development variables, which include: logarithm of per-capita GDP; the Human Development Index; the Social Progress Index; life expectancy; percentage of GDP spent on health; and the novel measure expressed by the Environmental Health Index. The novelty of our study is the introduction of a channel for the significant health-wealth correlation, speculating that the driving forces are psychological.
    Keywords: development, self-assessed-health-status, diseases, environmental hazards, psychological motives, SHARE, Europe
    JEL: I1 I15
    Date: 2019–10
  19. By: Adsera, Alicia (Princeton University); Dalla Pozza, Francesca (EBRD, London); Guriev, Sergei (New Economic School, Moscow); Kleine-Rueschkamp, Lukas (University of Oxford); Nikolova, Elena (Central European Labour Studies Institute)
    Abstract: Using newly available data, we re-evaluate the impact of transition from plan to market in former communist countries on objective and subjective well-being. We find clear evidence of the high social cost of early transition reforms: cohorts born around the start of transition are shorter than their older or younger peers. The difference in height suggests that the first years of reform in former communist countries were accompanied by major deprivation. We provide suggestive evidence on the importance of three mechanisms which partially explain these results: the decline of GDP per capita, the deterioration of healthcare systems, and food scarcity. On the bright side, we find that cohorts that experienced transition in their infancy are now better educated and more satisfied with their lives than their counterparts. Taken together, our results imply that the transition process has been a traumatic experience, but that its negative impact has largely been overcome.
    Keywords: transition from plan to market, structural reforms, height, well-being, Russia
    JEL: P36 I14 I31 O12
    Date: 2019–09

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