nep-hea New Economics Papers
on Health Economics
Issue of 2021‒10‒25
eighteen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. When Labor Enforcement and Immigration Enforcement Collide: Deterring Worker Complaints Worsens Workplace Safety By Amanda M. Grittner; Matthew S. Johnson
  2. The Psychosocial Effects of the Flint Water Crisis on School-Age Children By Sam Trejo; Gloria Yeomans-Maldonado; Brian Jacob
  3. Why Do Couples and Singles Save During Retirement? By De Nardi, M.; French, E.; Bailey Jones, J.; McGee, R.
  4. A Taste of Their Own Medicine: Guideline Adherence and Access to Expertise By Amy Finkelstein; Petra Persson; Maria Polyakova; Jesse M. Shapiro
  5. Providing Vouchers and Value Information for Already Free Eye Exams Increases Uptake Among a Low-Income Minority Population: A Randomized Trial By Seema Kacker; Mario Macis; Prateek Gajwani; David S. Friedman
  6. Optimal mixed payment system and medical liability. A laboratory study By Finocchiaro Castro, Massimo; Ferrara, Paolo Lorenzo; Guccio, Calogero; Lisi, Domenico
  7. Income-related inequality in smoking habits: A comparative assessment in the European Union By Paolo Liberati; Giovanni Carnazza; Giuliano Resce
  8. Support from grandparents and mothers’ depression around the time of separation By Niina Metsä-Simola; Anna Baranowska-Rataj; Hanna Remes; Mine Kühn; Pekka Martikainen
  9. Exploring the Heterogeneous Effects of State Price Transparency Laws on Charge Prices, Negotiated Prices, and Operating Costs By Sebastian Linde; Ralph Siebert
  10. Is Transparency a Free Lunch? Evidence from the Italian Local Health Authorities By Ferrara, Paolo Lorenzo; Guccio, Calogero; Scaglioni, Carla
  11. Comparisons of Australian Mental Health Distributions By David Gunawan; William Griffiths; Duangkamon Chotikapanich
  12. Juggling Paid Work and Elderly Care Provision in Japan: Does a Flexible Work Environment Help Family Caregivers Cope? By Niimi, Yoko
  13. Gene‐Environment Effects on Female Fertility By Barban, Nicola; De Cao, Elisabetta; Francesconi, Marco
  14. The Economics of the COVID-19 Pandemic in Poor Countries By Edward Miguel; Ahmed Mushfiq Mobarak
  15. The effects of India’s COVID-19 lockdown on critical non-COVID health care and outcomes: evidence from a retrospective cohort analysis of dialysis patients By Jain, Radhika; Dupas, Pascaline
  16. COVID-19 in long-term care: Impact, policy responses and challenges By Eileen Rocard; Paola Sillitti; Ana Llena-Nozal
  17. Optimally Targeting Interventions in Networks during a Pandemic: Theory and Evidence from the Networks of Nursing Homes in the United States By Roland Pongou; Guy Tchuente; Jean-Baptiste Tondji
  18. The Cost of Worrying About an Epidemic: Ebola Concern and Cognitive Function in the US By Christian Apenbrink

  1. By: Amanda M. Grittner (Abt Associates); Matthew S. Johnson (Duke University)
    Abstract: Regulatory agencies overseeing the labor market often rely on worker complaints to direct their enforcement. However, if workers face differential barriers to complain, this system could result in ineffective targeting and create disparities in working conditions. To investigate these implications, we examine how the onset of Secure Communities—a localized immigration enforcement program—affected occupational safety and health. Counties’ participation in Secure Communities substantially reduced complaints to government safety regulators, but increased injuries, at workplaces with Hispanic workers. We show that these effects are most consistent with employers reducing safety inputs in response to workers’ decreased willingness to complain.
    Keywords: labor regulations; workplace safety; immigration enforcement
    JEL: J28 J81 I18
    Date: 2021–10
  2. By: Sam Trejo; Gloria Yeomans-Maldonado; Brian Jacob
    Abstract: Lead poisoning has well-known impacts for the developing brain of young children, with a large literature documenting the negative effects of elevated blood lead levels on academic and behavioral outcomes. In April of 2014, the municipal water source in Flint, Michigan was changed, causing lead from aging pipes to leach into the city’s drinking water. In this study, we use Michigan’s universe of longitudinal, student-level education records, combined with home water service line inspection data containing the location of lead pipes, to empirically examine the effect of the Flint Water Crisis on educational outcomes of Flint public school children. We leverage parallel causal identification strategies, a between-district synthetic control analysis and a within-Flint difference-in-differences analysis, to separate out the direct health effects of lead exposure from the broad effects of living in a community experiencing a crisis. Our results highlight a less well-appreciated consequence of the Flint Water Crisis – namely, the psychosocial effects of the crisis on the educational outcomes of school-age children. These findings suggest that cost estimates which rely only on the negative impact of direct lead exposure substantially underestimate the overall societal cost of the crisis.
    JEL: I10 I21 I28 I30 J01 J18
    Date: 2021–10
  3. By: De Nardi, M.; French, E.; Bailey Jones, J.; McGee, R.
    Abstract: While the savings of retired singles tend to fall with age, those of retired couples tend to rise. We estimate a rich model of retired singles and couples with bequest motives and uncertain longevity and medical expenses. Our estimates imply that while medical expenses are an important driver of the savings of middle-income singles, bequest motives matter for couples and highincome singles and generate transfers to nonspousal heirs whenever a household member dies. The interaction of medical expenses and bequest motives is a crucial determinant of savings for all retirees. Hence, to understand savings, it is important to model household structure, medical expenses, and bequest motives.
    Keywords: Savings, bequests, medical spending
    JEL: C51 D14 D15 I14
    Date: 2021–10–20
  4. By: Amy Finkelstein; Petra Persson; Maria Polyakova; Jesse M. Shapiro
    Abstract: We use population administrative data from Sweden to study adherence to 63 medication-related guidelines. We compare the adherence of patients without personal access to medical expertise to the adherence of those with access, namely doctors and their close relatives. We estimate that, among observably similar patients, access to expertise is associated with 3.8 percentage points lower adherence, relative to a baseline adherence rate of 54.4 percent among those without access. This association is larger for recommendations with a weaker clinical motivation. Our findings suggest an important role in non-adherence for factors other than those, such as ignorance, complexity, or failures of patient-provider communication, that would be expected to diminish with access to expertise.
    JEL: D83 I12 I18
    Date: 2021–10
  5. By: Seema Kacker; Mario Macis; Prateek Gajwani; David S. Friedman
    Abstract: We study whether vouchers with and without value information encourage completion of already free follow-up appointments in a low-income minority population in Baltimore City referred for definitive evaluation of possible eye disease. Between May 2017 and September 2018, 821 individuals referred for free follow-up from 114 screening events received 1) standard referral, 2) a voucher redeemable for free follow-up and prescription glasses, or 3) a voucher including a statement of monetary value ($250). All referred individuals received patient education, counseling, and appointment reminders. We find that vouchers with and without value information increase follow-up appointments by 12.5 and 20.3 percentage points, respectively, corresponding to a 36%-58% increase compared to the standard referral with no voucher. We conclude that reframing free targeted health service offers by providing vouchers with value information is a promising, low-cost tool to increase uptake.
    JEL: D9 I1 I12
    Date: 2021–10
  6. By: Finocchiaro Castro, Massimo; Ferrara, Paolo Lorenzo; Guccio, Calogero; Lisi, Domenico
    Abstract: In a controlled laboratory environment, we test the role of medical malpractice liability on physicians’ service provision under fee-for-service, capitation, and mixed payment. We find that the introduction of medical liability causes a significant deviation from patient-optimal treatment that it is not mitigated by the use of a standard mixed payment system. Specifically, we find that the presence of medical liability pressure involves a proper optimal calibration of mixed payment system. Our findings have relevant policy implications for the correct calibration and implementation of the mixed payment system.
    Keywords: medical liability; defensive medicine; payment systems; physicians’ behaviour; laboratory experiment
    JEL: C91 I12 K13
    Date: 2021–10–20
  7. By: Paolo Liberati; Giovanni Carnazza (Università di Roma Tre); Giuliano Resce (Università del Molise)
    Abstract: This paper investigates the association between income and the habit of smoking in 30 European countries. Using the European Health Interview Survey carried out between 2013 and 2015, the analysis focuses on the relationship among net monthly equivalised income of the household, the type of smoking behaviour, and the daily average number of cigarettes smoked. Income-related inequalities are estimated using the Erreygers Index. Results show that smoking is a habit which is mainly rooted in the lowest part of the income distribution both at individual and country level, regardless of the average level of per capita income. Considering that tobacco use worsens poverty conditions by diverting household spending from basic needs to tobacco itself, our results give support to a tax increase in order to discourage its use and to the implementation of educational and prevention programs aimed at helping people to quit smoking.
    Keywords: Risky behaviours, Smoking, Income-related health inequalities, European Union
    JEL: I12 I14 O52
    Date: 2021–10
  8. By: Niina Metsä-Simola; Anna Baranowska-Rataj; Hanna Remes; Mine Kühn (Max Planck Institute for Demographic Research, Rostock, Germany); Pekka Martikainen (Max Planck Institute for Demographic Research, Rostock, Germany)
    Abstract: Objective. This study examined mothers’ depression trajectories around the time of separation by potential availability of support from their youngest child’s grandparents. Background. Separation and single motherhood are both associated with an increased risk of depression. Grandparents are often the most important source of support to families with children, and their support may moderate separating mothers’ depression trajectories. Method. Using longitudinal Finnish register data on 118,006 separating mothers whose youngest child was age 12 or less, we examined the mothers’ depression trajectories, based on antidepressant use 4 years before and 4 years after separation. The trajectories were examined by grandparental characteristics – age, employment, health, geographical distance to the mother, and union stability – using logistic panel regression. Results. Grandparent’s availability for providing support, as proxied by younger age, employment, and lack of severe health problems all predicted a lower probability of maternal depression both before and after separation. The level of depression was also lower if grandparents lived close to the mother, and if the maternal grandparents’ union was intact. Overall, the maternal grandmothers appeared to matter the most. Conclusion. The availability of support from grandparents may partially compensate for the resource losses related to separation, and it is associated with lower maternal depression both before and after separation. Keywords. Separation, depression, mothers, grandparents, social support
    Keywords: Finland
    JEL: J1 Z0
    Date: 2021
  9. By: Sebastian Linde; Ralph Siebert
    Abstract: To limit the dramatic growth of U.S. health care expenditures, some states have mandated that medical providers publicly report their charge prices. Our study evaluates the heterogeneous effects of this price transparency policy. We use a comprehensive database that covers more than 2,000 hospitals nationwide from 1996 to 2017. We employ a flexible generalized synthetic control method that allows for heterogeneous treatment effects. We find that the price transparency policy not only reduced charge prices by 3.9% (which corresponds to savings of $1,164 per hospital stay) but also diminished negotiated prices by 15.9% and hospital costs by 4.7%. Our estimation results show that the effects on charge prices do not last as long as the impacts on negotiated prices and costs. We also find large heterogeneous responses across hospitals that depend on: (1) hospitals’ past charge prices prior to adopting the price transparency law, that is, high-price hospitals reduce charge and negotiated prices, while low-price hospitals increase charges; (2) hospital characteristics such as ownership, case mix, and payer mix; and (3) hospital size and market competition. We also conduct counterfactuals to predict price changes of non-treated states and find large reductions in negotiated prices.
    Keywords: charge prices, difference-in-difference, heterogeneous treatment effects, hospitals, hospital costs, interactive fixed effects, negotiated prices, price transparency laws, synthetic controls
    JEL: C10 C33 I10 I11
    Date: 2021
  10. By: Ferrara, Paolo Lorenzo; Guccio, Calogero; Scaglioni, Carla
    Abstract: The healthcare sector is often considered one of the most prone to corruption and transparency policies have been proposed in several countries to fight bribery and corruption. Indeed, the transparency of public bodies potentially play a relevant role in preventing misbehaviours and favouring accountability. The paper contributes to the broader understanding of the transparency role in the healthcare sector using Italy as a case study. For this purpose we first build a composite indicator of transparency, already proposed in the literature in the field, to assess the differences in transparency and integrity between Italian Local Health Authorities (LHAs). Then we use multivariate regression to explore the relationship between the performance for different expenditure functions at LHAs level and transparency index. Our results show a wide difference in transparency and integrity among LHAs that does not always follow the classic north-south divide in the country. In addition, we find results consistent with the idea that transparency is generally associated with better performance of the LHAs in containment total health expenditure while imposing larger administrative burdens.
    Keywords: Transparency,Administrative burdens,Accountability,Local Health Authorities,Italian NHS
    JEL: C92 H30 H41
    Date: 2021
  11. By: David Gunawan; William Griffiths; Duangkamon Chotikapanich
    Abstract: Bayesian nonparametric estimates of Australian mental health distributions are obtained to assess how the mental health status of the population has changed over time, and to compare the mental health status of female/male and indigenous/non-indigenous population subgroups. First-order and secondorder stochastic dominance are used to compare distributions, with results presented in terms of the posterior probability of dominance and the posterior probability of no dominance. If a criterion for dominance is satisfied, then, in terms of that criterion, the mental health status of the dominant population is superior to that of the dominated population. If neither distribution is dominant, then the mental health status of neither population is superior in the same sense. Our results suggest mental health has deteriorated in recent years, that males' mental health status is better than that of females, and that non-indigenous health status is better than that of the indigenous population.
    Keywords: stochastic dominance, Bayesian nonparametric estimation, posterior probabilities, indigenous population, male and female populations
    Date: 2021
  12. By: Niimi, Yoko
    Abstract: Using unique data from a Japanese survey, this paper examines whether flexible work arrangements targeted specifically at workers with caregiving responsibilities under the Child Care and Family Care Leave Act help family caregivers reconcile paid work with care provision. The regression results suggest that access to caregiver leave, which allows family caregivers to take a continuous leave of up to 93 days, is negatively and significantly associated with the probability of leaving one’s job within one year of the onset of demand for parental care. This alleviating effect of access to caregiver leave remains robust even in the longer term and in a specification where we take into account the possible endogeneity of care provision to the labor supply decision. The findings of this paper thus suggest that the caregiver leave introduced pursuant to the Act in Japan helps meet the need of family caregivers to take a certain period of time off from work to make the necessary arrangements for accommodating the sudden and unexpected demand for elderly care in their daily lives.
    Keywords: elderly care, informal care, flexible work, labor supply, long-term care, Japan, J14, J22
    Date: 2021–10
  13. By: Barban, Nicola; De Cao, Elisabetta; Francesconi, Marco
    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 heterogeneous 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
    Date: 2021–10–18
  14. By: Edward Miguel; Ahmed Mushfiq Mobarak
    Abstract: The COVID-19 pandemic has upended health and living standards around the world. This article provides an interim overview of these effects, with a particular focus on low- and middle-income countries (LMICs). Economists have explained how the pandemic is likely to have differential consequences for LMICs, and demand distinct policy responses, compared to rich countries. We survey the rapidly expanding body of empirical research that documents its many adverse economic and non-economic effects in terms of living standards, education, health, and gender equality, which appear to be unprecedented in depth and scale. We also review research on successful and failed policy responses, including the failure to ensure widespread vaccine coverage in LMICs, which is needed to end the pandemic. We close with a discussion of implications for public policy in LMICs, and for the institutions of international governance, given the likelihood of future pandemics and other major shocks (e.g., climate).
    JEL: I15 O1
    Date: 2021–10
  15. By: Jain, Radhika; Dupas, Pascaline
    Abstract: India’s COVID-19 lockdown, one of the most severe in the world, is widely believed to have disrupted critical non-COVID health services. However, linking these disruptions to effects on health outcomes has been difficult due to the lack of reliable, up-to-date health outcomes data. We identified all dialysis patients under a statewide health insurance program in Rajasthan, India, and conducted surveys to examine the effects of the lockdown on care access, morbidity, and mortality. 63% of patients experienced a disruption to their care. Transport barriers, hospital service disruptions, and difficulty obtaining medicines were the most common causes. We compared monthly mortality in the four months after the lockdown with pre-lockdown mortality trends, as well as with mortality trends for a similar cohort in the previous year. Mortality in May 2020, after a month of exposure to the lockdown, was 1.70 percentage points or 64% (p=0.01) higher than in March 2020 and total excess mortality between April and July was estimated to be 22%. Morbidity, hospitalization, and mortality between May and July were strongly positively associated with lockdown-related disruptions to care, providing further evidence that the uptick in mortality was driven by the lockdown. Females, socioeconomically disadvantaged groups, and patients living far from the health system faced worse outcomes. The results highlight the unintended consequences of the lockdown on critical, life-saving non-COVID health services that must be taken into account in the implementation of future policy efforts to control the spread of pandemics.
    Keywords: COVID-19; Pandemic; Non-pharmaceutical intervention; Excess mortality; Non-communicable disease; Dialysis; Chronic kidney disease; Health systems
    JEL: I10 I14 I18
    Date: 2021–06–11
  16. By: Eileen Rocard (OECD); Paola Sillitti (OECD); Ana Llena-Nozal (OECD)
    Abstract: The COVID-19 crisis has hit the long-term care (LTC) sector particularly hard, with large numbers of people dependent on care and particularly vulnerable to COVID-19 have fallen ill, and a disproportionate rate of LTC workers both exposed to, and infected by, COVID-19. The analysis presented in this report describes the effects of COVID-19 on LTC in OECD countries, mainly showing infection rates and mortality of LTC recipients. It takes stock of the wide range of policy responses that countries have implemented, detailing the changes over time on testing strategies, reduction of interactions and isolation measures, digitalisation of services, and workforce. The report also assesses emergency preparedness in the sector, as well as workforce, organisational and coordination challenges. Finally, the report analyses how policy responses affected care continuity and the well-being of residents while also outlining the effectiveness of vaccination.
    JEL: H75 I31 I38
    Date: 2021–10–21
  17. By: Roland Pongou; Guy Tchuente; Jean-Baptiste Tondji
    Abstract: This study develops an economic model for a social planner who prioritizes health over short-term wealth accumulation during a pandemic. Agents are connected through a weighted undirected network of contacts, and the planner's objective is to determine the policy that contains the spread of infection below a tolerable incidence level, and that maximizes the present discounted value of real income, in that order of priority. The optimal unique policy depends both on the configuration of the contact network and the tolerable infection incidence. Comparative statics analyses are conducted: (i) they reveal the tradeoff between the economic cost of the pandemic and the infection incidence allowed; and (ii) they suggest a correlation between different measures of network centrality and individual lockdown probability with the correlation increasing with the tolerable infection incidence level. Using unique data on the networks of nursing and long-term homes in the U.S., we calibrate our model at the state level and estimate the tolerable COVID-19 infection incidence level. We find that laissez-faire (more tolerance to the virus spread) pandemic policy is associated with an increased number of deaths in nursing homes and higher state GDP growth. In terms of the death count, laissez-faire is more harmful to nursing homes than more peripheral in the networks, those located in deprived counties, and those who work for a profit. We also find that U.S. states with a Republican governor have a higher level of tolerable incidence, but policies tend to converge with high death count.
    Date: 2021–10
  18. By: Christian Apenbrink (Bonn Graduate School of Economics, University of Bonn)
    Abstract: Do emotional responses to the spread of an infectious disease affect the quality of economic decision-making? In the context of an episode of heightened public concern about Ebola in the US in October 2014, I document that worrying about the possibility of an epidemic can impair cognitive function. My analysis relies on data from cognitive tests administered as part of a wave of survey interviews by a large US panel study, which I combine with measures of local concern about Ebola based on internet search volume. For identification, I exploit temporal and spatial variation in Ebola concern caused by the emergence of four cases of Ebola that were diagnosed in the US. Using proximity to the US cases as an instrumental variable, I show that the local level of Ebola concern individuals are exposed to at the time and place of the interview reduces their scores on the cognitive test. In additional analyses, I find no indication of fear-induced selection effects that could plausibly explain these results. Moreover, proximity to subsequent Ebola locations is unrelated to test scores for interviews conducted before the emergence of the first US case. My findings indicate that emotional responses to epidemics can entail a temporary cognitive cost even for individuals for whom the actual health risk never materializes.
    Keywords: Worry, Fear, Emotions, Ebola, Epidemics, Cognitive Function
    JEL: D91 D80 D01
    Date: 2021–10

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