nep-hea New Economics Papers
on Health Economics
Issue of 2020‒02‒10
eighteen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. The challenges of universal health insurance in developing countries: Evidence from a large-scale randomized experiment in Indonesia By Banerjee, Abhijit; Finkelstein, Amy; Hanna, Rema; Olken, Benjamin; Rema Hanna,; Ornaghi, Arianna
  2. Demand Shocks, Procurement Policies, and the Nature of Medical Innovation: Evidence from Wartime Prosthetic Device Patents By Jeffrey Clemens; Parker Rogers
  3. The Economic Consequences of Being Denied an Abortion By Sarah Miller; Laura R. Wherry; Diana Greene Foster
  4. Income Volatility, Health and Well-Being By Amélie Adeline; Ismael Choinière Crèvecoeur; Raquel Fonseca Benito; Pierre-Carl Michaud
  5. Long Term Care Insurance with State-Dependent Preferences By Philippe De Donder; Marie-Louise Leroux
  6. Informal caregiving and quality of life among older adults: Prospective analyses from the Swedish Longitudinal Occupational Survey of Health (SLOSH) By Sacco, Lawrence B; König, Stefanie; Westerlund, Hugo; Platts, Loretta G.
  7. College Access and Adult Health By Benjamin W. Cowan; Nathan Tefft
  8. Ancient Plagues in Modern Times: The Impact of Desert Locust Invasions on Child Health By Conte, Bruno; Piemontese, Lavinia; Tapsoba, Augustin
  9. Health, wealth, and informality over the life cycle By Julien Albertini; Xavier Fairise; Anthony Terriau
  10. Short-term health effects of public transport disruptions: air pollution and viral spread channels By A. GODZINSKI; M. SUAREZ CASTILLO
  11. Measuring the Economic Risk of Epidemics By Ilan Noy; Nguyen Doan; Benno Ferrarini; Donghyun Park
  12. Household Food Security in the United States in 2018 By Coleman-Jensen, Alisha; Rabbitt, Matthew P.; Gregory, Christian A.; Singh, Anita
  13. Can we learn from our mistakes? A case study of problems in implementing evidence-based mental health policy. By Foreman, David
  14. Democracy and Health: Evidence from Within-Country Heterogeneity in the Congo By van der Windt, Peter Cornelis; Vandoros, Sotiris
  15. What are Households Willing to Pay for Better Tap Water Quality? A Cross-Country Valuation Study By Olivier Beaumais; Anne Briand; Katrin Millock; Céline Nauges
  16. Social Security Expansion and Neighborhood Cohesion: Evidence from Community-Living Older Adults in China By Bradley, Elizabeth; Chen, Xi; Tang, Gaojie
  17. Health Inequality among Chinese Older Adults: The Role of Childhood Circumstances By Yan, Binjian; Chen, Xi; Gill, Thomas M.
  18. Early Life Environments and Frailty in Old Age among Chinese Older Adults By Li, Xaxi; Xue, Qian-Li; Odden, Michelle C.; Chen, Xi; Wu, Chenkai

  1. By: Banerjee, Abhijit (MIT); Finkelstein, Amy (MIT); Hanna, Rema (Harvard University); Olken, Benjamin (MIT); Rema Hanna,; Ornaghi, Arianna (University of Warwick Sudarno Sumarto, TNP2K and SMERU)
    Abstract: To assess ways to achieve widespread health insurance coverage with financial solvency in developing countries, we designed a randomized experiment involving almost 6,000 households in Indonesia who are subject to a nationally mandated government health insurance program. We assessed several interventions that simple theory and prior evidence suggest could increase coverage and reduce adverse selection: substantial temporary price subsidies (which had to be activated within a limited time window and lasted for only a year), assisted registration, and information. Both temporary subsidies and assisted registration increased initial enrollment. Temporary subsidies attracted lowercost enrollees, in part by eliminating the practice observed in the no subsidy group of strategically timing coverage for a few months during health emergencies. As a result, while subsidies were in effect, they increased coverage more than eightfold, at no higher unit cost; even after the subsidies ended, coverage remained twice as high, again at no higher unit cost. However, the most intensive (and effective) intervention – assisted registration and a full one-year subsidy – resulted in only a 30 percent initial enrollment rate, underscoring the challenges to achieving widespread coverage.
    Date: 2020
  2. By: Jeffrey Clemens; Parker Rogers
    Abstract: We analyze wartime prosthetic device patents to investigate how procurement policy affects the cost, quality, and quantity of medical innovation. Analyzing whether inventions emphasize cost and/or quality requires generating new data. We do this by first hand-coding the economic traits emphasized in 1,200 patent documents. We then train a machine learning algorithm and apply the trained models to a century's worth of medical and mechanical patents that form our analysis sample. In our analysis of these new data, we find that the relatively stingy, fixed-price contracts of the Civil War era led inventors to focus broadly on reducing costs, while the less cost-conscious procurement contracts of World War I did not. We provide a conceptual framework that highlights the economic forces that drive this key finding. We also find that inventors emphasized dimensions of product quality (e.g., a prosthetic's appearance or comfort) that aligned with differences in buyers' preferences across wars. Finally, we find that the Civil War and World War I procurement shocks led to substantial increases in the quantity of prosthetic device patenting relative to patenting in other medical and mechanical technology classes. We conclude that procurement environments can significantly shape the scientific problems with which inventors engage, including the choice to innovate on quality or cost.
    JEL: H57 I1 O31
    Date: 2020–01
  3. By: Sarah Miller; Laura R. Wherry; Diana Greene Foster
    Abstract: Restrictions on abortion are pervasive, yet relatively little is known about the financial and economic impact of being denied an abortion on pregnant women who seek one. This paper evaluates the economic consequences of being denied an abortion on the basis of the gestational age of the pregnancy. Our analysis relies on new linkages to ten years of administrative credit report data for participants in the Turnaway Study, the first study to collect high-quality, longitudinal data on women receiving or being denied a wanted abortion in the United States. Some women had pregnancies close to the facility's gestational age limit, but below it, and received a wanted abortion (Near Limit Group). A second group of women had pregnancies just over the facility's gestational age limit and were turned away without receiving an abortion (Turnaway Group). Using these linked data, we compare differences in credit report outcomes for the two groups of women over time using an event study design. We find evidence of a large and persistent increase in financial distress for the women who were denied an abortion that is sustained for the 6 years following the intended abortion.
    JEL: I1 I18
    Date: 2020–01
  4. By: Amélie Adeline; Ismael Choinière Crèvecoeur; Raquel Fonseca Benito; Pierre-Carl Michaud
    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: 2020–01–27
  5. By: Philippe De Donder; Marie-Louise Leroux
    Abstract: We study the demand for actuarially fair Long Term Care (LTC hereafter) insurance in a setting where autonomous agents only care for daily life consumption while dependent agents also care for LTC expenditures. We assume that dependency decreases the marginal utility of daily life consumption. We first obtain that some agents optimally choose not to insure themselves, while no agent wishes to buy complete insurance. We then show that the comparison of marginal utility of income (as opposed to consumption) across health states depends on (i) whether agents do buy LTC insurance at equilibrium or not, (ii) the comparison of the degree of risk aversion for consumption and for LTC expenditures, and (iii) the income level of agents. Our results then offer testable implications that can explain (i) why few people buy Long Term Care insurance and (ii) the discrepancies between various empirical works when measuring the extent of state-dependent preferences for LTC.
    Keywords: long term care insurance puzzle, actuarially fair insurance, risk aversion
    JEL: D11 I13
    Date: 2019
  6. By: Sacco, Lawrence B (Stockholm University); König, Stefanie; Westerlund, Hugo; Platts, Loretta G. (Stockholm University)
    Abstract: Providing unpaid informal care to someone who is ill or disabled is a common experience in later life. While a supportive and potentially rewarding role, informal care can become a time and emotionally demanding activity, which may hinder older adults’ quality of life. In a context of rising demand for informal carers, we investigated how caregiving states and transitions are linked to overall levels and changes in quality of life, and how the relationship varies according to care intensity and burden. We used fixed effects and change analyses to examine six-wave panel data (2008–2018) from the Swedish Longitudinal Occupational Survey of Health (SLOSH, n=5076; ages 50–74). The CASP-19 scale is used to assess both positive and negative aspects of older adults’ quality of life. Caregiving was related with lower levels of quality of life in a graded manner, with those providing more weekly hours and reporting greater burden experiencing larger declines. Two-year transitions corresponding to starting, ceasing and continuing care provision were associated with lower levels of quality of life, compared to continuously not caregiving. Starting and ceasing caregiving were associated with negative and positive changes in quality of life score, respectively, suggesting that cessation of care leads to improvements despite persistent lower overall levels of quality of life. Measures to reduce care burden or time spent providing informal care are likely to improve the quality of life of older people.
    Date: 2020–02–03
  7. By: Benjamin W. Cowan; Nathan Tefft
    Abstract: We investigate the relationship between college openings, college attainment, and health behaviors and outcomes later in life. Though a large prior literature attempts to isolate the causal effect of education on health via instrumental variables (IV), most studies use instruments that affect schooling behavior in childhood or adolescence, i.e. before the college enrollment decision. Our paper examines whether an increase in 2- and 4-year institutions per capita (“college accessibility”) in a state contributes to higher college attainment and better health later in life. Using 1980-2015 Census and American Community Survey data, we find consistent evidence that accessibility of public 2-year institutions positively affects schooling attainment and subsequent employment and earnings levels, particularly among whites and Hispanics. With restricted-use 1984-2000 National Health Interview Survey data, we again find that public 2-year accessibility increases schooling and benefits a host of health behaviors and outcomes in adulthood: it deters smoking, raises exercise levels, and improves self-reported health. However, most long-term health conditions are unaffected, which may be partially due to the age of our sample.
    JEL: I12 I23 I26
    Date: 2020–01
  8. By: Conte, Bruno; Piemontese, Lavinia; Tapsoba, Augustin
    Abstract: This paper estimates the causal impact on child health of a locust plague that occurred in Mali during the mid 2000s. Using a Difference-in-Differences strategy, we show that children who were exposed in utero to the plague suffer major health setbacks. Affected children have, on average, a height-for-age Z-score 0.33 points lower than non-exposed children. We argue that, in this type of agricultural economy, locust invasions could have an impact on child health mainly through two channels: first, a speculative/anticipatory price effect that kicks in during the plague itself, followed by local crop failures effect that would constitute an income shock for affected farmers and a local food supply shock for markets. We find that children exposed only to the speculative price effect in utero suffer as much as those exposed to the actual crop failure effect.
    Keywords: Child Health; Plagues; Agricultural Shocks; Differences-in-Differences.
    JEL: I15 O12 Q12 Q18
    Date: 2020–01
  9. By: Julien Albertini (GATE Lyon Saint-Étienne - Groupe d'analyse et de théorie économique - ENS Lyon - École normale supérieure - Lyon - UL2 - Université Lumière - Lyon 2 - UCBL - Université Claude Bernard Lyon 1 - Université de Lyon - UJM - Université Jean Monnet [Saint-Étienne] - Université de Lyon - CNRS - Centre National de la Recherche Scientifique); Xavier Fairise (GAINS - Groupe d'Analyse des Itinéraires et des Niveaux Salariaux - UM - Le Mans Université); Anthony Terriau (GAINS - Groupe d'Analyse des Itinéraires et des Niveaux Salariaux - UM - Le Mans Université)
    Abstract: How do labor market and health outcomes interact over the life cycle in a country characterized by a large informal sector and strong inequalities? To quantify the effects of bad health on labor market trajectories, wealth, and consumption, we develop a life-cycle heterogeneous agents model with a formal and an informal sector. We estimate our model using data from the National Income Dynamics Study, the first nationally representative panel study in South Africa. We run counterfactual experiments and show that health shocks have an important impact on wealth and consumption. The channel through which these shocks propagate strongly depends on the job status of individuals at the time of the shock. For formal workers, bad health reduces labor efficiency, which translates into lower earnings. For informal workers and the non-employed, the shock lowers the job finding rate and increases job separation into non-employment, which results in a surge in non-employment spells. As bad health spells persist more for non-employed than for employed individuals, the interaction between labor market risks and health risks generates a vicious circle.
    Keywords: Health,Wealth,Life cycle,Informality
    Date: 2020
  10. By: A. GODZINSKI (Insee); M. SUAREZ CASTILLO (Insee)
    Abstract: When public transport supply decreases, urban population health may be strongly affected. First, as ambient air pollution increases, respiratory diseases may be exacerbated during a few days. Second, reduced interpersonal contacts may lead to a slower viral spread, and therefore, after a few incubation days, lower morbidity. We evidence these two channels, using a difference-in-differences strategy, considering public transport strikes in the ten most populated French cities over the 2010-2015 period. On the two days following the strike, we find less emergency hospital admissions for influenza and gastroenteritis. In spite of the existence of this contagion channel, which tends to mitigate the increase of admissions for respiratory diseases, we also evidence a substantial air pollution channel. On the strike day, we find more admissions for acute diseases of the upper respiratory system, while on the following day of the strike, more abnormalities of breathing. Our results suggest that urban population daily transportation choices do matter as they engender dynamic spillovers on health.
    Keywords: Dynamic health effects, transport strike, air pollution, contagion, difference-in-differences
    JEL: I12 I18 C23 L91 Q53 R41
    Date: 2019
  11. By: Ilan Noy; Nguyen Doan; Benno Ferrarini; Donghyun Park
    Abstract: We measure the economic risk of epidemics at a geo-spatially detailed resolution. In addition to data about the epidemic hazard prediction, we use data from 2014-2019 to compute measures for exposure, vulnerability, and resilience of the local economy to the shock of an epidemic. Using a battery of proxies for these four concepts, we calculate the hazard (the zoonotic source of a possible epidemic), the principal components of exposure and vulnerability to it, and of the economy’s resilience (its ability of the recover rapidly from the shock). We find that the economic risk of epidemics is particularly high in most Africa, the Indian subcontinent, China, and Southeast Asia. These results are consistent when comparing an ad-hoc (equal) weighting algorithm for the four components of the index, with one based on an estimation algorithm using Disability-Adjusted Life Years associated with communicable diseases.
    Keywords: epidemic, influenza, risk measurement, economic impact
    JEL: E01 Q54
    Date: 2019
  12. By: Coleman-Jensen, Alisha; Rabbitt, Matthew P.; Gregory, Christian A.; Singh, Anita
    Abstract: An estimated 88.9 percent of U.S. households were food secure throughout the entire year in 2018, with access at all times to enough food for an active, healthy life for all household members. The remaining households (11.1 percent, down from 11.8 percent in 2017) were food insecure at least some time during the year, including 4.3 percent with very low food security (not significantly different from 4.5 percent in 2017), where the food intake of one or more household members was reduced and their eating patterns disrupted at times because the household lacked money and other resources for obtaining food. The 2018 prevalence of food insecurity declined, for the first time, to pre-recession (2007) levels. Among children, changes from 2017 in food insecurity and very low food security were not statistically significant. Children and adults were food insecure in 7.1 percent of U.S. households with children in 2018; very low food security among children was 0.6 percent. In 2018, the typical food-secure household spent 21 percent more on food than the typical food-insecure household of the same size and household composition. About 56 percent of food-insecure households participated in one or more of the three largest Federal food and nutrition assistance programs (Supplemental Nutrition Assistance Program (SNAP, formerly food stamps); Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and the National School Lunch Program) during the month prior to the 2018 survey.
    Keywords: Agricultural and Food Policy, Consumer/Household Economics, Food Consumption/Nutrition/Food Safety, Food Security and Poverty, Health Economics and Policy
    Date: 2019–09–24
  13. By: Foreman, David
    Abstract: I examined the failure of the UK mental health framework policy NSF-9 to sustain the intended development in Child and Adolescent Mental Health Services (CAMHS) in England from its inception in 2003. NSF-9 used Evidence-Based Policy/Practice (EBP) with Key Performance Indicators (KPIs) derived from both research and expert practitioner advice. Adequate funding was provided, the workforce was engaged from the outset, and the KPIs were supported by dedicated data collection and dissemination systems, so failure was unexpected. I reviewed theories from the social sciences of Public Administration and Policy Research (PAPR) from the perspective of three questions. 1. Are there applicable Public Administration Theories (PATs) that can account for this unexpected outcome? 2. Did the metrics used, or their delivery, have administrative or policy characteristics which undermined their expected impact? 3. Are there organisational factors, separate from EBP commitment, which could have jeopardised the NSF model? I undertook a qualitative synthesis of the findings of several qualitative and quantitative datasets, using constant comparison between the datasets’ results and candidate PATs. I concluded that the currently accepted explanation; NSF-9’s failure was caused by inadequacies in culture and values was incomplete, as they resulted from weaknesses in the EBP model itself. When I applied relevant PATs to the data, it was clear NSF-9 had many faults as a policy within the NHS bureaucracy, which were not compensated within its design, and drove its eventual failure. I concluded that policy success without including evidence from PAPR is extremely uncertain, and is a continuing structural risk, as there is currently a disjunction between PAPR and Health Services Research. This needs urgent correction.
    Date: 2020–01–19
  14. By: van der Windt, Peter Cornelis; Vandoros, Sotiris
    Abstract: The literature documents a positive association between democracy and health, and studies supporting this claim have largely relied on cross-country panel analyses. In many developing countries, however, local traditional leaders at the micro-level play a key role in individuals' daily lives while the influence of the national government is largely negligible. In response, this study revisits the relationship between democracy and health using micro-level household data from 816 randomly selected villages in Eastern Congo. We find little or no evidence that health outcomes are better in villages that are governed by elected leaders compared to villages where leaders are not elected. Our data suggest that efforts to improve health outcomes in this setting may need to focus on issues such as gender discrimination and education.
    Date: 2020–01–14
  15. By: Olivier Beaumais (LISA - Lieux, Identités, eSpaces, Activités - UPP - Université Pascal Paoli - CNRS - Centre National de la Recherche Scientifique); Anne Briand (LASTA - Laboratoire d'Analyse des Sociétés, Transformations et Adaptations - UNIROUEN - Université de Rouen Normandie - NU - Normandie Université); Katrin Millock (PSE - Paris School of Economics); Céline Nauges (LERNA-INRA - TSE - Toulouse School of Economics - UT1 - Université Toulouse 1 Capitole - INRA - Institut National de la Recherche Agronomique - EHESS - École des hautes études en sciences sociales - CNRS - Centre National de la Recherche Scientifique)
    Abstract: We estimate willingness to pay (WTP) for better quality of tap water on a unique cross-section sample from 10 OECD countries. On the pooled sample, households are willing to pay 7.5% of the median annual water bill to improve the tap water quality. The highest relative WTP for better tap water quality was found in the countries with the highest percentage of respondents being unsatisfied with tap water quality because of health concerns. The expected WTP increased with income, education, environmental concern, and health and taste concerns with the tap water.
    Date: 2020–01–07
  16. By: Bradley, Elizabeth; Chen, Xi; Tang, Gaojie
    Abstract: Grants and services provided by the government may crowd out informal arrangements, thus weakening informal caring relations and networks. In this paper, we examine the impact of social security expansion on neighborhood cohesion of elders using China’s New Rural Pension Scheme (NRPS), one of the largest existing pension program in the world. Since its launch in 2009, more than 400 million Chinese have enrolled in NRPS. We use two waves of China Health and Retirement Longitudinal Study (CHARLS) to examine the effect of pension receipt on two dimensions of neighborhood cohesion among older adults, i.e. participation in collective recreational activities (e.g., socializing and organizational activities) and altruistic activities (e.g., helping those in need in the community), and the frequencies of these activities. Employing an instrumental variable approach, our empirical strategy addresses the endogeneity of pension receipt via exploiting geographic variation in pension program roll-out. We find evidence that receiving pension only slightly reduces collective recreational activities while significantly crowding out altruistic activities in the communities.
    Keywords: neighborhood cohesion,pension,crowd out,diversity
    JEL: H55 I38 O22
    Date: 2020
  17. By: Yan, Binjian; Chen, Xi; Gill, Thomas M.
    Abstract: This paper examines the extent to which childhood circumstances contribute to health inequality in old age and how the contributions may vary across key dimensions of health. We link the China Health and Retirement Longitudinal Study (CHARLS) in 2013 and 2015 with its Life History Survey in 2014 to quantify health inequality due to childhood circumstances for which they have little control. We evaluate comprehensive dimensions of health ranging from cognitive health, mental health, physical health, self-rated health to mortality. Our analytic sample includes about 8,000 Chinese persons age above 60. Using the Shapley value decomposition approach, we first show that childhood circumstances may explain 1-23 percent of health inequality in old age across multiple health outcomes. Second, while both direct health-related circumstances and indirect health-related circumstances contribute significantly to health inequality, the latter tends to be more sizable. Our findings support the value of a life course approach in identifying the key determinants of health in old age.
    Keywords: Life course approach,Inequality of opportunity,Physical health,Cognitive ability,Mental health,Mortality
    JEL: I14 D63 I18 J13 J14
    Date: 2020
  18. By: Li, Xaxi; Xue, Qian-Li; Odden, Michelle C.; Chen, Xi; Wu, Chenkai
    Abstract: Exposures in childhood and adolescence may impact the development of diseases and symptoms in late life. However, evidence from low- and middle- income countries is scarce. In this study, we examined the association of early life risk factors with frailty among older adults using a large, nationally representative cohort of community-dwelling Chinese sample. 6,806 participants aged ≥60 years from the China Health and Retirement Longitudinal Study were included. We measured 13 risk factors in childhood or adolescence through self-reports, encompassing six dimensions (education, family economic status, nutritional status, domestic violence, neighborhood, and health). We used multinomial regression models to examine the association between risk factors and frailty and further calculated the absolute risk difference for the statistically significant factors. Results show that worse health condition in childhood and unfavorable childhood and adolescent socioeconomic status as measured by educational attainment and neighborhood quality may increase the risk of late-life frailty among Chinese older adults. Severe starvation in childhood was associated with higher risk of prefrailty. The risk differences of being frail were 5.7% lower for persons with a high school or above education, 1.5% lower for those whose fathers were literate, 4.8% lower for the highest neighborhood quality, and 2.9% higher for worse childhood health status compared to their counterparts.
    Keywords: Early Life Environments,Life Course Health,Physical Health,Frailty,Aging,China
    JEL: I10 I14 I18
    Date: 2020

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