nep-hea New Economics Papers
on Health Economics
Issue of 2020‒01‒06
seventeen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. Health Insurance and Mortality: Experimental Evidence from Taxpayer Outreach By Jacob Goldin; Ithai Z. Lurie; Janet McCubbin
  2. Medicaid Expansion and the Unemployed By Thomas C. Buchmueller; Robert G. Valletta; Helen Levy
  3. A behavioral decomposition of willingness to pay for health insurance By Aurélien Baillon; Aleli Kraft; Owen O'Donnell; Kim van Wilgenburg
  4. Marriage Equality Laws and Youth Mental Health By Anderson, D. Mark; Matsuzawa, Kyutaro; Sabia, Joseph J.
  5. Local Exposure to School Shootings and Youth Antidepressant Use By Maya Rossin-Slater; Molly Schnell; Hannes Schwandt; Sam Trejo; Lindsey Uniat
  6. Rising US Suicides: Achieving Health Equity By Perry, Seth W; Allison, Stephen; Bastiampillai, Tarun; Wong, Ma-Li; Licinio, Julio; Sharfstein, Steven S.; Wilcox, Holly C.
  7. Income Volatility, Health and Well-Being By Adeline, Amelie; Crèvecoeur, Ismael Choinière; Fonseca, Raquel; Michaud, Pierre-Carl
  8. Non-parametric well-being comparisons By Koen Decancq; Annemie Nys
  9. Low emission zones and population health By Margaryan, Shushanik
  10. Education and adult health: Is there a causal effect? By Marisa Hidalgo-Hidalgo; Pedro Albarrán; Iñigo Iturbe-Ormaetxe
  11. Detecting the Effects of Early-Life Exposures: Why Fecundity Matters By Nobles, Jenna; Hamoudi, Amar
  12. Abandoned by Coal, Swallowed by Opioids? By Gilbert E. Metcalf; Qitong Wang
  13. Estimating Biases in Smoking Cessation: Evidence from a Field Experiment By Frank J. Chaloupka IV; Matthew R. Levy; Justin S. White
  14. A multiscale spatial analysis of obesity determinants in Phoenix, Arizona By Oshan, Taylor M.; Smith, Jordan; Fotheringham, Alexander Stewart
  15. On discrimination in health insurance By Thomas Boyer-Kassem; Sébastien Duchêne
  16. Confidence intervals in health and medical journals show an implausible excess of statistically significant results By Barnett, Adrian; wren, Jonathan
  17. Adult Mortality Differentials and Regional Development at the local level in Brazil, 1980-2010 By Queiroz, Bernardo L; Lima, Everton; Gonzaga, Marcos Roberto; Freire, Flávio

  1. By: Jacob Goldin; Ithai Z. Lurie; Janet McCubbin
    Abstract: We evaluate a randomized pilot study in which the IRS sent informational letters to 3.9 million taxpayers who paid a tax penalty for lacking health insurance coverage under the Affordable Care Act. Drawing on administrative data, we study the effect of the intervention on taxpayers’ subsequent health insurance enrollment and mortality. We find the intervention led to increased coverage in the two years following treatment and that this additional coverage reduced mortality among middle-aged adults over the same time period. Our results provide the first experimental evidence that health insurance reduces mortality.
    JEL: H2 I12 I13
    Date: 2019–12
  2. By: Thomas C. Buchmueller (National Bureau of Economic Research; Stephen M. Ross School of Business); Robert G. Valletta (National Bureau of Economic Research; University of California; Federal Reserve Bank); Helen Levy (University of Michigan)
    Abstract: We examine how a key provision of the Affordable Care Act—the expansion of Medicaid eligibility—affected health insurance coverage, access to care, and labor market transitions of unemployed workers. Comparing trends in states that implemented the Medicaid expansion to those that did not, we find that the ACA Medicaid expansion substantially increased insurance coverage and improved access to health care among unemployed workers. We then test whether this strengthening of the safety net affected transitions from unemployment to employment or out of the labor force. We find no meaningful statistical evidence in support of moral hazard effects that reduce job finding or labor force attachment.
    Keywords: Medicaid; access to care; unemployment; insurance coverage; labor force transitions
    JEL: A12 A13 I13 I18
    Date: 2019–12–16
  3. By: Aurélien Baillon (Erasmus University Rotterdam); Aleli Kraft (University of the Philippines Diliman); Owen O'Donnell (Erasmus University Rotterdam); Kim van Wilgenburg (Erasmus University Rotterdam)
    Abstract: Despite widespread exposure to substantial medical expenditure risk in low-income populations, health insurance enrollment is typically low. This is puzzling from the perspective of expected utility theory. To help explain it, this paper introduces a decomposition of the stated willingness to pay (WTP) for insurance into its fair price and three behavioral deviations from that price due to risk perception and risk attitude consistent with prospect theory, plus a residual. To apply this approach, we elicit WTP, subjective distributions of medical expenditures and risk attitude (utility curvature and probability weighting) from Filipino households in a nationwide survey. We find that the mean stated WTP of the uninsured is less than both the actuarially fair price and the subsidized price at which public insurance is offered. This is not explained by downwardly biased beliefs: both the mean and the median subjective expectation are greater than the subsidized price. Convex utility in the domain of losses pushes mean WTP below the fair price and the subsidized price, and the transformation of probabilities into decision weights depresses the mean further, at least using one of two specific decompositions. WTP is reduced further by factors other than risk perception and attitude.
    Keywords: Health insurance, willingness to pay, subjective probability, prospect theory, medical expense
    JEL: I13 D84
    Date: 2019–11–17
  4. By: Anderson, D. Mark (Montana State University); Matsuzawa, Kyutaro (San Diego State University); Sabia, Joseph J. (San Diego State University)
    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 for the period 1999-2017, we explore the relationship between marriage equality and suicidal behaviors among LGBQ-identifying youths. 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.
    Keywords: same-sex marriage laws, youth suicide, risky health behaviors
    JEL: I18 I12
    Date: 2019–12
  5. By: Maya Rossin-Slater; Molly Schnell; Hannes Schwandt; Sam Trejo; Lindsey Uniat
    Abstract: While over 240,000 American students experienced a school shooting in the last two decades, little is known about the impacts of these events on the mental health of surviving youth. Using large-scale prescription data from 2006 to 2015, we examine the effects of 44 school shootings on youth antidepressant use in a difference-in-difference framework. We find that local exposure to fatal school shootings increases youth antidepressant use by 21.4 percent in the following two years. These effects are smaller in areas with a higher density of mental health providers who focus on behavioral, rather than pharmacological, interventions.
    JEL: I18 I31 J13
    Date: 2019–12
  6. By: Perry, Seth W; Allison, Stephen; Bastiampillai, Tarun; Wong, Ma-Li; Licinio, Julio; Sharfstein, Steven S.; Wilcox, Holly C.
    Abstract: Evidence suggests that increased availability of mental health treatment has not significantly reduced depression prevalence and suicide in the US, and that significant personal (i.e., stigma) or practical/logistical barriers to effective mental health care remain. Mental health treatment has increased in the US since the early 1990s with greater use of antidepressant medications, especially SSRIs, however suicide rates continue to climb, with significant gender, ethnic, geographic, socioeconomic, and other health disparities. Depression rates are at best stable, but are increasing in certain subpopulations such as youths ages 12-17. Combating these distressing trends to achieve health equity will require more attention to promising and evidence-based, sustainable, proactive, practical solutions that address the varied causes, demographics, and differential risk factors and mechanisms of suicide deaths. Herein we explore sociodemographic disparities that exist in suicide deaths, with emphasis on two of the largest modifiable targets for suicide prevention: untreated or undertreated depression, and access to the lethal means (firearms) that cause more suicide deaths than all other means combined, and thus pose the greatest threat to individual and public health. Furthermore, we newly define increased or unsafe (i.e. disparate) access to firearms as a suicide health disparity that promotes health inequities. To achieve the greatest results in suicide prevention across all groups, we need 1) more emphasis on policies and universal programs shown to reduce suicidal behaviors, and 2) enhanced focus on the two largest modifiable targets for suicide prevention: depression and firearms.
    Date: 2019–11–23
  7. By: Adeline, Amelie (University of Cergy-Pontoise); Crèvecoeur, Ismael Choinière (University of Québec at Montréal); Fonseca, Raquel (University of Québec at Montréal); Michaud, Pierre-Carl (HEC Montreal)
    Abstract: While there is mounting evidence that large income shocks, e.g. in the form of a job loss, may impact health and mortality, little evidence exist on the potential relationship between sustained income volatility, keeping average lifetime income constant, and health. This paper exploits rich survey data on the near-elderly in Canada paired with their administrative tax records to investigate whether a relationship exists between health and well-being on the one hand, and individual-specific volatility of income on the other, decomposing volatility into a permanent and transitory component. Controlling for average lifetime income, we find that a one unit increase in the standard deviation of the permanent component of (log) income experienced over the working life is associated with a lower probability of being in excellent (-23.9%) and very good health (-13.3%), to be satisfied with life (-34.9%), and implies the onset of 1.1 additional mental health issues. Similar results, albeit smaller in size, are found for the transitory component of income. These results have potentially important implications for public policy, as well as, understanding the relationship between the labor market and population health.
    Keywords: income volatility, health, well-being, Canada
    JEL: C22 D31 I10 I14 I31
    Date: 2019–12
  8. By: Koen Decancq; Annemie Nys
    Abstract: We study the problem of making interpersonal well-being comparisons when individuals have heterogeneous preferences. We present a robust criterion for interpersonal well-being comparisons that states that one individual is better off than another one if the intersection between the extended upper contour set of the better off individual and the extended lower contour set of the worse off individual is empty. We implement the criterion in the consumption-health space using an online survey with 2,260 respondents in the United States to investigate how complete the resulting interpersonal well-being comparison is. To chart the contour sets of the respondents, we propose a new “adaptive bisectional dichotomous choice” (ABDC) procedure that is based on a limited number of dichotomous choices and some mild non-parametric assumptions on the preferences. We find that between one fifth and half of all pairs of respondents can be ranked with the criterion.
    Date: 2019–07–22
  9. By: Margaryan, Shushanik
    Abstract: Air pollution has a major detrimental impact on population health but little is known about the effectiveness of policy measures targeting pollution. I exploit the staggered implementation of low emission zones in large cities in Germany as a nat-ural experiment to asses their health impact. Using outpatient and inpatient health care data, I demonstrate that low emission zones reduce the number of patients with cardiovascular diagnoses by 2-3 percent. This effect is particularly pronounced for the elderly above 65.
    Date: 2019
  10. By: Marisa Hidalgo-Hidalgo (Universidad Pablo de Olavide); Pedro Albarrán (Universidad de Alicante); Iñigo Iturbe-Ormaetxe (Universidad de Alicante)
    Abstract: Many studies find a strong positive correlation between education and adult health. A subtler question is whether this correlation can be interpreted as a causal relationship. We combine multi-country data from two cross-sections of EU-SILC (European Union Statistics on Income and Living Conditions) and use exogenous variation in compulsory years of schooling across countries and cohorts induced by compulsory school laws. We find no causal effect of education on any of our several health measures. This finding is extremely robust to different changes in our main specification and holds using other databases. We discuss different explanations.
    Keywords: health; education; instrumental variables
    JEL: I12 I21
    Date: 2019–12
  11. By: Nobles, Jenna; Hamoudi, Amar
    Abstract: Prenatal exposures have meaningful effects on health across the lifecourse. Innovations in causal inference have shed new light on these effects. Here, we motivate the importance of innovation in the characterization of fecundity, and prenatal selection in particular. We argue that such innovation is crucial for expanding knowledge of the fetal origins of later life health. Pregnancy loss is common, responsive to environmental factors, and closely related to maternal and fetal health outcomes. As a result, selection into live birth is driven by many of the same exposures that shape the health trajectories of survivors. Lifecourse effects that are inferred without accounting for these dynamics may be significantly distorted by survival bias. We use a set of Monte Carlo simulations with realistic parameters to examine the implications of prenatal survival bias. We find that even in conservatively specified scenarios, true fetal origin effects can be underestimated by 50% or more. In contrast, effects of exposures that reduce the probability of prenatal survival but improve the health of survivors will be overestimated. The absolute magnitude of survival bias can even exceed small effect sizes, resulting in inferences that beneficial exposures are harmful or vice-versa. We also find reason for concern that moderately sized true effects, underestimated due to failure to account for selective survival, are missing from scientific knowledge because they do not clear statistical significance filters. This bias has potential real-world costs; policy decisions about interventions to improve maternal and infant health will be affected by underestimated program impact.
    Date: 2019–12–05
  12. By: Gilbert E. Metcalf; Qitong Wang
    Abstract: Opioid addition and mortality skyrocketed over the past decade. A casual look at the geographic incidence of opioid mortality shows sharply higher mortality rates in the Appalachian region, especially in coal-mining areas. This has led observers to make a link that was characterized by one newspaper as “abandoned by coal, swallowed by opioids.” We test that theory using restricted death data and mine level coal production data. Specifically, we examine whether higher reliance on coal mining in a county’s economy leads to higher or lower opioid mortality. We find a positive relationship between the share of coal miners among total local labor force and county-level opioid mortality rates. This contradicts the “abandoned by coal, swallowed by opioids” story. Rather our results suggest that the higher rates of injury in underground coal mining (in particular) lead to greater amounts of opioid consumption and mortality. An implication is that the decline in coal mining in the United States may have a positive spillover in the form of reduced mortality from opioid use.
    JEL: I1 Q32 Q35
    Date: 2019–12
  13. By: Frank J. Chaloupka IV; Matthew R. Levy; Justin S. White
    Abstract: We conduct a randomized field experiment to quantify biases that affect consumers of addictive goods: present-biased preferences, naïve beliefs regarding present bias, and projection-biased beliefs over future abstinence. These biases reflect departures from the neoclassical benchmark needed to accommodate intertemporal and state-dependent prediction errors and have important theoretical and policy ramifications. Our experiment employs a new approach for remote monitoring to ensure truthful reporting of behavior and valuations, and a novel identification of subjects’ biases based on willingness to pay for future abstinence incentives that serve as partial commitment devices. We find that cigarette smokers overestimate their likelihood of future abstinence by more than 100%, consistent with partially-naïve present-biased preferences. We estimate that on average smokers are present biased and only partially aware of their present bias, with substantial heterogeneity and a positive correlation between the two at the individual level. Smokers mispredict the effects of an abstinence intervention. Ex ante smokers anticipate no effect of the intervention on their future abstinence and ex post fail to recognize the intervention’s positive effect. Our estimates highlight that smokers suffer from a constellation of biases: under their own long-run preferences, smokers’ choices lead to a private welfare loss of $400 per week.
    JEL: C93 D91 I12
    Date: 2019–12
  14. By: Oshan, Taylor M.; Smith, Jordan; Fotheringham, Alexander Stewart
    Abstract: Obesity rates are recognized to be at epidemic levels in the United States, posing significant threats to both the health and financial security of the nation. The causes of obesity can vary but are often complex and multifactorial, and while many contributors can be targeted for interventions, an understanding of where these interventions are needed is necessary in order to implement effective policy. This has prompted an interest in incorporating geographic context into the analysis and modeling of obesity determinants, especially through the use of geographically weighted regression (GWR). This paper provides a critical review of previous GWR models of obesogenic processes and then presents a novel application of multiscale (M)GWR using the Phoenix metropolitan area as a case study. The results show that a mix of global and local processes are able to best model obesity rates in Phoenix and that MGWR is superior to both GWR and ordinary least squares. Best practices for building and interpreting MGWR models are suggested and policy formation strategies are recommended.
    Date: 2019–07–19
  15. By: Thomas Boyer-Kassem (MAPP - Métaphysique allemande et philosophie pratique - Université de Poitiers); Sébastien Duchêne (CEE-M - Centre d'Economie de l'Environnement - Montpellier - FRE2010 - INRA - Institut National de la Recherche Agronomique - UM - Université de Montpellier - CNRS - Centre National de la Recherche Scientifique - Montpellier SupAgro - Institut national d’études supérieures agronomiques de Montpellier)
    Abstract: In many countries, private health insurance companies are allowed to vary their premiums based on some information on individuals. This practice is intuitively justified by the idea that people should pay the premium corresponding to their own known risk. However, one may consider this as a form of discrimination or wrongful differential treatment. Our goal in this paper is to assess whether profiling is ethically permissible in health insurance. We go beyond the existing literature in considering a wide range of parameters, be they genetic, non-genetic, or even non-medical such as age or place of living. Analyzing several ethical concerns, and tackling the difficult question of responsibility, we argue that profiling is generally unjust in health insurance.
    Date: 2019
  16. By: Barnett, Adrian (Queensland University of Technology); wren, Jonathan
    Abstract: Results that are statistically significant are more likely to be reported by authors and more likely to be accepted by journals. These common biases warp the published evidence and undermine the ability of research to improve health by giving an incomplete body of evidence. We aimed to show the effect of the bias towards statistical significance on the evidence-base using published confidence intervals. We examined over 968,000 ratios and their confidence intervals in the abstracts of health and medical journals from Medline between 1976 and January 2019. We plotted the distributions of lower and upper confidence interval limits to visually show the strong bias for statistically significant results. There was a striking change in the distributions around 1, which is the statistically significant threshold for ratios. There was an excess of lower intervals just above 1, corresponding to a statistically significant increase in risk. There was a similar excess of upper intervals just below 1, corresponding to a statistically significant decrease in risk. These biases have not improved in recent years. The huge excesses of confidence intervals that are just above and below the statistically significant threshold are not statistically plausible. Large changes in research practice are needed to provide more results that better reflect the truth.
    Date: 2019–03–28
  17. By: Queiroz, Bernardo L (Universidade Federal de Minas Gerais, Brazil); Lima, Everton; Gonzaga, Marcos Roberto; Freire, Flávio
    Abstract: In this paper, we study study spatial and temporal adult mortality trends in small areas of Brazil, from 1980 to 2010, and its relation to socioeconomic and public health developments. Brazil is marked by huge regional and social inequality and it is important to understand how it could be related to trends and differences in adult mortality. There are several studies about trends in infant and child mortality, but much less is known about adult mortality. We are also interested in understand whether there is a convergence or divergence in adult mortality. This is relevant because changes in life expectancy in the near future could be heavily explained by differences in adult mortality as infant and child mortality have shown signs of convergence in recent years
    Date: 2018–08–07

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