nep-hea New Economics Papers
on Health Economics
Issue of 2021‒10‒18
twenty papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. The Causal Effects of Place on Health and Longevity By Tatyana Deryugina; David Molitor
  2. The effect of nutritional status on historical infectious disease morbidity: evidence from the London Foundling Hospital, 1892-1919 By Schneider, Eric B.
  3. Medicaid Expansion and the Mental Health of Spousal Caregivers By Joan Costa-i-Font; Nilesh Raut; Courtney Harold Van Houtven
  4. The heterogeneous effects of the Great Recession on informal care to the elderly By Carro, Jesús M.; Pronkina, Elizaveta
  5. Long-Term Care Partnership Effects on Medicaid and Private Insurance By Joan Costa-i-Font; Nilesh Raut
  6. Elderly Care and Informal Family Care By Miyake, Atsushi; Shintani, Masaya; Yasuoka, Masaya
  7. Physicians' incentives, patients' characteristics, and quality of care: A systematic experimental comparison of fee-for-service, capitation, and pay for performance By Brosig-Koch, Jeannette; Groß, Mona; Hennig-Schmidt, Heike; Kairies-Schwarz, Nadja; Wiesen, Daniel
  8. Appointments: A More Effective Commitment Device for Health Behaviors By Laura Derksen; Jason Kerwin; Natalia Ordaz Reynoso; Olivier Sterck
  9. Time Preferences, Illness, and Death By Norrgren, Lisa
  10. The Impact of the Crisis-inducted Reduction in Air Pollution on Infant Mortality in India: A Policy Perspective By Olexiy Kyrychenko
  11. Environmental Regulations, Air Pollution, and Infant Mortality in India: A Reexamination By Olexiy Kyrychenko
  12. De-Linking Tobacco Taxation and Illicit Trade in Africa By Gallien, Max
  13. Gene-Environment Effects on Female Fertility By Nicola Barban; Elisabetta De Cao; Marco Francesconi
  14. Partial Identification of Marginal Treatment Effects with discrete instruments and misreported treatment By Santiago Acerenza
  15. Unequal mortality during the Spanish Flu By Basco, Sergi; Domenech, Jordi; Roses, Joan R.
  16. Gimme shelter: Social distancing and income support in times of pandemic By Aminjonov, Ulugbek; Bargain, Olivier; Bernard, Tanguy
  17. Food insecurity, safety nets, and coping strategies during the COVID-19 pandemic: multi-country evidence from sub-saharan Africa By Dasgupta, Shouro; Robinson, Elizabeth J.Z.
  18. The effect of COVID-19 and Vaccine rollout on school enrollment in the US By Ogundari, Kolawole
  19. Fear of COVID-19 Contagion: The Idiosyncratic Effects of an Aggregate Pandemic Shock By Junichi Kikuchi; Ryoya Nagao; Yoshiyuki Nakazono
  20. Let’s call! Using the phone to increase acceptance of COVID-19 vaccines By Alex Armand; Mattia Fracchia; Pedro C. Vicente

  1. By: Tatyana Deryugina; David Molitor
    Abstract: Life expectancy varies substantially across local regions within a country, raising conjectures that place of residence affects health. However, population sorting and other confounders make it difficult to disentangle the effects of place on health from other geographic differences in life expectancy. Recent studies have overcome such challenges to demonstrate that place of residence substantially influences health and mortality. Whether policies that encourage people to move to places that are better for their health or that improve areas that are detrimental to health are desirable depends on the mechanisms behind place effects, yet these mechanisms remain poorly understood.
    Keywords: life expectancy, regional variation, place effects
    JEL: I10 R10
    Date: 2021
  2. By: Schneider, Eric B.
    Abstract: There is a complex inter-relationship between nutrition and morbidity in human health. Many diseases reduce nutritional status, but on the other hand, having low nutritional status is also known to make individuals more susceptible to certain diseases and to more serious illness. Modern evidence on these relationships, determined after the introduction of antibiotics and vaccines, may not be applicable to historical settings before these medical technologies were available. This paper uses a historical cohort study based on records from the London Foundling Hospital to determine the causal effect of nutritional status of children, proxied by weight- and height-for-age Z-scores, on the odds of contracting five infectious diseases of childhood (measles, mumps, rubella, chicken pox and whooping cough) and on sickness duration from these diseases. I identify a causal effect by exploiting the randomisation of environmental conditions as foundling children were removed from their original homes, then fostered with families in counties nearby London and later returned to the Foundling Hospital’s main site in London. I find no effect of nutritional status on the odds of contracting the five diseases, but I do find a historically important and statistically significant effect of nutritional status on sickness duration for measles and mumps. These findings have three implications. First, historical incidence of these diseases was unrelated to nutritional status, meaning that poor nutritional status during famines or during the Colombian Exchange did not affect the spread of epidemics. However, undernutrition in these events may have exacerbated measles severity. Second, improving nutritional status in the past 150 years would have reduced the severity of measles and mumps infections but not affect the decline in whooping cough mortality. Finally, selective culling effects from measles would be larger than those from whooping cough since whooping cough severity was not correlated with underlying nutritional status.
    Keywords: morbidity; nutritional status; infectious diseases; health transition
    JEL: N01 N30
    Date: 2021–07
  3. By: Joan Costa-i-Font; Nilesh Raut; Courtney Harold Van Houtven
    Abstract: Health insurance expansions can exert wellbeing effects on individuals who provide informal care to their loved ones, reducing their experience of depression. This study exploits evidence from the Affordable Care Act’s (ACA) Medicaid expansion to examine the effects on the mental wellbeing of informal caregivers. Drawing on an event study and a Difference-in-Differences (DID) design we investigate the policy impact of ACA Medicaid expansion using longitudinal evidence (from the Health and Retirement Study, HRS) for 2010 to 2018 for low-income individuals aged 64 or below. We find that ACA’s Medicaid expansion reduced depressive symptoms among caregivers, and specifically we estimate that exposure to ACA Medicaid expansion gives rise to a 0.38 points (equivalent to 4-5%) reduction in the CESD score (a negative scale in which the lowest scale indicates the best mental wellbeing). We also find that ACA Medicaid causes a spillover effect at the household level, improving the well-being of the spouse care recipient. Our results are robust to various specifications, and we identify several potential driving mechanisms for the findings: reductions in out of -pocket expenses and labor supply and, as expected, increased Medicaid uptake. The evidence from falsification tests confirms that the estimated effects are purely due to ACA’s Medicaid expansion and no other phenomena.
    Keywords: insurance expansion, Medicaid, mental wellbeing, ACA, spousal mental health, informal care
    JEL: I18
    Date: 2021
  4. By: Carro, Jesús M.; Pronkina, Elizaveta
    Abstract: This paper studies the role of unobserved factors to measure the impact of the economic downturn on informal care availability to the elderly in Europe. We use the Survey of Health, Ageing and Retirement in Europe (SHARE), which allows controlling for socio-demographic variables. Our results show that the impact of the Great Recession on care receipt depends not only on observed, but also on unobserved characteristics. For 21 percent of the sample, the effect is three to four times larger than the average effect for the entire sample. For 57 percent of the sample, there is no effect of the economic crisis, and this is due to unobservable factors. In our estimation process, we are able to characterize how this unobserved heterogeneity correlates with the observable variables. Moreover, we show that if the unobserved heterogeneity in the effect of the crisis is ignored, then we are not able to capture that there is no effect for more than half of the individuals, even if we allow for unobserved heterogeneity in the intercept of the model and for the heterogeneous effect of the crisis based on observables.
    Keywords: Informal Care; Great Recession; Unobserved Heterogeneity
    JEL: I18 J14 C2
    Date: 2021–10–13
  5. By: Joan Costa-i-Font; Nilesh Raut
    Abstract: Can the expansion of Medicaid, a means-tested health and long-term care insurance, be slowed down by incentivising the purchase of private long-term care insurance (LTCI)? We study the implementation of the long-term care insurance partnership (LTCIP) program, a joint federal and state-level program that intended to promote LTCI coverage. Drawing on a difference-in-differences (DD) design we study the effect of the rollout of the LTCIP program between 2005 and 2016 on both LTCI uptake and Medicaid eligibility, and we estimate the effect on Medicaid savings. Drawing on a difference-in-differences (DD) design, we find that, unlike previous estimates, the introduction of the LTCIP does significantly increase LTCI coverage and reduce the uptake of Medicaid. The effects are driven by the introduction of LTCIP in states after 2010. We estimate that the adoption of LTCIP has given rise to an average Medicaid saving of $36 for every 65-year-old. This suggests scope for LTCI arrangements to reduce Medicaid spending.
    Keywords: long-term care partnerships, long-term care insurance, Medicaid, United States, difference-in-differences
    JEL: I18 H11 H24
    Date: 2021
  6. By: Miyake, Atsushi; Shintani, Masaya; Yasuoka, Masaya
    Abstract: Informal family care presents important difficulties for the entire economy. Because of short supplies of formal elderly care, some family members are compelled to leave work to provide care for elderly relatives. Therefore, the overall loss of added value caused by informal family care is not negligible. After developing a model to assess how households determine allocation of formal and informal elderly care, we analyze subsidy effects for elderly care in the economy. Results show that subsidies for formal care that is bought by people of the younger generation are more effective for decreasing losses attributable to informal elderly care.
    Keywords: Formal Care, Informal Care, Subsidy for Elderly Care, Unemployed Family Caregiver
    JEL: J14 O17
    Date: 2021–10–11
  7. By: Brosig-Koch, Jeannette; Groß, Mona; Hennig-Schmidt, Heike; Kairies-Schwarz, Nadja; Wiesen, Daniel
    Abstract: This paper systematically studies how performance pay, complementing either baseline feefor-service or capitation, affects physicians' medical service provision and the quality of care. Using a series of controlled experiments with physicians and students, we test the incentive effect of performance pay at a within-subject level. A discrete bonus is granted if a quality threshold is reached, which varies with the patients' severity of illness. We find that performance pay significantly reduces non-optimal service provision and enhances the quality of care. Effect sizes depend on the patients' severity of illness and whether the baseline is fee-for-service or capitation. Health policy implications, including a cost benefit analysis of introducing performance pay, are discussed.
    Keywords: Fee-for-service,capitation,pay for performance,heterogeneous patients,artefactual field experiment,laboratory experiments
    JEL: C91 I11
    Date: 2021
  8. By: Laura Derksen; Jason Kerwin; Natalia Ordaz Reynoso; Olivier Sterck
    Abstract: Health behaviors are plagued by self-control problems, and commitment devices are frequently proposed as a solution. We show that a simple alternative works even better: appointments. We randomly offer HIV testing appointments and financial commitment devices to high-risk men in Malawi. Appointments are much more effective than financial commitment devices, more than doubling testing rates. In contrast, most men who take up financial commitment devices lose their investments. Appointments address procrastination without the potential drawback of commitment failure, and also address limited memory problems. Appointments have the potential to increase demand for healthcare in the developing world.
    Date: 2021–10
  9. By: Norrgren, Lisa (Department of Economics, School of Business, Economics and Law, Göteborg University)
    Abstract: This paper investigates the predictive power of time preferences on the risk of early mortality and illness in adulthood. Using a unique Swedish cohort of 12,956 individuals born in 1953, interviewed in 1966, and followed with register data up to 2018, the paper finds that patient adolescents are 17–21% less likely to die before age 65. Patient adolescents have fewer hospitalizations and diagnoses in their adult life and are less likely to be diagnosed with conditions associated with lifestyle risk factors. Patient adolescents are also more in favor of sports activities and school rules on smoking. The investigated channels for the relationship between time preferences and future health include lifestyle, mother’s time preferences, and the adolescent’s education attainment and future income. Controlling for education and income reduces the coefficient for time preferences on early mortality by one-fourth.
    Keywords: Time preferences; illnes; death
    JEL: D90 D91 I10 I12
    Date: 2021–10
  10. By: Olexiy Kyrychenko
    Abstract: Credible estimates of the health effects associated with changes in air pollution exposure are of considerable importance for research and policy agendas, especially for developing countries. This paper estimates the impact of the sharp reduction in particulate air pollution driven by the Global Financial Crisis of 2008 on district-level infant mortality in India. Utilizing plausibly exogenous geographic variation in the crisis-induced changes in air quality and novel data from household surveys and satellite-based sources, I find that the infant mortality rate fell by 24% more in the most affected districts, implying 1338 fewer infant deaths than would have occurred in the absence of the crisis. Analysis of the mechanisms indicates that the PM2.5 reductions affected infant mortality mainly through respiratory diseases and two biological mechanisms: in utero and postbirth PM2.5 exposure. Back-of-the-envelope calculations suggest that the estimated decline in infant mortality translates into a three-year after crisis total of 312.5 million U.S. dollars. The resulting health benefits could be used as a benchmark for assessing the effectiveness of the policies designed to improve air quality in India.
    Keywords: air pollution; infant mortality; crisis; India;
    JEL: Q53 I12 O13
    Date: 2021–09
  11. By: Olexiy Kyrychenko
    Abstract: This paper reexamines empirical evidence on the effectiveness of environmental regulations in India from a recent study by Greenstone and Hanna (GH, 2014). GH report that air pollution control policies in India were effective in improving air quality but had a modest and statistically insignificant effect on infant mortality. These somewhat counterintuitive findings are likely to stem from the limited availability of ground-based air pollution data used in GH and the absence of critical meteorological confounders. I leverage recent advances in satellite technology and GH’s methodology to test the sensitivity of their findings to revised air pollution outcomes, an extended number of observations, and meteorological controls. Despite striking differences between the two datasets, reexamination using satellite-based data confirms the conclusions drawn from GH’s data. The effects of the policies are, however, substantially weaker. The paper urges further research on the effectiveness of environmental regulations in developing countries and the use of satellite imagery in the examination of this important question.
    Keywords: air pollution; infant mortality; environmental regulation; India;
    JEL: I12 J13 O13 Q53 Q58
    Date: 2021–09
  12. By: Gallien, Max
    Abstract: Smoking tobacco has been much less common traditionally in Africa than in Europe or North America. But this is changing. As Africa has become a growth market for the tobacco industry, adverse health effects are increasingly visible. While increasing tobacco taxation has been shown as the most effective policy tool in curbing tobacco consumption, many countries in Africa have maintained relatively low levels of tobacco taxation. One of the most common arguments against raising taxes on tobacco has been that this would increase smuggling. Drawing on recent studies from across Africa, this brief highlights the complex relationship between smuggling and taxation, and argues that smuggling should not deter African governments from increasing taxes on tobacco products.
    Keywords: Development Policy, Economic Development, Health, Trade,
    Date: 2020
  13. By: Nicola Barban; Elisabetta De Cao; Marco Francesconi
    Abstract: Fertility has a strong biological component generally ignored by economists. Using the UK Biobank, we analyze the extent to which genes, proxied by polygenic scores, and the environment, proxied by early exposure to the contraceptive pill diffusion, affect age at first sexual intercourse, age at first birth, completed family size, and childlessness. Both genes and environment exert substantial influences on all outcomes. The anticipation of sexual debut and the postponement of motherhood led by the diffusion of the pill are magnified by gene-environment interactions, while the decline in family size and the rise in childlessness associated with female emancipation are attenuated by gene-environment effects. The nature-nurture interplay becomes stronger in more egalitarian environments that empower women, allowing genes to express themselves more fully. These conclusions are confirmed by heterogenous effects across the distributions of genetic susceptibilities and exposure to environmental risks, sister fixed effects models, mother-daughter comparisons, and counterfactual simulations.
    Keywords: fertility, genetics, polygenic score, contraceptive pill, nature versus nurture, social norms
    JEL: D10 I14 I15 J01 J13 J16
    Date: 2021
  14. By: Santiago Acerenza
    Abstract: This paper provides partial identification results for the marginal treatment effect ($MTE$) when the binary treatment variable is potentially misreported and the instrumental variable is discrete. Identification results are derived under different sets of nonparametric assumptions. The identification results are illustrated in identifying the marginal treatment effects of food stamps on health.
    Date: 2021–10
  15. By: Basco, Sergi; Domenech, Jordi; Roses, Joan R.
    Abstract: The outburst of deaths and cases of Covid-19 around the world has renewed the interest to understand the mortality effects of pandemics across regions, occupations, age and gender. The Spanish Flu is the closest pandemic to Covid-19. Mortality rates in Spain were among the largest in today’s developed countries. Our research documents a substantial heterogeneity on mortality rates across occupations. The highest mortality was on low-income workers. We also record a rural mortality penalty that reversed the historical urban penalty temporally. The higher capacity of certain social groups to isolate themselves from social contact could explain these mortality differentials. However, adjusting mortality evidence by these two factors, there were still large mortality inter-provincial differences for the same occupation and location, suggesting the existence of a regional component in rates of flu contagion possibly related to climatic differences.
    Keywords: pandemics; health inequality; socio-economic mortality differences; urban penalty
    JEL: D6 I18 J15 N0
    Date: 2021–02
  16. By: Aminjonov, Ulugbek; Bargain, Olivier; Bernard, Tanguy
    Abstract: Strict containment limits the spread of pandemics but is difficult to achieve when people must continue to work to avoid poverty. A new role is emerging for income support: by enabling people to effectively stay home, it can produce substantial health externalities. We examine this issue using data on human mobility and poverty rates in 729 subnational regions of low- and middle-income countries during the first year of COVID-19. Shelter-in-place orders decrease work-related mobility in general, but much less so in the poorest regions. Emergency income support significantly mitigates this mobility gap between regions. It reduces by half the additional contagion caused, via the mobility channel, by regional poverty differences.
    Keywords: WORLD; Coronavirus; coronavirus disease; Coronavirinae; COVID-19; physical distancing; shelter; income; pandemics; poverty; policies; social protection; compliance; lockdown; mobility
    Date: 2021
  17. By: Dasgupta, Shouro; Robinson, Elizabeth J.Z.
    Abstract: The COVID-19 pandemic has affected food security across the world. As governments respond in different ways both with regards to containing the pandemic and addressing food insecurity, in parallel detailed datasets are being collected and analysed. To date, literature addressing food insecurity during the pandemic, using these datasets, has tended to focus on individual countries. By contrast, this paper provides the first detailed multi-country cross-sectional snapshot of the social dimensions of food insecurity during the COVID-19 pandemic across nine African countries (Chad, Djibouti, Ethiopia, Kenya, Malawi, Mali, Nigeria, South Africa, and Uganda). Econometric analysis reveals that female-headed households, the poor, and the less-formally educated, appear to suffer more in terms of food insecurity during this global pandemic. Importantly, our findings show that the negative consequences of the pandemic are disproportionately higher for lower-income households and those who had to borrow to make ends meet rather than relying on savings; impacts are country-specific; and there is considerable spatial heterogeneity within country food insecurity, suggesting that tailored policies will be required. These nine countries employ both food and cash safety nets, with the evidence suggesting that, at least when these data were collected, cash safety nets have been slightly more effective at reducing food insecurity. Our results provide a baseline that can be used by governments to help design and implement tailored policies to address food insecurity. Our findings can also be used as lessons to reshape policies to tackle the heterogeneous impacts of climate change.
    Keywords: Covid-19; food insecurity; multi-country models; socioeconomic determinants; coronavirus
    JEL: R14 J01
    Date: 2021–10–01
  18. By: Ogundari, Kolawole
    Abstract: The COVID-19 pandemic outbreaks forced families to decide the safest and most effective learning environments for their children because of the virus's threat to health and life. Hence, because of the nationwide school closure, policymakers have raised concerns about the missing children cases-those who have not enrolled in school at all because of the pandemic. The present study investigates whether there is a difference in the school enrollment during the pre-COVID-19 period, COVID-19 period, and vaccine rollout period. We employed the U.S. Current Population Survey (CPS), covering January 2020 to May 2021, while we use both the logistic and multinomial regression models for the empirical analysis. Our results showed that school enrollment is lower during the COVID-19 pandemic compared to the Pre-COVID-19 period. Other results showed that school enrollment is higher since vaccine rollout compared to the COVID-19 period. A possible explanation for this could be that families consider the vaccine the safe path to enrolling their children in school. We also found that school enrollment varies significantly across race and ethnic groups.
    Keywords: COVID-19, Enrollment, High School, College, USA
    JEL: C5 C54 I21 I25
    Date: 2021–10–12
  19. By: Junichi Kikuchi; Ryoya Nagao; Yoshiyuki Nakazono
    Abstract: We examine how the fear of COVID-19 contagion influences consumer expenditure patterns. We show that the consumption expenditure responses to the spread of the COVID-19 pandemic are significantly heterogeneous across generations. We find that the elderly spend less than the younger generation by at least 5% as COVID-19 spread. In fact, those aged above 60 significantly decreased their spending even on food and drink products by 13%. We also find that the elderly forgo shopping in favor of the younger generation. These heterogeneous responses are likely to be due to the fear of the COVID-19 infection.
    Date: 2021–10
  20. By: Alex Armand; Mattia Fracchia; Pedro C. Vicente
    Abstract: Vaccinating against COVID-19 is the main hope to end the current pandemic. We develop and test experimentally three phone-based cumulative interventions to increase COVID-19 vaccine acceptance in Mozambique. First, the provision of a simple positive message informing about these vaccines. Second, the activation of social memory on the country’s success in eradicating wild polio. Finally, the inoculation against fake news by developing among participants a critical view towards misleading information. We find that the combination of the three interventions increases COVID-19 vaccine acceptance and trust in institutions.
    Keywords: COVID-19, vaccines, acceptance, hesitancy, information, trust, social memory, fake news, misinformation, inoculation theory, Mozambique, Africa
    JEL: O12 D83 D91 I12 I15
    Date: 2021

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