nep-hea New Economics Papers
on Health Economics
Issue of 2021‒07‒26
twenty papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. A Denial a Day Keeps the Doctor Away By Abe Dunn; Joshua D. Gottlieb; Adam Shapiro; Daniel J. Sonnenstuhl; Pietro Tebaldi
  2. The Causal Effect of an Income Shock on Children’s Human Capital By Cristina Borra; Ana Costa-Ramon; Libertad González; Almudena Sevilla-Sanz
  3. The long shadow of childhood disadvantage on lifelong health: getting worse over time? By Maria Melchior
  4. Does informal care delay nursing home entry? Evidence from Dutch linked survey and administrative data By Bergeot, Julien; Tenand, Marianne
  5. Switching Costs in Competitive Health Insurance Markets: The Role of Insurers’ Pricing Strategies By Lamiraud, Karine; Stadelmann, Pierre
  6. School Health Programs: Education, Health, and Welfare Dependency of Young Adults By Abrahamsen, Signe A.; Ginja, Rita; Riise, Julie
  7. Do Policies to Increase Access to Treatment for Opioid Use Disorder Work? By Eric Barrette; Leemore Dafny; Karen Shen
  8. Geographic Spillover Effects of Prescription Drug Monitoring Programs (PDMPs) By Daniel Guth; Shiyu Zhang
  9. An Examination of the Intracorrelation of Family Health Insurance By Aouad, Marion
  10. Does a Spoonful of Sugar Levy Help the Calories Go Down? An Analysis of the UK Soft Drinks Industry Levy By Dickson, Alex; Gehrsitz, Markus; Kemp, Jonathan
  11. Deteriorated Sleep Quality Does Not Explain the Negative Impact of Smartphone Use on Academic Performance By Amez, Simon; Vujic, Suncica; Abrath, Margo; Baert, Stijn
  12. Temperature, Workplace Safety, and Labor Market Inequality By Park, R. Jisung; Pankratz, Nora; Behrer, A. Patrick
  13. The role of selective mortality in the dynamics of SES-related health inequality across the lifecycle By Paul Allanson; Dennis Petrie
  14. Child health inequality in Sub-Saharan Africa By Pérez-Mesa, David; Marrero, Gustavo A.; Darias-Curvo, Sara
  15. Public Health, Technology, and Human Rights: Lessons from Digital Contact Tracing By Maria Carnovale; Khahlil Louisy
  16. Field Evidence of the Effects of Pro-sociality and Transparency on COVID-19 App Attractiveness By Dooley, Samuel; Turjeman, Dana; Dickerson, John P; Redmiles, Elissa M.
  17. Can a Supranational Medicines Agency Restore Trust After Vaccine Suspensions? The Case of Vaxzevria By Albanese, Andrea; Fallucchi, Francesco; Verheyden, Bertrand
  18. Do COVID-19 Containment Measures Work? Evidence from Switzerland By Regina Pleninger; Sina Streicher; Jan-Egbert Sturm
  19. Job Displacement, Unemployment Benefits and Domestic Violence By Sonia Bhalotra; Diogo G. C. Britto; Paolo Pinotti; Breno Sampaio
  20. COVID-19 Infection Spread and Human Mobility By Masahiko Shibamoto; Shoka Hayaki; Yoshitaka Ogisu

  1. By: Abe Dunn; Joshua D. Gottlieb; Adam Shapiro; Daniel J. Sonnenstuhl; Pietro Tebaldi
    Abstract: Who bears the consequences of administrative problems in healthcare? We use data on repeated interactions between a large sample of U.S. physicians and many different insurers to document the complexity of healthcare billing, and estimate its economic costs for doctors and consequences for patients. Observing the back-and-forth sequences of claims' denials and resubmissions for past visits, we can estimate physicians' costs of haggling with insurers to collect payments. Combining these costs with the revenue never collected, we estimate that physicians lose 17% of Medicaid revenue to billing problems, compared with 5% for Medicare and 3% for commercial payers. Identifying off of physician movers and practices that span state boundaries, we find that physicians respond to billing problems by refusing to accept Medicaid patients in states with more severe billing hurdles. These hurdles are just as quantitatively important as payment rates for explaining variation in physicians' willing to treat Medicaid patients. We conclude that administrative frictions have first-order costs for doctors, patients, and equality of access to healthcare.
    JEL: H52 H75 I11 I13 I14 I18 L14 L33 L88
    Date: 2021–07
  2. By: Cristina Borra; Ana Costa-Ramon; Libertad González; Almudena Sevilla-Sanz
    Abstract: We investigate the causal impact of a generous unconditional cash transfer at birth on children's later health outcomes and academic performance. Using rich administrative data, we take advantage of the unexpected introduction of a “baby bonus” in Spain in 2007, and implement a difference-in-discontinuity approach comparing children born in the surrounding months in different years. We find that the subsidy did not have a significant effect on health outcomes during childhood, nor on test scores in primary school. In line with this result, we show that the benefit did not affect the main potential mechanisms that could in turn have affected children’s health and academic performance. Our results contribute to understanding which interventions are effective at improving children's health and human capital formation.
    Keywords: children, health, education, income shock, Child benefit, Spain
    JEL: I12 J13 H31 H24
    Date: 2021–07
  3. By: Maria Melchior (iPLESP - Institut Pierre Louis d'Epidémiologie et de Santé Publique - SU - Sorbonne Université - INSERM - Institut National de la Santé et de la Recherche Médicale)
    Abstract: Social inequalities in health and their early life origins have been extensively documented. Although the complex direct and intermediate mechanisms linking early life disadvantage to later health are not yet fully understood, new findings on biological markers distinctly related with early life experiences suggest a causal relation. In their paper, Fuller-Rowell et al step back to examine the role of childhood disadvantage in the United States in different periods, and observe that the relationship with later health seems to have strengthened over time. The main explanation the authors bring up has to do with increased income segregation and changes in labour market composition which limit opportunities for persons with low educational attainment. In other words, while the rich get richer, the poor get poorer, the middle class shrinks, and there are fewer interactions across different socio-economic groups and the social ladder is blocked. Other evidence suggests that investments in children, through early education and academic support programs, could help reduce the consequences of childhood disadvantage on long-term health.
    Keywords: Social Inequalities,Childhood,Socioeconomic position
    Date: 2021
  4. By: Bergeot, Julien; Tenand, Marianne
    Abstract: We assess whether informal care receipt affects the probability of transitioning to a nursing home. Available evidence points towards informal care decreasing the chance of admission but it only derives from the US, where nursing home stays are often temporary. Exploiting linked survey and administrative data on the 65+ in the Netherlands, we use the gender mix of children to retrieve plausibly exogenous variation in informal care receipt. Our results suggest that nursing home admissions within a three-year period are reduced with informal care for individuals with mild limitations, while they are increased for individuals with severe limitations. For the latter, although informal care increases formal care costs, it also results in lower post-acute care use and mortality. Therefore, policy makers should not expect that promoting informal care systematically results in lower institutionalization rate and care costs. Still, informal support can well be welfare-enhancing: a timely admission may come along with benefits in terms of well-being and survival that may outweigh additional costs.
    Keywords: Long-term care, nursing home care, informal care, instrumental variables, bivariate probit
    Date: 2021–07
  5. By: Lamiraud, Karine (ESSEC Research Center, ESSEC Business School); Stadelmann, Pierre (Service de la santé publique, Etat de Vaud)
    Abstract: Our article deals with pricing strategies in Swiss health insurance markets and focuses on the relationship between basic and supplementary insurance. We analyzed how firms’ pricing strategies (i.e., pricing of basic and supplementary products) can create switching costs in basic health insurance markets, thereby preventing competition in basic insurance from working properly. More specifically, using unique market and survey data, we investigated whether firms use bundling strategies or supplementary products as low-price products to attract and retain basic insurance consumers. To our knowledge, this is the first paper to analyze these pricing strategies in the context of insurance/health insurance. We found no evidence of bundling in the Swiss setting. We did however observe that firms used low-price supplementary products that contributed to lock in consumers. A majority of firms offered at least one of such product at a low price. None offered low-price products in both basic and supplementary markets. Low-price insurance products differed across firms. When buying a lowprice supplementary product, consumers always bought their basic contract from the same firm. Furthermore, those who opted for low-price supplementary products were less likely to declare an intention to switch basic insurance firms in the near future. This result was true for all risk category levels.
    Keywords: Managed Competition; Swiss Health Care Systems; Pricing; Consumer Inertia; Switching Costs; Supplementary Insurance; low-price supplementary product; Bundling
    JEL: I10
    Date: 2020–05–13
  6. By: Abrahamsen, Signe A. (University of Bergen); Ginja, Rita (University of Bergen); Riise, Julie (University of Bergen)
    Abstract: This paper provides new evidence that preventive health care services delivered at schools and provided at a relatively low cost have positive and lasting impacts. We use variation from a 1999-reform in Norway that induced substantial differences in the availability of health professionals across municipalities and cohorts. In municipalities with one fewer school nurse per 1,000 school-age children before the reform there was an increase in the availability of nurses of 35% from the pre- to the post-reform period, attributed to the policy change. The reform reduced teenage pregnancies and increased college attendance for girls. It also reduced the take-up of welfare benefits by ages 26 and 30 and increased the planned use of primary and specialist health care services at ages 25-35, without impacts on emergency room admissions. The reform also improved the health of newborns of affected new mothers and reduced the likelihood of miscarriages.
    Keywords: school health services, teenage pregnancy, welfare dependency, utilization of health services, health status
    JEL: H75 I10 I12 I28 I30 I38
    Date: 2021–07
  7. By: Eric Barrette; Leemore Dafny; Karen Shen
    Abstract: Even among commercially-insured individuals, opioid use disorder (OUD) is undertreated in the U.S.: nearly half receive no treatment within 6 months of a new diagnosis. Using a difference-in-differences specification exploiting the extension of insurance parity requirements for substance disorder treatment to small group enrollees in 2014, we find that parity increases utilization of residential treatment but decreases utilization of agonist medications, the standard of care. We find direct interventions to increase access to medication may be more promising: increases in the county-level share of physicians able to prescribe agonists are associated with substitution toward medication-assisted treatment.
    JEL: H51 I1 I12 I13 I28
    Date: 2021–07
  8. By: Daniel Guth; Shiyu Zhang
    Abstract: Prescription Drug Monitoring Programs (PDMPs) seek to potentially reduce opioid misuse by restricting the sale of opioids in a state. We examine discontinuities along state borders, where one side may have a PDMP and the other side may not. We find that electronic PDMP implementation, whereby doctors and pharmacists can observe a patient's opioid purchase history, reduces a state's opioid sales but increases opioid sales in neighboring counties on the other side of the state border. We also find systematic differences in opioid sales and mortality between border counties and interior counties. These differences decrease when neighboring states both have ePDMPs, which is consistent with the hypothesis that individuals cross state lines to purchase opioids. Our work highlights the importance of understanding the opioid market as connected across counties or states, as we show that states are affected by the opioid policies of their neighbors.
    Date: 2021–07
  9. By: Aouad, Marion (University of California, Irvine)
    Abstract: A negative shock to one household member can have consequences for other household members. This paper demonstrates the extent of job lock and health insurance plan stemming from the unanticipated health shock of a child family member. In response to the shock, I estimate a 7 – 14 percent decreased likelihood of all family members leaving the current health insurance network and health plan. This is plausibly driven by reduced rates of job switching by the plan's primary policyholder. Furthermore, switching frictions stemming from the non-portability of health insurance products may contribute to the observed job and "health plan lock."
    Keywords: household, health shock, health insurance, job lock
    JEL: I10 I12 J10 J20
    Date: 2021–07
  10. By: Dickson, Alex (University of Strathclyde); Gehrsitz, Markus (University of Strathclyde); Kemp, Jonathan (AG Barr)
    Abstract: This study evaluates the effects of the 2018 UK Soft Drinks Industry Levy on soft drinks prices, sales, reformulation activities, and consequently calories consumed. We combine novel electronic point of sale data that cover most of the UK soft drinks market with longitudinal nutritional information and a variety of event-study specifications. We document that all but a few global soft drinks brands reduced sugar content and hence avoided the tiered levy. For brands that maintained their original sugar content, the levy was on average over-shifted resulting in substantial retail price increases. Consumers responded by reducing their consumption of levied drinks by around 18% which is indicative of an inelastic demand response, especially in the drink-now and energy drink segments of the market. We also document substitution into diet drinks in response to the tax. In total, the levy is responsible for a reduction in intake of just under 6,500 calories from soft drinks per annum per UK resident. More than 80% of reductions were due to manufacturers' reformulation activities and occurred in the two years between the announcement of the levy and its implementation.
    Keywords: sugar tax, soda tax, reformulation, tax pass-through, sin taxes
    JEL: H21 H23 H51 I12 I18
    Date: 2021–07
  11. By: Amez, Simon (Ghent University); Vujic, Suncica (University of Antwerp); Abrath, Margo (University of Antwerp); Baert, Stijn (Ghent University)
    Abstract: University students' smartphone use has recently been shown to negatively affect their academic performance. Surprisingly, research testing the empirical validity of potential mechanisms underlying this relationship is very limited. In particular, indirect effects of negative health consequences due to heavy smartphone use have never been investigated. To fill this gap, we investigate, for the first time, whether deteriorated sleep quality drives the negative impact on academic performance. To this end, we examine longitudinal data on 1,635 students at two major Belgian universities. Based on a combination of a random effects approach and seemingly unrelated regression, we find no statistically significant mediating effect of sleep quality in the relationship between smartphone use and academic performance.
    Keywords: smartphone use, academic performance, sleep quality, mediation analysis
    JEL: I21 I23 J24
    Date: 2021–07
  12. By: Park, R. Jisung (University of California, Los Angeles); Pankratz, Nora (UCLA); Behrer, A. Patrick (Stanford University)
    Abstract: Using data covering the universe of injury claims from the nation's largest worker's compensation system (2001-2018), we explore the relationship between temperature and workplace safety and its implications for labor market inequality. Hotter temperature increases workplace injuries significantly, causing approximately 20,000 injuries per year. The effects persist in both outdoor and indoor settings (e.g. manufacturing, warehousing), and for injury types ostensibly unrelated to temperature (e.g. falling from heights), consistent with cognitive or cost-related channels. The risks are substantially larger for men versus women; for younger versus older workers; and for workers at the lower end of the income distribution, suggesting that accounting for workplace heat exposure may exacerbate total compensation inequality. We document a decline in the heat-sensitivity of injuries over the study period, suggesting significant scope for adaptation using existing technologies.
    Keywords: inequality, labor, workplace safety, temperature, climate change, adaptation
    JEL: J20 J32 I18 Q50
    Date: 2021–07
  13. By: Paul Allanson; Dennis Petrie
    Abstract: The life course literature on the social gradient in health has been dominated by the cumulative advantage and age-as-leveller hypotheses, with selective mortality also recognised as a potentially important confounder in older cohorts. The main contribution of this paper is to establish a unified framework to fully account for the changing social gradient in terms of a sufficient set of mobility indices characterising the co-evolution of the joint distribution of socioeconomic status and health within any particular cohort. The main innovation is to identify selective mortality effects using a counterfactual health distribution for the start of the study period in the absence of those who are known to die before the end, rather than for the end of the period if there had been no deaths since the start which requires the imputation of the ‘would be’ health of non-survivors. Using longitudinal data for Great Britain, selective mortality is found to be an important driver of social gradient changes within older cohorts, contrary to the findings of a number of previous studies. We explain this contrast by demonstrating how estimates of selective mortality effects are affected by the choice of counterfactual health distribution and socioeconomic status measure.
    Keywords: life course, social gradient, mobility analysis, selective mortality, longitudinal data
    JEL: D39 D63 I18
    Date: 2020–08
  14. By: Pérez-Mesa, David; Marrero, Gustavo A.; Darias-Curvo, Sara
    Abstract: This paper contributes to the understanding of child health inequalities in Sub-Saharan African (SSA), the poorest and the second most unequal region in the world. Since health inequality begins at birth, correcting it during childhood is crucial to improving future opportunities for development and fighting against other forms of inequality during adulthood. For 33 SSA countries, we estimate child health inequality by cohorts: from 0-1 up to 4-5 years old. We pay special attention to the part of inequality explained by factors widely used in the literature, such as family background, the mother socio-demographic and anthropometric characteristics, household structure, household facilities and the region of residence. Our starting measure of child health is the standardized height-for-age z-score. We show that child health inequality is systematically lesser for the older cohort than for the younger one. However, the aforementioned set of factors is impeding a further reduction in health inequality, as far as the share caused by these factors has risen along the age distribution in more than 80% of the countries. We do not find evidences that these results are caused by a mortality-selection bias. Instead, we find that family background, followed by household facilities and the region of residence contribute to explaining the differences observed in child health inequality along the age distribution in SSA.
    Keywords: Child health inequality, child age distribution, Sub-Saharan Africa, family background, anthropometric.
    JEL: I14 I15 O10 P52
    Date: 2021–07
  15. By: Maria Carnovale; Khahlil Louisy
    Abstract: To mitigate inefficiencies in manual contact tracing processes, Digital Contact Tracing and Exposure Notifications Systems were developed for use as public-interest technologies during the SARS-CoV-2 global pandemic. Effective implementation of these tools requires alignment across several factors, including local regulations and policies and trust in government and public health officials. Careful consideration should also be made to minimize any potential conflicts with existing processes in public health which has demonstrated effectiveness. Four unique cases-of Ireland, Guayaquil, Haiti, and the Philippines-detailed in this paper will highlight the importance of upholding the principles of Scientific Validity, Necessity, Time Boundedness, and Proportionality.
    Date: 2021–07
  16. By: Dooley, Samuel; Turjeman, Dana (University of Michigan); Dickerson, John P; Redmiles, Elissa M. (Microsoft Research)
    Abstract: COVID-19 exposure-notification apps have struggled to gain adoption. Existing literature posits as potential causes of this low adoption: privacy concerns, insufficient data transparency, and the type of appeal used to pitch the pro-social behavior of installing the app. In a field experiment, we advertised CovidDefense, Louisiana's COVID-19 exposure-notification app, at the time it was released. We find that all three hypothesized factors -- privacy, data transparency, and appeals framing -- relate to app adoption, even when controlling for age, gender, and community density. Specifically, we find that collective-good appeals are effective in fostering pro-social COVID-19 app behavior in the field. Our results empirically support existing policy guidance on the use of collective-good appeals and offer real-world evidence in the on-going debate on the efficacy of such appeals. Further, we offer nuanced findings regarding the efficacy of transparency -- about both privacy and data collection -- in encouraging health technology adoption and pro-social COVID-19 behavior. Our results may aid in fostering pro-social public-health-related behavior and for the broader debate regarding privacy and data transparency in digital healthcare.
    Date: 2021–07–22
  17. By: Albanese, Andrea (LISER); Fallucchi, Francesco (LISER); Verheyden, Bertrand (LISER (CEPS/INSTEAD))
    Abstract: Over the first half of March 2021, the majority of European governments suspended Astrazeneca's Vaxzevria vaccine as a precaution following media reports of rare blood clots. We analyse the impact of the European Medicines Agency's (EMA) March 18th statement assuring the public of the safety of Vaxzevria and the immediate reinstatement of the vaccine by most countries on respondents' intention to get vaccinated. By relying on survey data collected in Luxembourg and neighbouring areas between early March and mid-April, we observe that the willingness to be vaccinated was severely declining in the days preceding the EMA statement. We implement a regression discontinuity design exploiting the time at which respondents completed the survey and find that the vaccine reinstatement substantially restored vaccination intentions.
    Keywords: COVID-19, vaccine hesitancy, supranational regulation, public health, regression discontinuity design
    JEL: I12 I18 C21 H12 H40
    Date: 2021–07
  18. By: Regina Pleninger (ETH Zurich, Switzerland); Sina Streicher (ETH Zurich, Switzerland); Jan-Egbert Sturm (ETH Zurich, Switzerland)
    Abstract: We study the interplay of non-pharmaceutical containment measures, human behavior, and the spread of COVID-19 in Switzerland. First, we collect sub-national data and construct indices that capture the stringency of containment measures at the cantonal level. Second, we use a vector autoregressive (VAR) model to analyze feedback effects between our variables of interest via structural impulse responses. Our results suggest that increases in the stringency of containment measures lead to a significant reduction of weekly infections as well as debit card transactions, which serve as a proxy for behavioral changes in the population. Furthermore, analyzing different policy measures individually shows that business closures, recommendations to work from home, and restrictions on gatherings have been particularly effective in containing the spread of COVID-19 in Switzerland. Finally, our findings indicate a sizeable voluntary reduction in debit card transactions in response to a positive infection shock.
    Keywords: COVID-19, Reproduction Rate, Stringency, Switzerland
    JEL: H12 H51 H73 H75 I18 R59
    Date: 2021–06
  19. By: Sonia Bhalotra; Diogo G. C. Britto; Paolo Pinotti; Breno Sampaio
    Abstract: We estimate impacts of male job loss, female job loss, and male unemployment benefits on domestic violence in Brazil. We merge employer-employee and social welfare registers with administrative data on domestic violence cases brought to criminal courts, use of public shelters by victims and mandatory notifications of domestic violence by health providers. Leveraging mass layoffs for identification, we find that both male and female job loss, independently, lead to large and pervasive increases in domestic violence. Exploiting a discontinuity in unemployment insurance eligibility, we find that eligible men are not less likely to commit domestic violence while benefits are being paid, and more likely to commit it once benefits expire. Our findings are consistent with job loss increasing domestic violence on account of a negative income shock and an increase in exposure of victims to perpetrators, with unemployment benefits partially offsetting the income shock while reinforcing the exposure shock.
    Keywords: domestic violence, unemployment, mass layoffs, unemployment insurance, income shock, exposure, Brazil
    Date: 2021
  20. By: Masahiko Shibamoto (Research Institute for Economics and Business Administration(RIEB), Kobe University, JAPAN); Shoka Hayaki (Graduate School of Business Administration, Kobe University, JAPAN); Yoshitaka Ogisu (Graduate School of Economics, Kobe University, JAPAN)
    Abstract: Given that real-world infection-spread scenarios pose many uncertainties, and predictions and simulations may differ from reality, this study explores factors essential for describing a more realistic evolution of an infection situation. It furnishes three approaches to the argument that human mobility can create an acceleration of the spread of the COVID-19 infection and its cyclicality under the simultaneous relationship. First, using time-series data in Japan, the study presents empirical evidence for a stochastic trend and cycle in new infection cases and the information content of human mobility for infection dynamics. Second, it presents a dynamic model comprising the infection–mobility trade-off and mobility demand, where an increase in human mobility can cause the infection explosion and an increase in new infections can be temporary by suppressing mobility. Third, it employs macroeconometrics to ascertain the feasibility of our model predictions. Accordingly, from March 2020 through May 2021, the sources of the COVID-19 infection spread in Japan varied significantly over time, and each change in the trend and cycle in the new infection cases explained approximately half the respective variation.
    Keywords: COVID-19; Stochastic trend and cycle; New infection cases; Infection–mobility trade-off; Mobility demand; Macroeconometrics
    JEL: C32 E31 E32 I10
    Date: 2021–07

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