nep-hea New Economics Papers
on Health Economics
Issue of 2019‒12‒09
nineteen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. Why are there long waits at English emergency departments? By Gaughan, James; Kasteridis, Panagiotis; Mason, Anne; Street, Andrew
  2. The "Red Herring" after 20 Years: Ageing and Health Care Expenditures By Friedrich Breyer; Normann Lorenz
  3. How Do Low-Income Enrollees in the Affordable Care Act Marketplaces Respond to Cost-Sharing? By Lavetti, Kurt; DeLeire, Thomas; Ziebarth, Nicolas R.
  4. Hospital Closures and Short-Run Change in Ambulance Call Times By Chaudhary, Sookti; Davis, Alison; Troske, Kenneth; Troske, SuZanne
  5. School Tracking and Mental Health By Böckerman, Petri; Haapanen, Mika; Jepsen, Christopher; Roulet, Alexandra
  6. The Earned Income Tax Credit and Infant Health Revisited By Daniel L. Dench; Theodore J. Joyce
  7. Income Mobility, Income Inequality and Mortality in the U.S. By Daza, Sebastian; Palloni, Alberto
  8. Does Access to Health Care Mitigate Environmental Damages? By Mullins, Jamie; White, Corey
  9. Health Dynamics Shape Life-Cycle Incomes By Rainer Franz Kotschy
  10. Fair Innings? The Utilitarian and Prioritarian Value of Risk Reduction over a Whole Lifetime By Adler, Matthew; Ferranna, Maddalena; Hammitt, James K.; Treich, Nicolas
  11. Consumer Preferences for Sustainable and Healthy Lifestyle: Five-Country Discrete Choice Experiments By Milan Scasny; Iva Zverinova; Vojtech Maca
  12. Passive Diagnosis of Mental Health Disorders Incorporating an Empathic Dialogue System By Delahunty, Fionn; Arcan, Mihael; Johansson, Robert
  13. Time-Varying Income Elasticities of Healthcare Expenditure for the OECD and Eurozone By Isabel Casas; Jiti Gao; Bin Peng; Shangyu Xie
  14. Deaths without denominators: using a matched dataset to study mortality patterns in the United States By Alexander, Monica
  15. The Intergenerational Transmission of Health in the United States: A Latent Variables Analysis By Halliday, Timothy J.; Mazumder, Bhashkar; Wong, Ashley
  16. Healthy Childhood in Kazakhstan: underweight and overweight By Kurmanov, Bakhytzhan; Pena-Boquete, Yolanda; Samambayeva, Aizhan; Makhmejanov, Galym
  17. Experiences with Government Sponsored Health Insurance Schemes in Indian States: A Fiscal Perspective. By Choudhury, Mita; Tripathi, Shruti; Dubey, Jay Dev
  18. Structure and dynamics of populations: The ‘years-to-live’ pyramid, national aspects and regional examples. By Riffe, Tim; Brouard, Nicolas
  19. 2018 OHE Annual Report to the Charity Commission By Office of Health Economics

  1. By: Gaughan, James; Kasteridis, Panagiotis; Mason, Anne; Street, Andrew
    Abstract: A core performance target for the English National Health Service (NHS) concerns waiting times at Emergency Departments (EDs), with the aim of minimising long waits. We investigate the drivers of long waits. We analyse weekly data for all major EDs in England from April 2011 to March 2016. A Poisson model with ED fixed effects is used to explore the impact on long (> 4 h) waits of variations in demand (population need and patient case-mix) and supply (emergency physicians, introduction of a Minor Injury Unit (MIU), inpatient bed occupancy, delayed discharges and long-term care). We assess overall ED waits and waits on a trolley (gurney) before admission. We also investigate variation in performance among EDs. The rate of long overall waits is higher in EDs serving older patients (4.2%), where a higher proportion of attendees leave without being treated (15.1%), in EDs with a higher death rate (3.3%) and in those located in hospitals with greater bed occupancy (1.5%). These factors are also significantly associated with higher rates of long trolley waits. The introduction of a co-located MIU is significantly and positively associated with long overall waits, but not with trolley waits. There is substantial variation in waits among EDs that cannot be explained by observed demand and supply characteristics. The drivers of long waits are only partially understood but addressing them is likely to require a multi-faceted approach. EDs with high rates of unexplained long waits would repay further investigation to ascertain how they might improve.
    Keywords: Accident and emergency (A&E); Emergency department (ED); Length of stay; National health service (NHS); Waiting time
    JEL: I10
    Date: 2019–10–24
  2. By: Friedrich Breyer; Normann Lorenz
    Abstract: 20 years ago, Zweifel, Felder and Meier (1999) established the by now famous “red-herring” hypothesis, according to which population ageing does not lead to an increase in per capita health care expenditures (HCE) because the observed positive correlation between age and health care expenditures (HCE) in cross-sectional data is exclusively due to the facts that mortality rises with age and a large share of HCE is caused by proximity to death. This hypothesis has spurned a large and still growing literature on the causes and consequences of growing HCE in OECD countries, but the results of empirical studies have been rather mixed. In light of the imminent population ageing in many of these countries it is still being discussed whether unfunded social health insurance systems will be sustainable, in particular as long as they promise to provide universal and unlimited access to medical care including the latest advances. In this paper, we present a critical survey of the empirical literature of the past 20 years on this topic and draw some preliminary conclusions regarding the policy question mentioned above. In doing so we distinguish four different versions of the red herring hypothesis and derive the logical connections between them. This will help to understand what empirical findings are suitable to derive predictions on the future sustainability of HCE.
    Keywords: health care expenditures, ageing, red-herring hypothesis
    JEL: H51 J11 I19
    Date: 2019
  3. By: Lavetti, Kurt (Ohio State University); DeLeire, Thomas (Georgetown University); Ziebarth, Nicolas R. (Cornell University)
    Abstract: The ACA requires insurers to provide cost-sharing reductions (CSRs) to low-income consumers on the marketplaces. We link 2013-2015 All-Payer Claims Data to 2004-2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the value of CSRs that are solely determined by income. We find that enrollees with lower cost sharing have higher levels of health care spending, controlling for past health care use. We estimate the demand elasticity of total health care spending to be -0.10, but find larger elasticities for emergency room care, lifestyle drugs, and low-value care. We also find positive cross-price elasticities between outpatient and inpatient care.
    Keywords: demand elasticities, health insurance, moral hazard, ACA, marketplaces, AV-variants, low-value care, lifestyle drugs, value-based CSRs, Utah
    JEL: H24 H41 H43 H51 I11 I18 J32 J33 J68
    Date: 2019–10
  4. By: Chaudhary, Sookti (University of Kentucky); Davis, Alison (University of Kentucky); Troske, Kenneth (University of Kentucky); Troske, SuZanne (University of Kentucky)
    Abstract: We measure one aspect of how access to emergency care through ambulance services changes for patients when a hospital closes. We empirically estimate the time needed to transport a patient to an emergency department in an ambulance in the period immediately after the hospital closes. We find urban patients in zip codes where a hospital closes have a small change in transportation time, where rural patients average an estimated 15.7 additional minutes – a 46% increase compared to the year before the closure. This increase is primarily the result of an almost 100 percent increase in the time it takes to transport a patient from the location of the incident to the hospital. The impact on rural Medicare-eligible patients is even larger. We find no change in the time it takes ambulances to arrive at an incident and only a small change in the time spent at the scene.
    Keywords: ambulance, hospital closure, access to care, rural vs urban
    JEL: I11 I14 I18 R10
    Date: 2019–11
  5. By: Böckerman, Petri (Labour Institute for Economic Research); Haapanen, Mika (Jyväskylä University School of Business and Economics); Jepsen, Christopher (University College Dublin); Roulet, Alexandra (INSEAD)
    Abstract: We examine the effects of a comprehensive school reform on mental health. The reform postponed the tracking of students into vocational and academic schools from age 11 to age 16. The reform was implemented gradually across Finnish municipalities between 1972 and 1977. We use difference-in-differences variation and administrative data. Our results show that there is no discernible effect on mental health related hospitalizations on average even though the effect is precisely estimated. Heterogeneity analysis shows that, after the reform, females from highly-educated families were more likely to be hospitalized for depression.
    Keywords: tracking age, comprehensive school, mental health, depression, hospitalization
    JEL: I12 I26 I28
    Date: 2019–10
  6. By: Daniel L. Dench; Theodore J. Joyce
    Abstract: Hoynes, Miller and Simon (2015), henceforth HMS, report that the national expansion of the Earned Income Tax Credit (EITC) is associated with decreases in low birth weight. We question their findings. HMS’s difference-in-differences estimates are unidentified in some comparisons, while failed placebo tests undermine others. Their effects lack a plausible mechanism as the association between the EITC and prenatal smoking also fails placebo tests. We contend that the waning of the crack epidemic is a possible confound, but we show that any number of policies directed at poor women also eliminate the effect of the EITC when aggregated to the national level. Identifying small, causal effects of a national policy at a single point in time is exceedingly challenging.
    JEL: H24 I38 J13
    Date: 2019–11
  7. By: Daza, Sebastian; Palloni, Alberto
    Abstract: We assess the magnitude of the association between intergenerational income mobility and US adult mortality by gender, age group, race/ethnicity and the causes of death. We use a data set from The Health Inequality Project and CDC mortality data at the county level. We find that under different model specifications the association between income mobility and adult mortality is strong, properly signed, and consistent with our hypotheses. If the association we find reflects a causal effect it would translate into shifts in life expectancy at age 40 of as much as 2.0-4.8 years among males and 0.1-2.0 among females, equivalent to 5.1-12.5 and 0.2-4.7 percent of the U.S. male and female life expectancy at age 40 respectively. On average, these effects are 1.5 to 2.5 times as large as those of income inequality and represent between 40 (males) and 25 (females) percent of the magnitude of an income shift from the lowest to the highest quartile of the U.S. income distribution.
    Date: 2018–11–12
  8. By: Mullins, Jamie (University of Massachusetts Amherst); White, Corey (California Polytechnic State University)
    Abstract: Differential access to health care is commonly cited as a source of heterogeneity in the health effects of environmental exposure, yet little causal evidence exists to support such claims. We test this hypothesis by utilizing exogenous variation in both access to health care and environmental exposure. Variation in access to care is derived from the roll-out of Community Health Centers (CHCs) across US counties in the 1960s and 1970s, and variation in environmental exposure comes from random year-to-year fluctuations in ambi-ent temperature within counties. We find that the provision of primary care through CHCs mitigates the relationship between heat and mortality by approximately 15%. Our results suggest that differential access to health care does contribute to observed heterogeneity in environmental health damages, and that improving access to primary care may be a useful means of mitigating harm from a warming climate.
    Keywords: health care, access, climate, temperature, environment
    JEL: I10 I14 I18 Q50 Q52 Q54 Q58
    Date: 2019–10
  9. By: Rainer Franz Kotschy
    Abstract: This paper empirically investigates the long-run effects of major health improvements on income growth in the United States. To isolate exogenous changes in health, the econometric model uses quasi-experimental variation in cardiovascular disease mortality across states over time. The results show that there is a causal link between health and income per person, and they provide novel evidence that health dynamics shape life-cycle incomes. Compared to previous generations, life-cycle income profiles slope more strongly at the beginning and at the end of work life, such that age becomes a more prominent determinant of income dynamics. The channels for this transformation include better health, higher educational attainment, and changing labor supply.
    Keywords: age, mortality, life expectancy, productivity, education, labor supply
    JEL: I15 J11 J24 J31 O40
    Date: 2019
  10. By: Adler, Matthew; Ferranna, Maddalena; Hammitt, James K.; Treich, Nicolas
    Abstract: The social value of risk reduction (SVRRi) is the marginal social value of reducing an individual’s fatality risk, as measured by some social welfare function (SWF). This Article investigates SVRR, using a lifetime utility model in which individuals are differentiated by age, lifetime income profile, and lifetime risk profile. We consider both the utilitarian SWF and a “prioritarian” SWF, which applies a strictly increasing and concave transformation to individual utility. We show that the prioritarian SVRR provides a rigorous basis in economic theory for the “fair innings” concept, proposed in the public health literature: as between an older individual and a similarly situated younger individual (one with the same income and risk profile), a risk reduction for the younger individual is accorded greater social weight even if the gains to expected lifetime utility are equal. The comparative statics of prioritarian and utilitarian SVRRs with respect to age, and to (past, present, and future) income and baseline survival probability, are significantly different from the conventional value per statistical life (VSL). Our empirical simulation based upon the U.S. population survival curve and income distribution shows that prioritarian SVRRs with a moderate degree of concavity in the transformation function conform to lay moral judgments regarding lifesaving policies: the young should take priority but income should make no difference.
    Keywords: Social welfare function (SWF); benefit-cost analysis (BCA); value of statistical life (VSL); fair innings; social value of risk reduction (SVRR); utilitaria; prioritarian; risk regulation
    Date: 2019–11
  11. By: Milan Scasny (Institute of Economic Studies, Faculty of Social Sciences, Charles University, Opletalova 26, 110 00, Prague, Czech Republic; Charles University Environment Centre, José Martího 407/2, 162 00, Prague, Czech Republic); Iva Zverinova (Charles University Environment Centre, José Martího 407/2, 162 00, Prague, Czech Republic); Vojtech Maca (Charles University Environment Centre, José Martího 407/2, 162 00, Prague, Czech Republic)
    Abstract: Consumers preferences for sustainable and healthier lifestyle are examined through stated preference discrete choice experiments. Specifically, we introduce several choice situations in which each respondent was asked to choose the best from three lifestyles presented, including the respondent’s current lifestyle. Each lifestyle alternative is described by a different diet, health risks, and monetary costs. Diet is described by a number of portions of five different food items eaten per week (fruits and vegetables, meat, fish, legumes, and confectionery, ice-cream and sugar-sweetened drinks). Using a split-sample treatment, lifestyles are then described by either physical activities or environmental impacts (in kg of CO2 emissions). We also examine the effect of self-affirmation and information about the environmental impacts provided separately or in a combination. A non-linear preference is tested for increasing versus decreasing cost of food expenditures. Preferences are analysed using an original stated preference survey conducted in five EU countries (the Czech Republic, Latvia, Portugal, Spain, and in the United Kingdom) in summer 2018, with dataset consisting of 10,288 observations. We find that importance of lifestyle attributes varies across the countries and information treatments. The cost is significant in every country, indicating that lower costs lead to a higher probability of choosing the alternative lifestyle. Reducing health risks and environmental impact motivated respondents to change their lifestyle, even though reducing 1 kg CO2 due to food consumption a week is valued 3–6 times less than reducing cardiovascular risk by one percent. Still, the implied WTP for a tone CO2 abatement is in a range of 300–1,200 Euro and VSC of cardiovascular disease lies between 4,000 and 35,000 Euro, depending on country and DCE variant. Increasing physical activity increases the likelihood of changing lifestyle only in Latvia and Portugal. Most respondents prefer to keep eating meat and eliminating meat or fish from food consumption is associated with large dis-benefit. Respondents also prefer to increase portions of health-improving vegetables and fruits, however, this is not the case of pulses.
    Keywords: Discrete choice experiment, willingness to pay, sustainable lifestyle, healthy diets, consumer preferences, physical activity, health risk, CO2 emissions
    JEL: D12 H31 Q51 R22
    Date: 2019–06
  12. By: Delahunty, Fionn; Arcan, Mihael; Johansson, Robert
    Abstract: Depression and anxiety are the two most prevalent mental health disorders worldwide, impacting the lives of millions of people each year. Current screening methods require individuals to manually complete psychometric questionnaires. In this work we develop a deep learning approach to predict psychometric scores given textual data through the use of psycholinguistics features. Data is collected via a dialogue system, were we develop and incorporate an approach to model empathy. Which aims to allow for appropriate use of these systems in a clinical setting. Following a public evaluation, we demonstrate that our approach to model empathy can out perform a similarly trained non empathic approach. Additionally, we show that our deep learning prediction approach performed well on evaluation data, but has difficulty generalizing to experimentally collected data. Limitations and implications as a result of this work are discussed.
    Date: 2019–10–07
  13. By: Isabel Casas; Jiti Gao; Bin Peng; Shangyu Xie
    Abstract: Income elasticity dynamics of health expenditure is considered for the OECD and Eurozone over the period 1995-2014. Motivated by some modelling challenges, this paper studies a class of non-linear cointegration panel data models, controlling for cross-section dependence and certain endogeneity. Using the corresponding methods, our empirical analyses show a slight increase in the income elasticity of the healthcare expenditure over the years, but still with values under 1, meaning that healthcare is not a luxury good in the OECD and Eurozone.
    Keywords: health expenditure, income elasticity, nonparametric kernel smoothing, nonstationarity
    JEL: C14 C23 H51
    Date: 2019
  14. By: Alexander, Monica
    Abstract: To understand national trends in mortality over time, it is important to study differences by demographic, socioeconomic and geographic characteristics. One issue with studying mortality inequalities, particularly by socioeconomic status, is that there are few micro-level data sources available that link an individual's SES with their eventual age and date of death. In this paper, a new dataset for studying mortality disparities and changes over time in the United States is presented. The dataset, termed 'CenSoc', uses two large-scale datasets: the full-count 1940 Census to obtain demographic, socioeconomic and geographic information; and that is linked to the Social Security Deaths Masterfile (SSDM) to obtain mortality information. This paper also develops mortality estimation methods to better use the 'deaths without denominators' information contained in CenSoc. Bayesian hierarchical methods are presented to estimate truncated death distributions over age and cohort, allowing for prior information in mortality trends to be incorporated and estimates of life expectancy and associated uncertainty to be produced.
    Date: 2018–07–23
  15. By: Halliday, Timothy J. (University of Hawaii at Manoa); Mazumder, Bhashkar (Federal Reserve Bank of Chicago); Wong, Ashley (Northwestern University)
    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. We develop an estimation procedure for a non-linear model with categorical outcomes in which the latent index is a mixed-linear model and contains covariates that might not vary within cross-sectional units. 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: 2019–10
  16. By: Kurmanov, Bakhytzhan; Pena-Boquete, Yolanda; Samambayeva, Aizhan; Makhmejanov, Galym
    Abstract: During the last 10 years, the prevalence of underweight has decreased considerably in Kazakhstan and, nowadays, it is set under 3% of the childs under 5 years old. However, the prevalence of overweight which was not important at all in the 90s, is reaching the 10% of children under 5, nowadays. This means that there is a co-existence between underweight and overweight in the same country and in the same regions. In order to design policies addressing both problems and avoiding policies which may solve underweight but worsting overweight, and vice versa, the aim of this paper is to analyze the socioeconomic determinants of the two problems. In order to estimate the determinants of underweight and overweight we run a logit model based on Multiple Indicator Cluster Surveys (MICS) database provided by UNICEF for Kazakhstan in 2006, 2010-2011, 2015. The probability of being underweight is quite low in the recent years so the fact that the family does not have the resources is not causing this problem. We should pay more attention to this variable, because the mother’s higher education is also associated with overweight. In the literature usually mother’s education tends to reduce the probability of being overweight, but this is not occurring in Kazakhstan. The probability of being overweight also increases for the wealth quintile 5th. It seems that richer families give bigger quantities or the food with more sugar and fat to the children.
    Keywords: healthy childhood,inequality,socio-economic status,child overweight,child underweight
    JEL: I1 I15
    Date: 2019
  17. By: Choudhury, Mita (National Council of Applied Economic Research); Tripathi, Shruti (National Institute of Public Finance and Policy); Dubey, Jay Dev (National Institute of Public Finance and Policy)
    Abstract: The implications of expanding GSHI schemes in India has not been analyzed from a fiscal perspective. This paper analyzes the experiences of some of the early and largest GSHI schemes implemented in Indian States - in Andhra Pradesh, Tamil Nadu and Karnataka to understand the fiscal implications of initiating such schemes. We analyze three aspects: (a) the extent of fiscal burden on account of GSHI schemes and its consequences on other health expenditures, (b) the factors contributing to the extent of fiscal burden and (c) the effectiveness of spending on the schemes in terms of reducing out of pocket expenditure, extent of hospitalization coverage, and improved access to hospitalization services. Results suggest that expansion of GSHI schemes may skew expenditure away from primary and secondary care towards tertiary care, if fiscal space is limited. Although the schemes are largely dependent on private health providers for delivering services, a competitive public health system may help in containing costs and the corresponding fiscal burden. The evidence on effectiveness of public spending through such schemes has been mixed.
    Date: 2019–11
  18. By: Riffe, Tim; Brouard, Nicolas
    Abstract: We translate Brouard (1986) to English from the original French. Figures are originals with translated captions. This article has been notable in the field of demography for its influence on later work relating to mortality tempo effects, the CAL index, and for mathematical demography on years lived and years left in stationary populations. A translation of a 1985 theorem on (and proof of) equality between age distributions and years-left distributions in stationary populations that is mentioned in section 1.1 is provided in an appendix.
    Date: 2018–03–04
  19. By: Office of Health Economics
    Abstract: We are pleased to submit the second report to the Charity Commission for England and Wales, OHE's second since becoming a registered charity in December 2016. OHE obtained its charitable status in 2016, an essential achievement towards OHE's development as a health economics research organisation. The report of 2018 demonstrates some of the ways in which OHE has worked to achieve its charitable objectives of advancing the education of the public in general/health care payers/policy makers on the subject of health economics and health care policy; and using health economics methods to produce evidence-based health policy and health care management that contributes to a more efficient and effective health care system.
    JEL: I1
    Date: 2019–11–01

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