nep-hea New Economics Papers
on Health Economics
Issue of 2020‒02‒17
sixteen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. Quality provision in competitive health care markets: Individuals vs. teams By Han, Johann; Kairies-Schwarz, Nadja; Vomhof, Markus
  2. Children of Crisis: The Effects of Economic Shocks on Newborns By Akbulut-Yuksel, Mevlude; Cilasun, Seyit Mumin; Turan, Belgi
  3. Children of War: In-Utero Stress and Child Health in Iraq By Sulin Sardoschau
  4. Rational Addiction and Time Consistency: An Empirical Test By Piccoli, Luca; Tiezzi, Silvia
  5. It could be could be raining: Ambulance response time and health outcomes By Elena, Lucchese
  6. Competition on Unobserved Attributes: The Case of the Hospital Industry By P. CHONÉ; L. WILNER
  7. Taxing Tobacco in Georgia : Welfare and Distributional Gains of Smoking Cessation By Fuchs Tarlovsky,Alan; Gonzalez Icaza,Maria Fernanda
  8. Food-Related Time Use: Changes and Demographic Differences By Anekwe,Tobenna D.; Zeballos, Eliana
  9. The cost of being too patient By Paola Giuliano; Paola Sapienza
  10. Predicting mid-life capital formation with pre-school delay of gratification and life-course measures of self-regulation By Dan Benjamin; David Laibson; Walter Mischel; Philip K. Peake; Yuichi Shoda; Alexandra Steiny Wellsjo; Nicole L. Wilson
  11. Pathways of Disadvantage: Unpacking the Intergenerational Correlation in Welfare By Bubonya, Melisa; Cobb-Clark, Deborah A.
  12. A Study of Longitudinal Trajectories of Health and Job Demand on Retirement Age By Amal Harrati; David Rehkopf
  13. Free Primary Education, Fertility, and Women's Access to the Labor Market : Evidence from Ethiopia By Chicoine,Luke
  14. Accounting for Protest Attitudes in Willingness to Pay for Universal Health Coverage By Mohammad Abu-Zaineh; Olivier Chanel; Khaled Makhloufi
  15. Estimating the Impact of Social Medical Insurance Schemes on Children’s Health and Hospital Use: The Chinese Case By Jing Guana; J.D. Tena
  16. Do women contribute more eort than men to a real public good? By Alger, Ingela; Juarez, Laura; Juarez-Torres, Miriam; Miquel-Florensa, Josepa

  1. By: Han, Johann; Kairies-Schwarz, Nadja; Vomhof, Markus
    Abstract: We investigate the quality provision behavior and its implications for the occurrence of collusion in competitive health care markets where providers are assumed to be altruistic towards patients. For this, we employ a laboratory experiment with a health care market framing where subjects decide on the quality levels for one of three competing hospitals respectively. We vary whether quality decisions within hospitals are made by individuals or teams. Realized monetary patient benefits go to real patients outside the lab. We find that degrees of cooperation quickly converge towards negative values implying absence of collusion and patient centered quality choices. Moreover, hospitals treat qualities as strategic complements and adjust their quality choice in the same direction as their competitors. The response magnitude for team markets is weaker. This is driven by the non-cooperative, or altruistic teams which tend to set qualities strategically independent.
    Keywords: quality competition,health care markets,team decisions,altruism,laboratory experiment
    JEL: C92 D03 D43 D64 I11 L13
    Date: 2020
  2. By: Akbulut-Yuksel, Mevlude (Dalhousie University); Cilasun, Seyit Mumin; Turan, Belgi (University of Houston)
    Abstract: In this paper, we explore the deep economic crisis experienced by the Turkish economy in 2001 and 2008 as quasi-experiments to causally identify the association between economically challenging conditions in-utero and child's birth weight. First, we utilize the temporal and spatial variations of the economic crisis. Second, we estimate mother fixed effects models by exploring the variation in the birth weight of siblings by their in-utero exposure to economic downturn. Using the Turkish Demographic Health Surveys (DHS), we find that a higher regional GDP contributes significantly to better birth outcomes among crisis-time children; adverse health effects are mainly observed in children born to mothers with low socio-economic status, suggesting that the main driver of the estimated effects of economic crises in Turkey is credit constraints. Our mother fixed effects models reveal that selective fertility, abortion, and unobserved heterogeneity across mothers are important omitted variables in the interpretation of regional regressions. The estimated effects of economic downturns cease to be statistically and economically significant once we control more accurately and directly for a family's firsthand experience with economic recessions. Thus, our results demonstrate that regional-level regressions estimating potential infant health costs of economic recessions potentially overestimate the true effects, and more direct measures of unobserved heterogeneity should also be considered in these analyses.
    Keywords: infant health, childhood environment, economic crisis
    JEL: J13
    Date: 2020–01
  3. By: Sulin Sardoschau (CES - Centre d'économie de la Sorbonne - UP1 - Université Panthéon-Sorbonne - CNRS - Centre National de la Recherche Scientifique, PSE - Paris School of Economics)
    Abstract: This paper combines detailed household-level data on child health with geo-coded incidences of vi- olence in Iraq to estimate the impact of in-utero exposure to violence on biometric, behavioral and cognitive outcomes of children. Rich data on severity (duration and casualties), type (bombings, ex- plosions, gun_re etc.), and perpetrators of violence (coalition, insurgent, or sectarian) on the district level allow me to discriminate between two possible mechanisms: damages to the infrastructure versus violence-induced pre-natal stress for mothers. Comparing siblings within the same household, I find that one single violent incidence during pregnancy significantly increases the risk of stuntedness, malnutrition and weakens major cognitive and behavioral skills. While the type of violence does not seem to play a major role, the perpetrator of violence seems to matter. Violent acts that explicitly target the civilian population, even if they have little e_ect on the general infrastructure, appear to be the driver behind the effect.
    Keywords: stress,violence,health,Iraq
    Date: 2019–11
  4. By: Piccoli, Luca; Tiezzi, Silvia (University of Siena)
    Abstract: This paper deals with one of the main empirical problems associated with the rational addiction theory, namely that its derived demand equation is not empirically distinguishable from models with forward looking behavior, but with time inconsistent preferences. The implication is that, even when forward looking behavior is supported by data, the standard rational addiction equation cannot distinguish between time consistency and inconsistency in preferences. We show that an encompassing general specification of the rational addiction model embeds the possibility of testing for time consistent versus time inconsistent naïve agents. We use a panel of Russian individuals to estimate a rational addiction equation for tobacco with time inconsistent preferences, where GMM estimators deal with errors in variables and unobserved heterogeneity. The results conform to the theoretical predictions and the proposed test for time consistency does not reject the hypothesis that Russian cigarettes consumers discount future utility exponentially. We further show that the proposed empirical specification of the Euler equation, whilst being indistinguishable from the general empirical specification of the rational addiction model, it allows to identify more structural parameters, such as an upper-bound for the parameter capturing present bias in time preferences.
    Keywords: rational addiction, general versus standard specification, time consistency, naïveté, GMM
    JEL: C23 D03 D12
    Date: 2020–01
  5. By: Elena, Lucchese
    Abstract: Ambulance response time to emergency calls is a key indicator of a health system's efficiency although its impact on health is not precisely known. This causal relation is identified by exploiting rainfall at the time of the ambulance run as a shock to responsiveness. The elasticity of the likelihood of a severe cardiovascular condition with respect to response time is 0.9 and that of the likelihood of death before reaching the hospital is 5. Finally, the economic value of time is quantified, and it is shown that improving the ambulance's ability to locate the scene would substantially increase efficiency.
    Keywords: efficiency, response time, health, policy.
    JEL: C26 I18 R41
    Date: 2020–02
  6. By: P. CHONÉ (Crest-Ensae); L. WILNER (Insee - Crest)
    Abstract: To assess strategic interactions in industries where endogenous product characteristics are unobserved to the researcher, we propose an empirical method that brings a competition-in-utility-space framework to the data. We apply the method to the French hospital industry. The utilities offered to patients are inferred from local market shares under AKM exclusion restrictions. The hospitals' objective functions are identified thanks to the gradual introduction of stronger financial incentives over the period of study. Offering more utility to each patient entails incurring higher costs per patient, implying that utilities are mostly strategic complements. Counterfactual simulations show that stronger incentives affect market shares but have little impact on the total number of patient admissions. We quantify the resulting gains for patients and losses for hospitals.
    Keywords: Competition in utility space; financial incentives; payment reform; hospital choice
    JEL: D22 D43 I11 L13
    Date: 2019
  7. By: Fuchs Tarlovsky,Alan; Gonzalez Icaza,Maria Fernanda
    Abstract: This paper analyzes the welfare and distributional impacts of increasing taxes on cigarettes in Georgia. Increasing taxes on tobacco is an effective measure to reduce smoking. According to some estimates, increasing tobacco taxes could save more than GEL 3.6 billion and 53 thousand lives over a 15-year period. However, concerns over potentially regressive effects on the poor are often raised. An Extended Cost Benefit Analysis (ECBA) is applied to simulate the welfare and distributional impacts of raising prices on cigarettes. Decile-specific price elasticities of demand are estimated to account for heterogenous behavioral responses of different income groups. Empirical estimations confirm that poorer households in Georgia tend to reduce consumption more intensely when faced with higher tobacco prices. The estimated magnitude and distribution of elasticities are comparable to peer countries. The simulations based on household survey data suggest that the long-term net distributional effects of increasing taxes on cigarettes in Georgia are likely progressive. Incorporating the indirect benefits of reduced smoking -- reductions in medical expenses and earnings from adverted premature deaths -- could bring small, albeit positive, income gains for large sectors of the population. The magnitude of those benefits is most significant among lower-income households, potentially contributing to lift them out of poverty.
    Date: 2020–01–29
  8. By: Anekwe,Tobenna D.; Zeballos, Eliana
    Abstract: Food-related time use can influence dietary choices and, in turn, influence health outcomes. Thus, tracking changes in food-related time use is key for understanding consumer decisions that affect diet. This report uses data from the 2004-17 American Time Use Survey (ATUS) to present an overview of food-related time-use patterns over time both for the U.S. population aged 15 years and older and for U.S. subgroups that are defined by educational attainment, household type (singles versus couples), and other demographic factors. Data from the supplemental Eating and Health Module (conducted annually during 2014-16 for a subset of the ATUS sample) are analyzed to provide time-use estimates for subgroups defined by Supplemental Nutrition Assistance Program (SNAP) participation, obesity, and food hardship. On an average day in 2014-17, Americans spent 64.0 minutes on eating and drinking as a “primary,” or main, activity, down 4.5 percent from 67.0 minutes in 2004-07. On an average day in 2014-17— counting only those who performed the activity—Americans spent 51.4 minutes on food preparation, 34.1 minutes on food-related cleanup, and 46.0 minutes on grocery shopping.
    Keywords: Agricultural and Food Policy, Food Consumption/Nutrition/Food Safety, Food Security and Poverty, Health Economics and Policy
    Date: 2019–11–20
  9. By: Paola Giuliano; Paola Sapienza
    Abstract: We study the cost of being too patient on happiness. We find that the relationship between patience and various measures of subjective well-being is hump-shaped: it exists an optimal amount of patience that maximizes happiness. Beyond this optimal level, higher levels of patience have a negative impact on well-being.
    JEL: A0 D01 D9 Z1
    Date: 2020–01
  10. By: Dan Benjamin (University of Southern California and NBER); David Laibson (Harvard University and NBER); Walter Mischel (Columbia University); Philip K. Peake (Smith College); Yuichi Shoda (University of Washington); Alexandra Steiny Wellsjo (University of California at Berkeley); Nicole L. Wilson (University of Oregon)
    Abstract: How well do pre-school delay of gratification and life-course measures of self-regulation predict mid-life capital formation? We surveyed 113 participants of the 1967–1973 Bing pre-school studies on delay of gratification when they were in their late 40’s. They re- ported 11 mid-life capital formation outcomes, including net worth, permanent income, absence of high-interest debt, forward-looking behaviors, and educational attainment. To address multiple hypothesis testing and our small sample, we pre-registered an analysis plan of well–powered tests. As predicted, a newly constructed and pre-registered mea- sure derived from preschool delay of gratification does not predict the 11 capital formation variables (i.e., the sign-adjusted average correlation was 0.02). A pre-registered composite self-regulation index, combining preschool delay of gratification with survey measures of self-regulation collected at ages 17, 27, and 37, does predict 10 of the 11 capital formation variables in the expected direction, with an average correlation of 0.19. The inclusion of the preschool delay of gratification measure in this composite index does not affect the index’s predictive power. We tested several hypothesized reasons that preschool delay of gratification does not have predictive power for our mid-life capital formation variables.
    Keywords: Self-regulation, Delay of gratification, Mid-life capital formation
    JEL: D91 D14 I31 I21 I12
    Date: 2019–11–22
  11. By: Bubonya, Melisa (ARC Centre of Excellence in Population Ageing Research (CEPAR)); Cobb-Clark, Deborah A. (University of Sydney)
    Abstract: Our goal is to investigate the pathways that link welfare receipt across generations. We undertake a mediation analysis in which we not only calculate the intergenerational correlation in welfare, but also quantify the portion of that correlation that operates through key mechanisms. Our data come from administrative welfare records for young people (aged 23 – 26) and their parents over nearly two decades which have been linked to survey responses from young people at age 18. The mediators we consider jointly explain nearly a third (32.2 percent) of the intergenerational correlation in welfare participation and more than half (52.6 percent) of the link between parental welfare participation and young people's total welfare benefits. The primary mechanism linking welfare receipt across generations is the failure to complete high school. Adolescents in welfare-reliant families experience more disruptions in their schooling (e.g., school changes and residential mobility, expulsions and suspensions) and receive less financial support from their families both of which impact on their chances of completing high school and avoiding the welfare roll. Young people's risk-taking behavior (smoking, illicit drug use, delinquency and pregnancy) is also a key mechanism underpinning intergenerational welfare reliance. Physical and mental health, work-welfare attitudes and academic achievement, in contrast, have a more modest role in transmitting welfare receipt across generations.
    Keywords: intergenerational welfare, social mobility, socioeconomic disadvantage, social assistance, welfare
    JEL: H53 I38 J62
    Date: 2020–01
  12. By: Amal Harrati; David Rehkopf
    Abstract: In this paper, we characterized health trajectories over an 18-year period for a cohort of American workers. We used administrative data to track monthly, health-related events for six chronic diseases (asthma, arthritis, diabetes, depression, ischemic heart disease, and hypertension) including the diagnoses of new disease, hospitalizations, and outpatient visits. Using these data, we first used sequence and cluster analysis to characterize long-term trajectories of health and to group workers according to their patterns of work experience. We then modeled the relationship of these health trajectories to retirement age, accounting for baseline underlying health, as well as a number of demographic and job-related characteristics. Finally, we consider the role of physical and psychosocial job demand in retirement age. Our analysis produces a number of findings that should be of interest to those studying retirement policy. In our data, workers can be categorized into a small number of distinct work trajectories. While the majority of workers in this sample remain relatively healthy for much of the observation window, others exhibit patterns of health-related events that are often marked by hypertension and/or arthritis. We find that clusters characterized with health events related to hypertension and arthritis are likely to retire later, not earlier. We offer a possible interpretation that these numerous health-related events are signaling the proper management of these chronic diseases, allowing workers to extend their working life. Moreover, we find an association with job demands and retirement, even after controlling for health. Specifically, we find that increases in exposure to heat are associated with lower retirement age, as is less decision-making autonomy. The limitations of this paper include the lack of a representative sample, a relatively small sample size, and the strong incentives of retirement pensions in this cohort that may overwhelm other factors related to retirement decisions.
    Date: 2020–01
  13. By: Chicoine,Luke
    Abstract: This article investigates the causal relationship between women's schooling and fertility by exploiting variation generated by the removal of school fees in Ethiopia. The increase in schooling caused by the reform is identified using both geographic variation in the intensity of its impact and temporal variation generated by the timing of the implementation. The model finds that the removal of school fees led to an increase in schooling for Ethiopian women and that each additional year of schooling led to a reduction in fertility. An investigation of the underlying mechanisms linking schooling and fertility finds that the decline in fertility is associated with an increase in labor market opportunity and a reduction in women's ideal number of children.
    Keywords: Educational Sciences,Health Care Services Industry,Primary Education,Economics of Education,Education Finance,Rural Labor Markets,Labor Markets
    Date: 2020–01–07
  14. By: Mohammad Abu-Zaineh (Aix-Marseille Univ., CNRS, EHESS, Centrale Marseille, AMSE); Olivier Chanel (Aix-Marseille Univ., CNRS, EHESS, Centrale Marseille, AMSE); Khaled Makhloufi (Faculty of Medicine, Aix-Marseille Univ, INSERM, IRD, UMR 912 (SESSTIM))
    Abstract: In their attempts to implement universal health coverage (UHC), different developing countries encounter different types of obstacles. In Tunisia, major challenges include a widespread informal sector and protestors’ general discontent with rising economic insecurity and inequality, the rollback of the state and public welfare. We apply a contingent valuation survey to a non-healthcare-covered Tunisian sample vis-à-vis joining and paying for a health insurance scheme. We pay attention to the nature of the willingness- to-pay (WTP) values obtained, distinguishing genuine null from protest values. The latter may reflect not only protesters’ beliefs regarding the survey, but also their lack of trust in government’s commitment to ensuring the provision of quality healthcare. We use alternative econometric modeling strategies to account and correct for selection issues arising from protest answers. Our results support the presence of self- selection and, by predicting protesters’ WTP, allow the “true” sample mean WTP to be computed. This appears to be about 14% higher than the elicited mean WTP. The WTP of the poorest non-covered respondents represents about one and a half times the current contributions of the poorest formal sector enrollees, suggesting that voluntary affiliation to the formal health insurance scheme could be a step towards achieving UHC. Overall, we highlight the importance of taking into account protest positions for the evaluation of progress towards UHC.
  15. By: Jing Guana; J.D. Tena
    Abstract: This study investigates the causal impact of acquiring social medical Insurance on hospital utilization and health status for children under 16 years old in China from 2010 to 2016. We consider the China Family Panel Studies (CFPS), a longitudinal database which allows us to control for the effect of unobserved individual heterogeneity by means of difference-in-difference regressions combined with matching regression techniques. Our findings suggest that participating in social medical insurance schemes significantly increases children’s yearly hospital use, especially for low income and rural children. Moreover, this increase is not significantly different for people who were not previously sick. It is also found that social medical insurance schemes have no effect or even a marginally negative effect on children’s health status in some cases. We discuss some potential explanations for this result.
    Keywords: China; Social Medical Insurance; Health Outcomes; Difference-in-difference; Propensity Score Matching
    JEL: I13
    Date: 2018–11
  16. By: Alger, Ingela; Juarez, Laura; Juarez-Torres, Miriam; Miquel-Florensa, Josepa
    Abstract: We present evidence from a lab-in-the-field experiment, conducted in eight small, rural villages in Mexico, in which subjects choose to exert real effort to fund real health centers in their own and other localities. We find that women are more willing than men to exert effort to fund the health center in another locality, relative to the one in their locality. This gender gap is mostly due to women who have some trust in the way the government spends taxes, and to women who benefit from a government program that targets women and fosters health care use. Our results also suggest that women might be aware of their higher willingness to exert effort for a public good that does not benefit them directly, compared to men, because they seem to reduce their individual effort the more female their environment is.
    JEL: H41 C91 O12
    Date: 2020–01

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