nep-hea New Economics Papers
on Health Economics
Issue of 2022‒01‒17
eighteen papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. Rising Geographic Disparities in US Mortality By Benjamin K. Couillard; Christopher L. Foote; Kavish Gandhi; Ellen Meara; Jonathan Skinner
  2. The Effects of Becoming a Physician on Prescription Drug Use and Mental Health Treatment By D. Mark Anderson; Ron Diris; Raymond Montizaan; Daniel I. Rees
  3. The Health Effects of Universal Early Childhood Interventions: Evidence from Sure Start By Cattan, Sarah; Conti, Gabriella; Farquharson, Christine; Ginja, Rita; Pecher, Maud
  4. The Effects of an Increase in the Retirement Age on Health – Evidence from Administrative Data By Barschkett, Mara; Geyer, Johannes; Haan, Peter; Hammerschmid, Anna
  5. Labour supply, service intensity, and contracts: Theory and evidence on physicians By Bernard Fortin; Nicolas Jacquemet; Bruce Shearer
  6. The Cost of Health Insurance and Entry into Entrepreneurship By Fossen, Frank M.; Hossain, Mobarak; Mukhopadhyay, Sankar; Toth, Peter
  7. Maternal mortality and women’s political participation By Bhalotra. Sonia; Clarke, Damian; Gomes, Joseph F.; Venkataramani, Atheendar
  8. Home Alone: Widows' Well-Being and Time By Adena, Maja; Hamermesh, Daniel S.; Myck, Michal; Oczkowska, Monika
  9. Taking the Pulse of Nations: A Biometric Measure of Well-being By David G. Blanchflower; Alex Bryson
  10. Access to education and disability insurance claims By Halapuu, Vivika
  11. Self-control and unhealthy body weight: The role of impulsivity and restraint By Cobb-Clark, Deborah A.; Dahmann, Sarah Christina; Kamhöfer, Daniel A.; Schildberg-Hörisch, Hannah
  12. Did the Affordable Care Act Affect Access to Medications for Opioid Use Disorder among the Already Insured? Evidence from the Rhode Island All-payer Claims Database By Mary A. Burke; Katherine Grace Carman; Riley Sullivan; Hefei Wen; James Frank Wharam; Hao Yu
  13. Causes and Consequences of Illicit Drug Epidemics By Timothy J. Moore; Rosalie Liccardo Pacula
  14. Accounting for Pandemic: Better Numbers for Management and Policy By Yuri Biondi
  15. COVID-19 and School Closures By Svaleryd, Helena; Vlachos, Jonas
  16. Excess mortality versus COVID-19 death rates: a spatial analysis of socioeconomic disparities and political allegiance across US states By Janine Aron; John Muellbauer
  17. Rights Redistribution and COVID-19 Lockdown Policy By Garzarelli, Giampaolo; Keeton, Lyndal; Sitoe, Aldo A.
  18. How laws affect the perception of norms: empirical evidence from the lockdown By Roberto Galbiati; Emeric Henry; Nicolas Jacquemet; Max Lobeck

  1. By: Benjamin K. Couillard; Christopher L. Foote; Kavish Gandhi; Ellen Meara; Jonathan Skinner
    Abstract: The 21st century has been a period of rising inequality in both income and health. In this study, we find that geographic inequality in mortality for midlife Americans increased by about 70 percent from 1992 to 2016. This was not simply because states such as New York or California benefited from having a high fraction of college-educated residents who enjoyed the largest health gains during the last several decades. Nor was higher dispersion in mortality caused entirely by the increasing importance of “deaths of despair,” or by rising spatial income inequality during the same period. Instead, over time, state-level mortality has become increasingly correlated with state-level income; in 1992 income explained only 3 percent of mortality inequality, but by 2016 state-level income explained 58 percent. These mortality patterns are consistent with the view that high-income states in 1992 were better able to enact public health strategies and adopt behaviors that, over the next quarter-century, resulted in pronounced relative declines in mortality. The substantial longevity gains in high-income states led to greater cross-state inequality in mortality.
    Keywords: health; health policy; mortality
    JEL: I11 I12 I14 I15 I18
    Date: 2021–09–01
  2. By: D. Mark Anderson; Ron Diris; Raymond Montizaan; Daniel I. Rees
    Abstract: There is evidence that physicians disproportionately suffer from substance use disorder and mental health problems. It is not clear, however, whether these phenomena are causal. We use data on Dutch medical school applicants to examine the effects of becoming a physician on prescription drug use and the receipt of treatment from a mental health facility. Leveraging variation from lottery outcomes that determine admission into medical schools, we find that becoming a physician increases the use of antidepressants, opioids, anxiolytics, and sedatives, especially for female physicians. Among female applicants towards the bottom of the GPA distribution, becoming a physician increases the likelihood of receiving treatment from a mental health facility.
    JEL: I1 I12 I18
    Date: 2021–12
  3. By: Cattan, Sarah (Institute for Fiscal Studies, London); Conti, Gabriella (University College London); Farquharson, Christine (Institute for Fiscal Studies, London); Ginja, Rita (University of Bergen); Pecher, Maud (Institute for Fiscal Studies, London)
    Abstract: We evaluate the short- and medium-term health impacts of Sure Start, a large-scale and universal early childhood program in England. We exploit the rollout of the program and implement a difference-in-difference approach, combining data on the exact location and opening date of Sure Start centers with administrative data on the universe of admissions to public-sector hospitals. Exposure to an additional Sure Start center per thousand age-eligible children increases hospitalization by 10% at age 1 (around 6,700 hospitalizations per year), but reduces them by 8-9% across ages 11 to 15 (around 13,150 hospitalizations per year). These findings show that early childhood programs that are less intensive than small-scale 'model programs' can deliver significant health benefits, even in contexts with universal healthcare. Impacts are driven by hospitalizations for preventable conditions and are concentrated in disadvantaged areas, suggesting that enriching early childhood environments might be a successful strategy to reduce inequalities in health.
    Keywords: health, early childhood intervention, difference-in-difference
    JEL: I10 I14 I18
    Date: 2021–11
  4. By: Barschkett, Mara (DIW Berlin); Geyer, Johannes (DIW Berlin); Haan, Peter (DIW Berlin); Hammerschmid, Anna (DIW Berlin)
    Abstract: This study analyzes the causal effect of an increase in the retirement age on health. We exploit a sizable cohort-specific pension reform for women using two complementary empirical approaches – a Regression Discontinuity Design and a Difference-in-Differences approach. The analysis is based on official records covering all individuals insured by the public health system in Germany and including all certified diagnoses by practitioners. This enables us to gain a detailed understanding of the multi-dimensionality in these health effects. The empirical findings reflect the multi-dimensionality but allow for deriving two broader conclusions. We provide evidence that the increase in the retirement age negatively affects health outcomes as the prevalence of several diagnoses, e.g., mental health, musculoskeletal diseases, and obesity, increases. In contrast, we do not find support for an improvement in health related to a prolonged working life since there is no significant evidence for a reduction in the prevalence of any health outcome we consider. These findings hold for both identification strategies, are robust to sensitivity checks, and do not change when correcting for multiple hypothesis testing.
    Keywords: Germany, retirement, pension reform, health, ICD-10, Regression Discontinuity Design, Difference-in-Differences
    JEL: I10 I12 I18 J14 J18 J26
    Date: 2021–11
  5. By: Bernard Fortin; Nicolas Jacquemet (PSE - Paris School of Economics - ENPC - École des Ponts ParisTech - ENS Paris - École normale supérieure - Paris - PSL - Université Paris sciences et lettres - UP1 - Université Paris 1 Panthéon-Sorbonne - CNRS - Centre National de la Recherche Scientifique - EHESS - École des hautes études en sciences sociales - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement); Bruce Shearer
    Abstract: Based on linked administrative and survey panel data, we analyze the labour supply behaviour of physicians who could adopt either a standard fee-for-service contract or a mixed remuneration (MR) contract. Under MR, physicians received a per diem and a reduced fee for services provided. We present estimates of a structural discrete choice model that incorporates service intensity (services provided per hour) and contract choice into a labour supply framework. We use our estimates to predict (ex ante) the effects of contracts on physician behaviour and welfare, as measured by average equivalent variations. The supply of services is reduced under a MR contract, suggesting incentives matter. Hours spent seeing patients is less sensitive to incentives than the supply of services. Our results suggest that a reform forcing all physicians to adopt the MR system would have substantially larger effects on physician behaviour than were measured under the observed reform. A pure salary (per diem) reform would sharply reduce services but would increase time spent seeing patients.
    Keywords: Practice Patterns of Physicians,Labour Supply,Service Intensity,Fee-for-Service Contract,Mixed Remuneration Contract,Discrete Choice Models
    Date: 2021–09
  6. By: Fossen, Frank M. (University of Nevada, Reno); Hossain, Mobarak (University of Nevada, Reno); Mukhopadhyay, Sankar (University of Nevada, Reno); Toth, Peter (University of Nevada, Reno)
    Abstract: Unavailable or expensive health insurance may hinder the transition of individuals from paid employment to entrepreneurship. The literature argues that the guaranteed availability of health insurance introduced by the Affordable Care Act (ACA) of 2010 could reduce this barrier to entrepreneurship and thereby increase entrepreneurial activity. In this paper, we investigate how much the cost of health insurance when leaving paid employment—given availability of health insurance—matters for the decision to become an entrepreneur. We use individual-level data from the Current Population Survey (CPS-ASEC) combined with county-level panel data on health insurance costs in local Health Insurance Exchanges (HIX) introduced by the ACA to estimate county-treatment fixed-effects regressions. The results indicate that increasing the premium of the benchmark HIX plan by $100 per month decreases the annual probability of entry into self-employment by 0.25 percentage points, which corresponds to 18% of the average annual entry rate.
    Keywords: entrepreneurship, health insurance, premium, deductible, MOOP
    JEL: I13 I11 J22 J23 L26
    Date: 2021–11
  7. By: Bhalotra. Sonia (University of Warwick); Clarke, Damian (Universidad de Chile); Gomes, Joseph F. (UC Louvain); Venkataramani, Atheendar (University of Pennsylvania)
    Abstract: Millions of women continue to die during and soon after childbirth, even where the knowledge and resources to avoid this are available. We posit that raising the share of women in parliament can trigger action. Leveraging the timing of gender quota legislation across developing countries, we identify sharp sustained reductions of 8–10 percent in maternal mortality. Investigating mechanisms, we find that gender quotas lead to increases in percentage points of 5–8 in skilled birth attendance and 4–8 in prenatal care utilization, alongside a decline in fertility of 6–7 percent and an increase in the schooling of young women of about 0.5 years. The results are robust to numerous robustness checks. They suggest a new policy tool for tackling maternal mortality.
    Keywords: maternal mortality ; women’s political representation ; gender ; quotas ; reproductive health services ; fertility ; schooling. JEL Classification: I14 ; I15 ; O15
    Date: 2021
  8. By: Adena, Maja (WZB - Social Science Research Center Berlin); Hamermesh, Daniel S. (Barnard College); Myck, Michal (Centre for Economic Analysis, CenEA); Oczkowska, Monika (Centre for Economic Analysis, CenEA)
    Abstract: Losing a partner is a life-changing experience. We draw on numerous datasets to examine differences between widowed and partnered older women and to provide a comprehensive picture of well-being in widowhood. Most importantly, our analysis accounts for time use in widowhood, an aspect which has not been studied previously. Based on data from several European countries we trace the evolution of well-being of women who become widowed by comparing them with their matched non-widowed 'statistical twins' and examine the role of an exceptionally broad set of potential moderators of widowhood's impact on well-being. We confirm a dramatic decrease in mental health and life satisfaction after the loss of partner, followed by a slow recovery. An extensive set of controls recorded prior to widowhood, including detailed family ties and social networks, provides little help in explaining the deterioration in well-being. Unique data from time-diaries kept by older women from several European countries and the U.S. tell us why: the key factor behind widows' reduced well-being is increased time spent alone.
    Keywords: widowhood, well-being, social networks, time use
    JEL: I31 I19 J14
    Date: 2021–11
  9. By: David G. Blanchflower (Bruce V. Rauner ’78 Professor of Economics, Dartmouth College, Hanover, NH 03755-3514. Adam Smith School of Business, University of Glasgow and NBER); Alex Bryson (Professor of Quantitative Social Science, UCL Social Research Institute, University College London, 20 Bedford Way, London WC1H 0AL)
    Abstract: A growing literature identifies associations between subjective and biometric indicators of wellbeing. These associations, together with the ability of subjective wellbeing (SWB) metrics to predict health and behavioral outcomes, have spawned increasing interest in SWB as an important concept in its own right. However, some social scientists continue to question the usefulness of SWB metrics. We contribute to this literature in three ways. First, we introduce a biometric measure of wellbeing – pulse – which has been largely overlooked. Using nationally representative data on 165,000 individuals from the Health Survey for England (HSE) and Scottish Health Surveys (SHeS) we show that its correlates are similar in a number of ways to those for SWB, and that it is highly correlated with SWB metrics, as well as self-assessed health. Second, we examine the determinants of pulse rates in mid-life (age 42) among the 9,000 members of the National Child Development Study (NCDS), a birth cohort born in a single week in 1958 in Britain. Third, we track the impact of pulse measured in mid-life (age 42) on health and labor market outcomes at age 50 in 2008 and age 55 in 2013. The probability of working at age 55 is negatively impacted by pulse rate a decade earlier. The pulse rate has an impact over and above chronic pain measured at age 42. General health at 55 is lower the higher the pulse rate at age 42, while those with higher pulse rates at 42 also express lower life satisfaction and more pessimism about the future at age 50. Taken together, these results suggest social scientists can learn a great deal by adding pulse rates to the metrics they use when evaluating people’s wellbeing.
    Keywords: pulse; wellbeing; mental health; general health; life satisfaction; paid work; life-course; birth cohort; NCDS.
    JEL: I10 J1
    Date: 2021–12–01
  10. By: Halapuu, Vivika (IFAU - Institute for Evaluation of Labour Market and Education Policy)
    Abstract: The paper provides the first causal evidence of how access to education affects disability insurance (DI) claims among low-skilled youths. The research design exploits recent changes in high school eligibility criteria among a set of low-performing compulsory school graduates in Sweden. The results show that the immediate inflow into the DI system increased by 5.1 percentage points among the students who were excluded from standard high school programs. The fact that outflow from DI is very low (half of all young claimants remain in the system after 10 years) together with auxiliary findings indicating that the impact remains high during the short follow-up period suggest that the effect is likely to persist over many years. The results highlight that the design of education systems is a crucial determinant of DI claims among young people and that reforms which limit low-skilled youths’ access to education can have lasting detrimental effects on their labor supply.
    Keywords: Access to education; Disability insurance; Education Policy
    JEL: I24 I26 I28
    Date: 2021–12–03
  11. By: Cobb-Clark, Deborah A.; Dahmann, Sarah Christina; Kamhöfer, Daniel A.; Schildberg-Hörisch, Hannah
    Abstract: We examine the relationship between trait self-control and body weight. Data from a population representative household survey reveal that limited self-control is strongly associated with both objective and subjective measures of unhealthy body weight. Those with limited self-control are characterized by reduced exercising, repeated dieting, unhealthier eating habits, and poorer nutrition. We propose an empirical method to isolate two facets of self-control limitations-high impulsivity and low restraint. Each has differential predictive power. Physical activity, dieting, and overall body weight are more strongly associated with restraint; impulsivity is more predictive of when, where, and what people eat.
    Keywords: Brief Self-Control Scale,Obesity,Body Mass Index,Diet,Exercise
    JEL: D91 I12
    Date: 2021
  12. By: Mary A. Burke; Katherine Grace Carman; Riley Sullivan; Hefei Wen; James Frank Wharam; Hao Yu
    Abstract: Previous research suggests that state Medicaid expansions implemented under the Patient Protection and Affordable Care Act (ACA) helped large numbers of patients suffering from opioid use disorder (OUD) gain access to life-saving medications, including buprenorphine. However, Medicaid expansions could have impeded access to care among individuals already enrolled in Medicaid, as new enrollees would have placed added demands on a limited supply of buprenorphine providers. Using a panel data set of medical claims from Rhode Island, we estimate the causal effects of the state’s January 2014 ACA implementation on buprenorphine receipt among incumbent (pre-ACA) Medicaid enrollees by leveraging geographic variation within Rhode Island in the intensity of treatment under the ACA. Using a difference-in-differences identification strategy, multivariate regression analysis yields no evidence that incumbent Medicaid enrollees experienced added difficulties in accessing buprenorphine as a result of the ACA, despite the fact that both Medicaid and non-Medicaid enrollment increased substantially under the policy. Supply-side factors may have helped to blunt any negative fallout, as we find that the number of buprenorphine prescribers in the state increased fairly steadily during the two years leading up to January 2014 and for at least 15 months after that date. Also, the average number of buprenorphine recipients per prescriber increased rapidly after January 2014, suggesting that providers had unused treatment capacity before the policy went into effect.
    Keywords: Medicaid expansion; opioid use disorder (OUD); methadone; buprenorphine; Rhode Island; all-payer claims database
    JEL: I12 I13 I14 I18
    Date: 2021–10–01
  13. By: Timothy J. Moore; Rosalie Liccardo Pacula
    Abstract: Large and rapid upswings in illicit drug use display similar properties to infectious disease epidemics. In this chapter, we review research to understand what causes drug epidemics and how they end. Drug market actors are subject to both positive and negative reinforcement that lead to rapid, nonlinear increases and decreases in drug market activity. There is evidence that drug epidemics cause serious problems, including drug overdoses, adverse birth outcomes, homicides, lower educational attainment, and migration from neighborhoods subject to intense drug market activity. Many of these costs are borne by those who do not consume or sell drugs. Given the frequency, size, and impacts of illicit drug epidemics, they deserve more attention by researchers and policy-makers.
    JEL: I12 I18 K42
    Date: 2021–12
  14. By: Yuri Biondi (CNRS - Centre National de la Recherche Scientifique, IRISSO - Institut de Recherche Interdisciplinaire en Sciences Sociales - Université Paris Dauphine-PSL - PSL - Université Paris sciences et lettres - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement)
    Abstract: Abstract Infection, hospitalization and mortality statistics have played a pivotal role in forming social attitudes and support for policy decisions about the 2020-21 SARS-CoV-2 (COVID-19) pandemic. This article raises some questions on some of the most widely-used indicators, such as the case fatality rate, derived from these statistics, recommending replacing them with information based on regular stratified statistical sampling, coupled with diagnostic assessment. Some implications for public health policies and pandemic management are developed, opposing individualistic and holistic approaches.
    Keywords: public health,pandemic management,non-pharmaceutical interventions (NPI),social statistics,Public health (I18),accounting (M40),specific statistics (C46),Social statistics
    Date: 2021–11–10
  15. By: Svaleryd, Helena; Vlachos, Jonas
    Abstract: To reduce the spread of COVID-19, schools closed to an unprecedented degree in the spring of 2020. To varying extent, students have moved between in-person and remote learning up until the spring of 2021. This chapter surveys the literature on the implications of school closures of primary to upper-secondary schools for virus transmission, student learning, and mental health among children and adolescents in high-income countries. Subject to severe methodological challenges, most studies indicate that the initial school closures at least to some extent contributed to a reduction of virus transmission. However, several studies find that schools could reopen safely, especially when substantial within-school preventive measures were implemented and the general level of transmission was moderate. Student age also matters and keeping schools open for younger students contributes less to overall virus transmission. Most studies find that students learned less and that learning inequalities widened when school closed. These patterns are particularly pronounced for younger students who face more challenges adjusting to remote instruction. Essentially nothing can be said concerning the implications for vocational training. High-quality evidence on the impact on mental health is scarce and the results are mixed, but there are some indications that older students coped better with school closures also in this regard. On balance, closing schools for younger students is less well-motivated than for older students.
    Keywords: COVID-19,Mental health,School closures,Student achievement,Virus transmission
    JEL: I12 I21
    Date: 2022
  16. By: Janine Aron; John Muellbauer
    Abstract: Excess mortality is a more robust measure than the counts of COVID-19 deaths typically used in epidemiological and spatial studies. Measurement issues around excess mortality, considering data quality and comparability both internationally and within the US, are surveyed. This paper is the first state-level spatial analysis of cumulative excess mortality for the US in the first full year of the pandemic. There is strong evidence that states with higher Democrat vote shares experienced lower excess mortality (consistent with county-level studies of COVID-19 deaths and partisanship). Important demographic and socio-economic controls from a broad set tested were racial composition, age structure, population density, poverty, income, temperature, timing of arrival of the pandemic and political allegiance. Interaction effects suggest the Democrat vote share effect of reducing mortality was even greater in states where the pandemic arrived early. Omitting political allegiance leads to a significant underestimation of the mortality disparities for minority populations.
    Keywords: Excess Mortality, COVID-19, Spatial Analysis, US States, Political Polarization
    Date: 2021–12–15
  17. By: Garzarelli, Giampaolo; Keeton, Lyndal; Sitoe, Aldo A.
    Abstract: What is the tenet upon which the public policy of lockdown by fiat experienced during the COVID-19 pandemic is based on? The work approaches this question about the rationale of the mandatory shelter-in-place policy as an interpersonal exchange of rights, but where the exchange occurs coercively instead of voluntarily. It compares, in positive political economy terms, the normative principles of utilitarianism and Rawlsianism, and shows that lockdown by fiat is a policy that is closer to a maximin equity criterion rather than to a utilitarian one. The work moreover shows, also with the aid of a thought experiment in the spirit of Rawls and with factual applications, that the fiat redistribution of rights to liberty in favor of rights to health – from those least affected to those most affected by COVID-19 – is, in the main, a policy choice that is to be expected under certain constraints.
    Keywords: Covid-19 pandemic,Health rights,Liberty,Public policy,Lockdown,Rawls
    JEL: D04 D78 H11 H12 I18
    Date: 2022
  18. By: Roberto Galbiati (ECON - Département d'économie (Sciences Po) - Sciences Po - Sciences Po - CNRS - Centre National de la Recherche Scientifique); Emeric Henry (ECON - Département d'économie (Sciences Po) - Sciences Po - Sciences Po - CNRS - Centre National de la Recherche Scientifique); Nicolas Jacquemet (PSE - Paris School of Economics - ENPC - École des Ponts ParisTech - ENS Paris - École normale supérieure - Paris - PSL - Université Paris sciences et lettres - UP1 - Université Paris 1 Panthéon-Sorbonne - CNRS - Centre National de la Recherche Scientifique - EHESS - École des hautes études en sciences sociales - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement, CES - Centre d'économie de la Sorbonne - UP1 - Université Paris 1 Panthéon-Sorbonne - CNRS - Centre National de la Recherche Scientifique); Max Lobeck (PJSE - Paris Jourdan Sciences Economiques - UP1 - Université Paris 1 Panthéon-Sorbonne - ENS Paris - École normale supérieure - Paris - PSL - Université Paris sciences et lettres - EHESS - École des hautes études en sciences sociales - ENPC - École des Ponts ParisTech - CNRS - Centre National de la Recherche Scientifique - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement)
    Abstract: Laws not only affect behavior due to changes in material payoffs, but they may also change the perception individuals have of societal norms, either by shifting them directly or by providing information on these norms. Using detailed daily survey data and exploiting the introduction of lockdown measures in the UK in the context of the COVID-19 health crisis, we provide causal evidence that the law drastically changed the perception of the norms regarding social distancing behaviors. We show this effect of laws on perceived norms is mostly driven by an informational channel.
    Date: 2020–10–05

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