nep-hea New Economics Papers
on Health Economics
Issue of 2021‒11‒22
sixteen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. The Right to Health and the Health Effects of Denials By Bhalotra, Sonia; Fernandez, Manuel
  2. The career costs of children's health shocks By Anne-Lise Breivik; Ana Costa-Ramón
  3. Understanding Algorithmic Discrimination in Health Economics Through the Lens of Measurement Errors By Anirban Basu; Noah Hammarlund; Sara Khor; Aasthaa Bansal
  4. Medication of Postpartum Depression and Maternal Outcomes: Evidence from Geographic Variation in Dutch Prescribing By Janet Currie; Esmée Zwiers
  5. A hard look at soft cost-control measures in healthcare organizations: Evidence from preferred drug policies in Germany By Daniel Avdic; Katharina E. Blankart
  6. The Economics of Medical Procedure Innovation By David Dranove; Craig Garthwaite; Christopher Heard; Bingxiao Wu
  7. Does Research Save Lives? The Local Spillovers of Biomedical Research on Mortality By Rebecca McKibbin; Bruce A. Weinberg
  8. Counting missing women: A reconciliation of the "flow measure" and the "stock measure" By Ebert, Cara; Klasen, Stephan; Vollmer, Sebastian
  9. Natural resources, child mortality and governance quality in African countries By Tadadjeu, Sosson; Njangang, Henri; Asongu, Simplice; Kamguia, Brice
  10. Association between Healthcare Provider Payment Systems and Health Outcomes in Ghana By Boachie, Micheal Kofi; Amporfu, Eugenia
  11. Modeling to Inform Economy-Wide Pandemic Policy: Bringing Epidemiologists and Economists Together By Darden, Michael E.; Dowdy, David; Gardner, Lauren; Hamilton, Barton H.; Kopecky, Karen A.; Marx, Melissa; Papageorge, Nicholas W.; Polsky, Daniel; Powers, Kimberly; Stuart, Elizabeth; Zahn, Matthew V.
  12. The COVID-19 Curtain: Can Past Communist Regimes Explain the Vaccination Divide in Europe? By Berniell, Maria Ines; Fawaz, Yarine; Laferrere, Anne; Mira, Pedro; Pronkina, Elizaveta
  13. Administrative border effects in Covid-19 related mortality By Berta, P.; Bratti, M.; Fiorio, C.V.; Pisoni, E.; Verzillo, S.
  14. Education and COVID-19 excess mortality By Bello, Piera; Rocco, Lorenzo
  15. The Effect of Repeated Lockdowns during the Covid-19 Pandemic on UK Mental Health Outcomes By Lindley, Joanne; Rienzo, Cinzia
  16. The Effectiveness of Job-Retention Schemes: COVID-19 Evidence From the German States By Mr. Shekhar Aiyar; Mai Chi Dao

  1. By: Bhalotra, Sonia (University of Warwick); Fernandez, Manuel (Universidad de los Andes)
    Abstract: We investigate supply-side barriers to medical care in Colombia, where citizens have a constitutional right to health, but insurance companies impose restrictions. We use administrative data on judicial claims for health as a proxy for unmet demand. We validate this using the health services utilization register, showing that judicial claims map into large, pervasive decreases in medical consultations, procedures, hospitalizations and emergency care. This manifests in population health outcomes. We identify increases in mortality pervasive across cause, age and sex, with larger increases for cancer, individuals over the age of fty, women and the poor.
    Date: 2021
  2. By: Anne-Lise Breivik; Ana Costa-Ramón
    Abstract: We provide novel evidence on the impact of a child's health shock on parental labor market outcomes. To identify the causal effect, we leverage long panels of high-quality Finnish and Norwegian administrative data and exploit variation in the timing of the health shock. We do this by comparing parents across families in similar parental and child age cohorts whose children experienced a health shock at different ages. We show that these families have very similar characteristics and were following parallel trends before the event. This allows us to use a simple difference-in-differences model: we construct counterfactuals for treated households with families who experience the same shock a few years later. We find a sharp break in parents' earnings trajectories that becomes visible just after the shock. The negative effect is persistent and stronger for mothers than for fathers. We also document a substantial impact on parents' mental well-being. Our results suggest that the effect on maternal labor earnings results from the combination of the increased time needed to care for the child and the worsening of mothers' mental health.
    Keywords: Children, health, mortality, parents, earnings, labor supply, mental health
    JEL: I10 I12
    Date: 2021–11
  3. By: Anirban Basu; Noah Hammarlund; Sara Khor; Aasthaa Bansal
    Abstract: There is growing concern that the increasing use of machine learning and artificial intelligence-based systems may exacerbate health disparities through discrimination. We provide a hierarchical definition of discrimination consisting of algorithmic discrimination arising from predictive scores used for allocating resources and human discrimination arising from allocating resources by human decision-makers conditional on these predictive scores. We then offer an overarching statistical framework of algorithmic discrimination through the lens of measurement errors, which is familiar to the health economics audience. Specifically, we show that algorithmic discrimination exists when measurement errors exist in either the outcome or the predictors, and there is endogenous selection for participation in the observed data. The absence of any of these phenomena would eliminate algorithmic discrimination. We show that although equalized odds constraints can be employed as bias-mitigating strategies, such constraints may increase algorithmic discrimination when there is measurement error in the dependent variable.
    JEL: C53 I10 I14
    Date: 2021–10
  4. By: Janet Currie; Esmée Zwiers
    Abstract: Using data on over 420,000 first time Dutch mothers, we examine the effects of postpartum antidepressant use on a wide range of maternal outcomes including further treatment for severe mental illness, labor market outcomes, and family formation. We exploit rules which state that Dutch general practitioners (GPs) must be available to make house calls to their patients. In practice many therefore use postal code boundaries to limit their practices. We instrument a postpartum woman’s receipt of antidepressants with the propensity to prescribe antidepressants to women aged 46 to 65 among GPs in her postal code. Ordinary Least Squares estimates suggest highly negative effects of postpartum treatment with antidepressants, but this is mainly due to selection into treatment. Instrumental variable estimates suggest that the marginal patient treated with postpartum antidepressants is much more likely to continue taking antidepressants long-term, with little evidence of effects on other outcomes.
    JEL: I1 J19
    Date: 2021–10
  5. By: Daniel Avdic (Monash University); Katharina E. Blankart (University of Duisburg-Essen)
    Abstract: Cost-control interventions that target physicians’ clinical discretion are common in healthcare, but evidence on their efficacy is scarce; in particular for "soft" policies when liability is unlikely to be enforced by the regulator. We study the effectiveness of preferred drug policies (minimum prescription quotas of specific "preferred" drugs) in altering physicians’ practice styles within the high volume drug class of HMG-CoA-reductase inhibitors (statins) in the German statutory health insurance system. Using a nationally representative panel of ambulatory care physicians between 2011 and 2014, we exploit the decentralized institutional setting to estimate physician responses to variation in preferred drug policies across regional physician associations over time in a generalized difference-in-differences design. Results show that although the cost-control mechanism increases average policy adherence, this effect is mainly driven by physicians with initially high use rates of preferred drugs. We argue that such misdirection may limit the policy’s usefulness in reducing inappropriate practice variation among healthcare providers.
    Keywords: cost-control, healthcare, practice style, difference-in-differences
    JEL: I12 I18 O33 H75
    Date: 2021–11
  6. By: David Dranove; Craig Garthwaite; Christopher Heard; Bingxiao Wu
    Abstract: This paper explores the economic incentives for medical procedure innovation. Using a proprietary dataset on billing code applications for emerging medical procedures, we highlight two mechanisms that could hinder innovation. First, the administrative hurdle of securing permanent, reimbursable billing codes substantially delays innovation diffusion. We find that Medicare utilization of innovative procedures increases nearly nine-fold after the billing codes are promoted to permanent (reimbursable) from provisional (non-reimbursable). However, only 29 percent of the provisional codes are promoted within the five-year probation period. Second, medical procedures lack intellectual property rights, especially those without patented devices. When appropriability is limited, specialty medical societies lead the applications for billing codes. We indicate that the ad hoc process for securing billing codes for procedure innovations creates uncertainty about both the development process and the allocation and enforceability of property rights. This stands in stark contrast to the more deliberate regulatory oversight for pharmaceutical innovations.
    JEL: I0 I1 O3
    Date: 2021–10
  7. By: Rebecca McKibbin; Bruce A. Weinberg
    Abstract: This paper investigates the local impact of biomedical research on mortality in the USA. Causally estimating the marginal value of biomedical research is challenging due to a lack of micro data linking health outcomes to plausibly exogenous variation in research. We create a new linkage between a research database (PubMed) and administrative death records that enables research to be related to mortality at the geographic, disease and time level. We then estimate the marginal impact of biomedical research on mortality using hospital market (HRR) level shocks to research activity by disease. Our identification strategy builds on the literature on the dissemination of knowledge, specifically that of local knowledge spillovers. By utilizing variation across diseases, time and distance from research we control for additional trends relative to the current literature. Our results show that an additional research publication on average reduces local mortality from a disease by 0.35%. Our results also provide novel evidence that there are health benefits to the local communities (local spillovers) in which biomedical research is conducted.
    JEL: I1 O33 O38
    Date: 2021–10
  8. By: Ebert, Cara; Klasen, Stephan; Vollmer, Sebastian
    Abstract: Existing estimates of the 'tock of missing women' suggest that the problem is mostly concentrated in South and East Asia, and often related to sex-selective abortions and postbirth neglect of female children. In contrast, estimates of yearly excess female deaths, referred to as the 'flow of missing women', suggest that gender bias in mortality is much larger than previously found (about 4 to 5 million excess female deaths per year vs. around 100 million missing women in total), is as severe among adults as it is among children in India, and is larger in Sub-Saharan Africa than in South and East Asia. We argue that these findings largely rely on the choice of the reference standard for sex-specific mortality and an incomplete correction for different disease environments in the flow measure. When alternative reference standards are used, the results of the flow measure can be reconciled with previous findings of the stock measure.
    Keywords: Missing women,gender bias,mortality,disease,age,Sub-Saharan Africa,China,India
    JEL: J16 D63 I10
    Date: 2021
  9. By: Tadadjeu, Sosson; Njangang, Henri; Asongu, Simplice; Kamguia, Brice
    Abstract: This paper contributes to the literature by investigating the effect of natural resources on under-five mortality in a sample of 50 African countries over the period 1996 to 2018. We also examine the extent to which governance shapes the relationship between natural resources and under-five mortality. Our results show that natural resources have increased under-five mortality. Resource rents also have detrimental effects on child mortality by age, gender, and the three major causes of infant mortality from infectious diseases. However, an extended analysis of different types of natural resources suggests that point resources (such as oil, natural gas and mineral rents) increase under-five mortality, in contrast to the diffuse resources (such as forest rent). We also find that governance mitigates the positive effect of natural resources on child mortality. Corresponding governance policy thresholds that should be attained in order to reverse the positive effects of natural resources on child mortality are provided. We thus suggest an increase in the funds allocated to the health sector from resource rents and encourage efforts to improve governance standards in sampled countries.
    Keywords: Natural resources; Child mortality; Governance; Africa
    JEL: J13 O55 Q33 Q34 Q38
    Date: 2021–01
  10. By: Boachie, Micheal Kofi; Amporfu, Eugenia
    Abstract: Different payment systems generate different incentives for patients, providers, and purchasers. This study uncovers the effect of provider-payment methods on patient health outcomes, utilization of healthcare services and referral patterns in Ghana. Using data on 250 enrollees of the National Health Insurance Scheme (NHIS) from each payment plan (i.e., capitation and Diagnosis Related Groupings/fee-for-service plans), ordered logit, negative binomial and logit regression results showed that patients under capitation were 4.6% less likely to report better health and had 29% fewer visits relative to patients under DRG/FFS. In relation to referrals, capitated providers were more likely to refer patients than under DRG/FFS plans. Better health outcomes were reported by patients of private health facilities. Capitation in Ghana led to under-provision of care and cost-shifting, hence decreasing any efficiency gain from the reform. Purchasing of healthcare needs to be strategized to ensure efficient utilization of resources.
    Keywords: Capitation; health outcomes; Referrals; Healthcare utilization
    JEL: I0 I1 I13
    Date: 2021
  11. By: Darden, Michael E. (Tulane University); Dowdy, David (Johns Hopkins University); Gardner, Lauren (Johns Hopkins University); Hamilton, Barton H. (Washington University, St. Louis); Kopecky, Karen A. (Federal Reserve Bank of Atlanta); Marx, Melissa (Johns Hopkins University); Papageorge, Nicholas W. (Johns Hopkins University); Polsky, Daniel (Johns Hopkins University); Powers, Kimberly (North Carolina State University); Stuart, Elizabeth (Johns Hopkins University); Zahn, Matthew V. (Johns Hopkins University)
    Abstract: Facing unprecedented uncertainty and drastic trade-offs between public health and other forms of human well-being, policy makers during the Covid-19 pandemic have sought the guidance of epidemiologists and economists. Unfortunately, while both groups of scientists use many of the same basic mathematical tools, the models they develop to inform policy tend to rely on different sets of assumptions and, thus, often lead to different policy conclusions. This divergence in policy recommendations can lead to uncertainty and confusion, opening the door to disinformation, distrust of institutions, and politicization of scientific facts. Unfortunately, to date, there have not been widespread efforts to build bridges and find consensus or even to clarify sources of differences across these fields, members of whom often continue to work within their traditional academic silos. In response to this "crisis of communication," we convened a group of scholars from epidemiology, economics, and related fields (e.g., statistics, engineering, and health policy) to discuss approaches to modeling economy-wide pandemics. We summarize these conversations by providing a consensus view of disciplinary differences (including critiques) and working through a specific policy example. Thereafter, we chart a path forward for more effective synergy between disciplines, which we hope will lead to better policies as the current pandemic evolves and future pandemics emerge.
    Keywords: economics, epidemiology, public health, COVID-19, behavior modeling, health outcomes, health-wealth tradeoffs
    JEL: C8 H0 I1 J
    Date: 2021–11
  12. By: Berniell, Maria Ines (University of La Plata); Fawaz, Yarine (CEMFI, Madrid); Laferrere, Anne (Université Paris-Dauphine); Mira, Pedro; Pronkina, Elizaveta (Université Paris-Dauphine)
    Abstract: As of November 2021, all former Communist countries from Central and Eastern Europe exhibit lower vaccination rates than Western European countries. Can institutional inheritance explain, at least in part, this heterogeneity in vaccination decisions across Europe? To study this question we exploit novel data from the second wave of the SHARE (Survey of Health, Ageing, and Retirement in Europe) Covid-19 Survey fielded in Summer 2021 that covers 27 European countries and Israel. First, we document lower Covid-19 vaccine take-up amongst individuals above 55 years old who were born under Communism in Europe. Next, we turn to reunified Germany to get closer to a causal effect of exposure to Iron curtain regimes. We find that exposure to the Communist regime in East Germany decreases one's probability to get vaccinated against Covid-19 by 8 percentage points, increases that of not wanting the vaccine by 4 percentage points. Both effects are quite large and statistically significant, and they hold when controlling for individual socio-economic and demographic characteristics. We identify low social capital -measured as voluntary work, political engagement, trust in people- as a plausible channel through which past Communist regimes would still affect individuals' preferences for Covid-19 vaccination.
    Keywords: SHARELIFE, vaccination, Communism, COVID-19
    JEL: I15 I12 P36 Z18
    Date: 2021–11
  13. By: Berta, P.; Bratti, M.; Fiorio, C.V.; Pisoni, E.; Verzillo, S.
    Abstract: Does the organisation of healthcare systems affect health outcomes? To answer this question, we analysed the effects of the Covid-19 pandemic by focusing on mortality rate outcomes and exploited the heterogeneity of the healthcare organisational models among Italian regions, which makes Italy an ideal "laboratory". Within a common national healthcare system, Italian regions are allowed large autonomy to organise themselves as mixed-markets based on choice and competition, network or centralised leadership models, each delivering different responses to the Covid-19 emergency. Exploiting the discontinuity of healthcare organisational models across the Italian regional borders around Lombardy - the region that most convincingly embraced the mixed-market model fostering competition among health service providers - we applied a difference in geographic regression discontinuity design (DiD-GRDD) to compare mortality rates in 2020 of Lombardy's municipalities with that of neighbouring municipalities in other regions and also exploited the pre-crisis period (2017-2019). Our analysis shows that mortality rates in Lombardy during the first wave were higher by 1-2 percentage points among the population of residents aged 80 years or more, compared to the past, as opposed to regions adopting different organisational models. The mortality rate differential disappeared during the second wave following the implementation of a national policy based on risk zones, limiting mobility and taking stock of the experience developed during the first wave. Finally, by investigating the channels causing higher mortality during the first wave, we show that the role of organisational model differences vanishes, as differential mortality is mostly explained by the decision of the Lombardy regional government to use care homes for hosting Covid-19 patients and reduce the excess demand on the hospital system.
    Keywords: Covid-19; mortality; administrative borders; regions; Italy;
    JEL: I10 H12
    Date: 2021–11
  14. By: Bello, Piera; Rocco, Lorenzo
    Abstract: We study the role of education during the COVID-19 epidemic in Italy. We compare the trends of mortality rates between municipalities with different shares of educated residents between 2012 and 2020, by means of a continuous event study model and controlling for many confounders. We find that education played a protective role, significantly reducing mortality rates, during the first wave of the pandemic (between March and May 2020), but not during the second wave (between October and December 2020). We tentatively interpret this finding as the outcome of the interplay between education and public health communication, whose coherence and consistency varied between the different stages of the epidemic.
    Keywords: COVID-19,education,excess mortality,municipality,parallel trend,public health communication
    JEL: I14 I18 I26 R00
    Date: 2021
  15. By: Lindley, Joanne; Rienzo, Cinzia
    Abstract: This paper assesses the impact of the Covid-19 lockdown measures on the mental health of individuals in the UK, starting from the early restrictions in April 2020, and covering three subsequent lockdowns, up until March 2021. It also considers three aspects of mental health; that is 'anxiety and depression', 'social dysfunction', and 'loss of confidence', in order to identify which specific dimensions of respondents' psychology have been adversely affected. Our findings show that women appear to be more sensitive to the effect of the pandemic, and report much higher levels of anxiety and depression than males; whilst social dysfunction appears to be a more permanent fixture. Initially, social dysfunction was higher for women and younger workers, but it remained high for women and the over 55s. Consequently, our evidence supports targeted policies aimed at reducing social isolation for women and older workers. Finally, we show that financial difficulties had a growing impact on all mental health outcomes, as the pandemic progressed.
    Keywords: Covid-19,mental health,subjective financial wellbeing
    JEL: I30 I10
    Date: 2021
  16. By: Mr. Shekhar Aiyar; Mai Chi Dao
    Abstract: Kurzarbeit (KA), Germany’s short-time work program, is widely credited with saving jobs and supporting domestic demand during the COVID-19 recession. We quantify the impact by exploiting state-level variation in exposure to the pandemic shock and KA take-up. We construct a shift-share measure of the labor demand shock and instrument KA take-up using the pre-existing, state-specific share of workers eligible for KA. We find, first, that KA was crucial in mitigating unemployment: absent its expansion the unemployment rate would have increased by an additional 3 pp on average at the trough of the recession. Second, KA also bolstered domestic demand: the contraction in consumption could have been 2 to 3 times larger absent the program. Finally, we provide preliminary evidence on the sensitivity of the medium-run reallocation of resources to the prevalence of jobretention schemes during the Global Financial Crisis.
    Keywords: Kurzarbeit, Short-time work, Unemployment, Covid-19
    Date: 2021–10–01

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