nep-hea New Economics Papers
on Health Economics
Issue of 2023‒04‒10
33 papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. Health Care Centralization: The Health Impacts of Obstetric Unit Closures in the US By Fischer, Stefanie; Royer, Heather; White, Corey
  2. Intergenerational Correlations in Longevity By Sandra E. Black; Neil Duzett; Adriana Lleras-Muney; Nolan G. Pope; Joseph Price
  3. Information and Disparities in Health Care Quality: Evidence from GP Choice in England By Zach Y. Brown; Christopher Hansman; Jordan Keener; Andre F. Veiga
  4. Longevity, Health and Housing Risks Management in Retirement By Pierre-Carl Michaud; Pascal St-Amour
  5. Do Older Adults Accurately Forecast Their Social Security Benefits? By Grant M. Seiter; Sita Slavov
  6. Precautionary Fertility: Conceptions, Births, and Abortions around Employment Shocks By Bárdits, Anna; Adamecz-Völgyi, Anna; Bisztray, Márta; Weber, Andrea; Szabó-Morvai, Agnes
  7. Air Pollution and Respiratory Infectious Diseases By Provenzano, Sandro; Roth, Sefi; Sager, Lutz
  8. Health Implications of Building Retrofits: Evidence from a Population-Wide Weatherization Program By Künn, Steffen; Palacios, Juan
  9. The Health-Consumption Effects of Increasing Retirement Age Late in the Game By Caroli, Eve; Pollak, Catherine; Roger, Muriel
  10. Prison, Mental Health, and Family Spillovers By Bhuller, Manudeep; Khoury, Laura; Loken, Katrine Vellesen
  11. Changing Tracks: Human Capital Investment after Loss of Ability By Humlum, Anders; Munch, Jakob R.; Plato, Pernille
  12. Family Affair? Long-Term Economic and Mental Effects of Spousal Cancer By Böckerman, Petri; Kortelainen, Mika; Salokangas, Henri; Vaalavuo, Maria
  13. Willingness to Pay for Clean Air: Evidence from the UK By Faten Saliba; Giorgio Maarraoui; Walid Marrouch; Ada Wossink
  14. Sejong's Effects on People's Health: Consequences of a Long Commute By Lim, Seulgi; Lee, Soohyung
  15. Determinants of Heat Risk in an Aging Population: A Machine Learning Approach By Klauber, Hannah; Koch, Nicolas
  16. Scars of War: The Legacy of WW1 Deaths on Civic Capital and Combat Motivation By Felipe Carozzi; Edward Pinchbeck; Luca Repetto
  17. Improved Menstrual Health and the Workplace: An RCT with Female Bangladeshi Garment Workers By Kristina Czura; Andreas Menzel; Martina Miotto
  18. The price of cost-effectiveness thresholds By Brekke, Kurt R.; Dalen, Dag Morten; Straume, Odd Rune
  19. Price transparency in neurosurgery: challenges and opportunities in the online publishing of treatment prices to enable cost-conscious and value-based practice By Srivatsa, Shaarada; Khan, Hammad A.; Benzel, Edward C.; Benzil, Deborah L.; Mroz, Thomas E.; Steinmetz, Michael P.; Salas-Vega, Sebastian
  20. Hit Where It Hurts: Healthcare Access and Intimate Partner Violence By Bellés Obrero, Cristina; Rice, Caoimhe T.; Castello, Judit Vall
  21. Defying distance? The provision of services in the digital age By Amanda Dahlstrand
  22. Correlates of Distress Financing In Case of Institutional Delivery In India: Evidence From The National Family Health Survey By Bhattacharyya, Bhaskar; Mandal, Biswajit; Sengupta, Sarbajit
  23. Best practices in addressing the major drivers of food security and nutrition to transform food systems By Carrasco Azzini, Giuseppe; Conti, Valentina; Holleman, Cindy; Smulders, Mark
  24. Envelope culture in the healthcare system: happy poison for the vulnerable By Vuong, Quan-Hoang; La, Viet-Phuong; Le, Tam-Tri; Hoang, Giang; Jin, Ruining; Quang-Loc, Nguyen; Vuong, Thu-Trang; Nguyen, Minh-Hoang
  25. Stronger together: Group incentives and the demand for prevention By Mylène Lagarde; Carlos Riumallo Herl
  26. Drug Shortages: Empirical Evidence from France By Dubois, Pierre; Majewska, Gosia; Reig, Valentina
  27. The Simple Math of Royalties and Drug Competition During the 180-Day Generic Exclusivity Period By Keith M. Drake; Thomas McGuire
  28. Health System Trust and Compliance with Covid-19 Restrictions By Joan Costa-i-Font; Cristina Vilaplana-Prieto
  29. From Syringes to Dishes: Improving Food Security through Vaccination By Aslim, Erkmen Giray; Fu, Wei; Tekin, Erdal; You, Shijun
  30. Who gets vaccinated? Cognitive and non-cognitive predictors of individual behavior in pandemics By Andor, Mark Andreas; Bauer, Thomas K.; Eßer, Jana; Schmidt, Christoph M.; Tomberg, Lukas
  31. Labour market shocks and parental investments during the Covid-19 pandemic By Hupkau, Claudia; Ruiz-valenzuela, Jenifer; Isphording, Ingo E.; Machin, Stephen
  32. A Lost Generation? Impact of COVID-19 on High School Students' Achievements By Contini, Dalit; Di Tommaso, Maria Laura; Muratori, Caterina; Piazzalunga, Daniela; Schiavon, Lucia
  33. Mobility decisions, economic dynamics and Epidemic By Giorgio Fabbri; Salvatore Federico; Davide Fiaschi; Fausto Gozzi

  1. By: Fischer, Stefanie (Monash University); Royer, Heather (University of California, Santa Barbara); White, Corey (Monash University)
    Abstract: Over the last few decades, health care services in the United States have become more geographically centralized. We study how the loss of hospital-based obstetric units in over 400 counties affect maternal and infant health via a difference-in-differences design. We find that closures lead mothers to experience a significant change in birth procedures such as inductions and C-sections. In contrast to concerns voiced in the public discourse, the effects on a range of maternal and infant health outcomes are negligible or slightly beneficial. While women travel farther to receive care, closures induce women to receive higher quality care.
    Keywords: obstetric, closure, infant health, maternal health, maternity ward, hospital quality
    JEL: J13 I18 J08 J18 I38
    Date: 2023–03
  2. By: Sandra E. Black; Neil Duzett; Adriana Lleras-Muney; Nolan G. Pope; Joseph Price
    Abstract: While there is substantial research on the intergenerational persistence of economic outcomes such as income and wealth, much less is known about intergenerational persistence in health. We examine the correlation in longevity (an overall measure of health) across generations using a unique dataset containing information about more than 26 million families obtained from the Family Search Family Tree. We find that the intergenerational correlation in longevity is 0.09 and rises to 0.14 if we consider the correlation between children and the average of their parents' longevity. This intergenerational persistence in longevity is much smaller than that of persistence in socio-economic status and lower than existing correlations in health. Moreover, this correlation remained low throughout the 19th and early 20th centuries despite dramatic changes in longevity and its determinants. We also document that the correlations in longevity and in education are largely independent of each other. These patterns are likely explained by the fact that stochastic factors play a large role in the determination of longevity, larger than for other outcomes.
    JEL: I1 I30 J6
    Date: 2023–03
  3. By: Zach Y. Brown; Christopher Hansman; Jordan Keener; Andre F. Veiga
    Abstract: Why do low income patients tend to go to lower quality health care providers, even when they are free? We show that differential information about provider quality is an important determinant of this disparity. Our empirical strategy exploits the temporary presence of a website that publicly displayed summary star ratings of general practitioner (GP) offices in England. Regression discontinuity estimates show that patient demand responds sharply to the information on the website, and that this response is almost entirely driven by residents of low income neighborhoods. The results are consistent with high income patients having better private information about quality. We incorporate our estimates into a structural model of demand that allows for heterogeneity in information, preferences, and consumer inertia. We find that information differences explain 24 percent of the relationship between income and GP quality and reinforce disparities in access to care.
    JEL: D83 I11 I14 L15
    Date: 2023–03
  4. By: Pierre-Carl Michaud; Pascal St-Amour
    Abstract: Annuities, long-term care insurance and reverse mortgages remain unpopular to manage longevity, medical and housing price risks after retirement. We analyze low demand using a life-cycle model structurally estimated with a unique stated-preference survey experiment of Canadian households. Low risk aversion, substitution between housing and consumption and low marginal utility when in poor health explain most of the reduced demand. Bequests motives are found to be a luxury good and play a limited role. The remaining disinterest is explained by information frictions and behavioural status-quo biases. We find evidence of strong spousal co-insurance motives motivating LTCI and of responsiveness to bundling with a near doubling of demand for annuities when reverse mortgages can be used to annuitize, instead of consuming home equity.
    Keywords: retirement wealth; insurance; health risk; housing risk
    JEL: J14 G52 G53
    Date: 2023
  5. By: Grant M. Seiter; Sita Slavov
    Abstract: How accurate are older people’s expectations about their future Social Security benefits? Using panel data from the Health and Retirement Study, we compare respondents’ observed Social Security claiming ages and benefits with subjective expectations provided during their 50s and early 60s. We find that, while older adults generally have accurate expectations about their claiming age, they underestimate their annual Social Security income by approximately $1, 896 (11.5 percent) on average. However, both accuracy and precision increase with age, and the forecast error for people in their early 60s is not statistically different from zero. Exploiting plausibly exogenous variation in the mailing of Social Security statements, which contain personalized information about future benefits, we show that information provision reduces the forecast error in annual income by $344 (2.1 percent of the average benefit).
    JEL: E21 H55 J14 J26
    Date: 2023–03
  6. By: Bárdits, Anna (KRTK KTI; Centre for Economic and Regional Studies, Institute of Economics); Adamecz-Völgyi, Anna (KRTK KTI; Centre for Economic and Regional Studies, Institute of Economics); Bisztray, Márta (KRTK KTI; Centre for Economic and Regional Studies, Institute of Economics); Weber, Andrea (Central European University); Szabó-Morvai, Agnes (KRTK KTI; Centre for Economic and Regional Studies, Institute of Economics)
    Abstract: We study fertility responses to employment shocks. Using unique Hungarian administrative data that allow linking firm-level mass layoff and closure events to individual-level records on births and abortions, we show that the main response happens in anticipation of the shock. Responses differ by the availability of dismissal protection. While pregnancies increase in anticipation of all events, births only rise in case of mass layoffs when pregnant women are protected from layoffs. If the firm closes protection is lost and we find an increase in abortions. We interpret these results as evidence for precautionary fertility behavior. Women threatened by job displacement bring births forward to exploit dismissal protection, a strategy that breaks down if the firm closes permanently.
    Keywords: abortion, birth, pregnancy, mass layoff, firm closure
    JEL: I12 J13 J65
    Date: 2023–03
  7. By: Provenzano, Sandro (London School of Economics); Roth, Sefi (London School of Economics); Sager, Lutz (London School of Economics)
    Abstract: Recent research suggests that short-term exposure to air pollution is associated with an elevated prevalence of respiratory infectious disease. We examine the relationship between the air quality index (AQI) and weekly cases of influenza-like illnesses (ILI) and COVID-19 in the United States. We address potential bias from omitted variables and measurement error with an instrumental variable approach using atmospheric temperature inversions. Unlike other recent studies, we find no relationship between air quality and either ILI or COVID-19 cases.
    Keywords: air pollution, respiratory disease, COVID-19
    JEL: I18 Q51 Q53
    Date: 2023–02
  8. By: Künn, Steffen (Maastricht University); Palacios, Juan (Massachusetts Institute of Technology)
    Abstract: What is the impact of housing upgrades on occupant health? Although economists and policymakers are certain about the health implications of housing upgrades, empirical evidence is largely missing or else only based on small-scale experiments in developing countries. This study provides the first population-representative quasi-experimental estimates based on a large-scale refurbishment program that renovated half of the East German housing portfolio in the aftermath of German reunification. During the 1990s, the German government devoted significant financial resources to upgrading the insulation and heating systems of over 3.6 million dwellings in East Germany. We link the renovations to individual demand for the healthcare of occupants using the German Socio-Economic Panel (SOEP) as well as administrative records of universal hospital admissions in Germany. Exploiting the staggered roll-out of the renovation program, our results show that an improvement in housing quality enhances the health of vulnerable age groups. Evidence from hospital records suggests that reductions in hospitalization were due to a lower risk of cardiovascular problems for older individuals (45 years or older) which were mainly driven by days with extremely hot and cold ambient temperatures. Our findings have strong policy implications and can enrich the cost-benefit analysis of public investments in weatherization programs.
    Keywords: housing quality, renovation program, health
    JEL: H54 I18 R21 R23 R38
    Date: 2023–03
  9. By: Caroli, Eve (Université Paris-Dauphine); Pollak, Catherine (New York University); Roger, Muriel (INRA-CORELA)
    Abstract: Using the differentiated increase in retirement age across cohorts introduced by the 2010 French pension reform, we estimate the health-consumption effects of a 4-month increase in retirement age. We focus on individuals who were close to retirement age but not retired yet by the time the reform was passed. Using administrative data on individual sick-leave claims and non-hospital health-care expenses, we show that the probability of having at least one sickness absence increases for all treated groups, while the overall number of sick days remains unchanged, conditional on having a sick leave. Delaying retirement does not increase the probability of seeing a GP, except for men in the younger cohorts. In contrast, it raises the probability of having a visit with a specialist physician for all individuals, except men in the older cohorts. Delaying retirement also increases the probability of seeing a physiotherapist among women from the older cohorts. Overall, it increases health expense claims, in particular in the lower part of the expenditure distribution.
    Keywords: pension reform, retirement age, health, health-care consumption
    JEL: I10 J14 J18 J26
    Date: 2023–03
  10. By: Bhuller, Manudeep (University of Oslo); Khoury, Laura (Paris School of Economics); Loken, Katrine Vellesen (Norwegian School of Economics)
    Abstract: Does prison cause mental health problems among inmates and their family members? Correlational studies tend to find much higher prevalence of mental health problems among inmates than in the general population, but remain silent on the issue of causality. We combine detailed Norwegian data on visits to health-care professionals with quasi-experimental designs to measure the impacts of incarceration on mental health-related visits by defendants and their family members. Our causal evidence consistently shows that the positive correlation is misleading: incarceration in fact lowers the prevalence of mental health-related visits among defendants. Family members, especially spouses, also experience positive mental health spillovers, while there are fewer episodes of child protection services involvement. We demonstrate that these effects last long after release and are unlikely driven by shifts in health-care demand holding health status constant. We interpret these findings in light of the rehabilitative role of correctional services in the Norwegian context.
    Keywords: mental health, incarceration, family spillovers
    JEL: K42 I10 I18
    Date: 2023–03
  11. By: Humlum, Anders (University of Chicago Booth School of Business); Munch, Jakob R. (University of Copenhagen); Plato, Pernille (University of Copenhagen)
    Abstract: We provide the first evidence on how workers invest in human capital after losing ability. Using quasi-random work accidents in Danish administrative data, we find that workers enroll in bachelor's programs after physical injuries, pursuing degrees that build on their work experiences and provide pathways to cognitive occupations. Exploiting differences in eligibility driven by prior vocational training, we find that higher education moves injured workers from disability benefits to full-time employment. Reskilled workers earn 25% more than before their injuries and do not end up on antidepressants. Without higher education, by contrast, these workers end up entirely on disability benefits and often resort to taking antidepressants. Reskilling subsidies for injured workers pay for themselves four times over, and current rates of reskilling are substantially below the social optimum, especially for middle-aged workers.
    Keywords: workplace injury, human capital investment, employment, disability insurance
    JEL: I26 J24 J62
    Date: 2023–03
  12. By: Böckerman, Petri (Labour Institute for Economic Research); Kortelainen, Mika (VATT, Helsinki); Salokangas, Henri (University of Turku); Vaalavuo, Maria (National Institute for Health and Welfare)
    Abstract: Emerging strands of research have examined the family spillover effects of health shocks, usually focusing on labour market outcomes. However, the results have been inconclusive and there is only little evidence on the longer term consequences of health shocks or the mechanisms behind the spillover effects. We analyse the short- and long-term effects of cancer on the healthy spouse's labour supply and mental health by gender and relative income status within the couple (i.e., the breadwinner type). We use full population register data on all cancer patients and their cohabiting partners in Finland over the period 1995-2019. Our identification strategy is based on the quasi-random variation in the timing of the cancer diagnosis and a dynamic difference-in-differences approach. We find two main results. First, cancer increases female spouses' employment. This result is consistent with the added worker effect, although we find the magnitude of the increase in annual earnings to be negligible. By contrast, among male spouses, earnings decrease as a consequence of a spouse's cancer. Second, among women, there is heterogeneity in the effects in terms of the breadwinner status, which is especially notable in the long-term. The results show that the added worker effect is visible only among secondary earners and the effect seems to hold only when the cancer patient dies. Secondary earner women also suffer more from psychiatric symptoms during bereavement. Consequently, we argue that the breadwinner status before the health shock is a neglected factor influencing the effects of health shocks in families, and that family-level specialisation between spouses alters substantially over time in response to a health shock.
    Keywords: health shock, cancer, family spillover effects, employment, earnings, household division of labour, event study, difference-in-differences
    JEL: I10 J12 J17 J22
    Date: 2023–03
  13. By: Faten Saliba; Giorgio Maarraoui; Walid Marrouch; Ada Wossink
    Abstract: This paper uses life satisfaction data to help the design of climate mitigation policies in the United Kingdom. We assess the effects of the exposure to ambient pollutants on long-term life satisfaction and short-term mental health in the UK. We estimate augmented Cobb-Douglas utility functions using pooled and random effects ordinal logit models. Results show that increases in NO2, PM10 and PM2.5 significantly decrease the odds of longterm happiness and short-term mental health in the UK. The willingness to pay for clean air is also significant and increases with level of education. These measurements derived can be used as benchmarks for pollution abatement subsidies or pollution taxes and can help in projecting a more comprehensive assessment of costs and benefits.
    Keywords: Air Pollution; Happiness; Policy Valuation; Climate Change; Environmental Policies; Pollution Taxes; Pollution Abatement Subsidies; life satisfaction data; dataset description; air pollutant; pollutants' correlation; household data; ordinal Logit; Income; Europe; Global
    Date: 2023–02–17
  14. By: Lim, Seulgi (National Assembly Budget Office); Lee, Soohyung (Seoul National University)
    Abstract: We examine the health impacts of long commute time by exploiting a large-scale placed-based policy in South Korea. The policy relocated public employers in the capital area to disadvantaged cities. However, some public employees kept their residences in the capital area and spend long hours commuting. Using this change, we estimate 2SLS models whose results suggest that having a long commute substantially increases usage of medical services, particularly to treat respiratory, circulatory, and endocrine & metabolic diseases. However, we find mixed effects of long commute time on medical checkup outcomes and health-related activities such as exercise.
    Keywords: commute, health, place-based policy, Sejong, innovation city
    JEL: I10 J18 H51 R11
    Date: 2023–03
  15. By: Klauber, Hannah (Mercator Research Institute on Global Commons and Climate Change (MCC)); Koch, Nicolas (Mercator Research Institute on Global Commons and Climate Change (MCC))
    Abstract: This paper identifies individual and regional risk factors for hospitalizations caused by heat within the German population over 65 years of age. Using administrative insurance claims data and a machine-learning-based regression model, we causally estimate heterogeneous heat effects and explore the geographic, morbidity, and socioeconomic correlates of heat vulnerability. Our results indicate that health effects distribute highly unevenly across the population. The most vulnerable are more likely to suffer from chronic diseases such as dementia and Alzheimer's disease and live in rural areas with more old-age poverty and less nursing care. We project that unabated climate change might bring heat to areas with particularly vulnerable populations, which could lead to a five-fold increase in heat-related hospitalization by 2100.
    Keywords: heat, climate change, hospitalization, risk factors, adaptation, machine learning
    JEL: I14 I18 Q51 Q54 Q58
    Date: 2023–03
  16. By: Felipe Carozzi; Edward Pinchbeck; Luca Repetto
    Abstract: How does the memory of lives lost in past wars shape communities and the next generation of soldiers? We use newly collected geolocated data on British servicemen to study the legacy of the Great War mortality shock on local communities and the behaviour of soldiers in WW2. We find that community-wide fatalities in WW1 increase the numbers of deaths of the next generation in WW2 and the likelihood that these soldiers receive military honours. To explain these findings, we report that WW1 deaths had promoted civic-oriented and cooperative behaviours in the inter-war period, as measured by the creation of lasting war memorials, veterans’ associations and charities, and increases in voter participation. Overall, we present evidence that part of the legacy of the Great War on British servicemen runs through and is amplified by civic capital and the remembrance of fallen soldiers.
    Keywords: World War, communities, combat motivation, conflict
    JEL: D74 D91 O15 Z10
    Date: 2023
  17. By: Kristina Czura; Andreas Menzel; Martina Miotto
    Abstract: Menstruation can limit female labor force participation, especially in low-income countries, where menstrual hygiene practices are constrained by lack of finances and information. In a randomized controlled trial with around 1, 900 female workers from four Bangladeshi garment factories, we relax both constraints individually and jointly by providing free sanitary pads and information on hygienic menstrual practices. Both access to sanitary pads and information improve menstrual practices, either by the adoption of new products, or by knowledge gains and improved use of traditional materials, and both interventions improve health outcomes. However, these positive effects do not translate to better labor outcomes, such as earnings and work attendance.
    Keywords: menstrual health, health behaviour, labor force participation, export manufacturing
    JEL: O14 O15 O35 M54 J32 J81
    Date: 2023
  18. By: Brekke, Kurt R. (Dept. of Economics, Norwegian School of Economics and Business Administration); Dalen, Dag Morten (BI Norwegian Business School); Straume, Odd Rune (University of Minho and University of Bergen)
    Abstract: Health systems around world are increasingly adopting cost-effectiveness (CE) analysis to inform decisions about access and reimbursement. We study how CE thresholds imposed by a health plan for granting reimbursement affect drug producers pricing incentives and patients access to new drugs. Analysing a sequential pricing game between an incumbent drug producer and a potential entrant with a new drug, we show that CE thresholds may have adverse effects for payers and patients. A stricter CE threshold may induce the incumbent to switch pricing strategy from entry accommodation to entry deterrence, limiting patients access to the new drug. Otherwise, irrespective of whether entry is deterred or accommodated, a stricter CE threshold is never pro-competitive and may in fact facilitate a collusive outcome with higher prices of both drugs. Compared to a laissez-faire policy, the use of CE thresholds can only increase the surplus of a health plan if it leads to entry deterrence in which the price reduction by the incumbent necessary to deter entry outweighs the health loss to patients not getting access to the new drug.
    Keywords: Pharmaceuticals; Health Plans; Cost-effectiveness analysis; ICER; Therapeutic competition
    JEL: I11 I18 L13 L65
    Date: 2023–03–13
  19. By: Srivatsa, Shaarada; Khan, Hammad A.; Benzel, Edward C.; Benzil, Deborah L.; Mroz, Thomas E.; Steinmetz, Michael P.; Salas-Vega, Sebastian
    Abstract: Objective: There is a paucity of evidence describing the price information that is publicly available to patients wishing to undergo neurosurgical procedures. We sought to investigate the public availability and usefulness of price estimates for non-emergent, elective neurosurgical interventions. Methods: Google was used to search for price information related to 15 procedures in 8 major U.S. health care markets. We recorded price information that was published for each procedure and took note of whether itemized prices, potential discounts, and cross-provider price comparisons were available. Results: Online searches yielded 2356 websites, of which 228 (9.7%) offered geographically relevant price information for neurosurgical procedures. Although accounting for only 16.4% of total search results, price transparency websites provided most treatment price estimates (74.1% of all estimates), followed by clinical sites (19.3%), and other related sites (5.3%). The number of websites providing price information varied significantly by city and procedure. websites rarely divulged data sources, specified how prices were estimated, indicated how frequently price estimates were updated, offered itemized breakdowns of prices, or indicated whether price estimates encompassed the full spectrum of possible health care charges. Conclusions: Under 10% of websites queried yield geographically relevant price information for non-emergent neurosurgical imaging and operative procedures. Even when this information is publicly available, its usefulness to patients may be limited by various factors, including obscure data sources and methods, as well as sparse information on discounts and bundled price estimates. Inconsistent availability and clarity of price information likely impede patients' ability to discern expected costs of treatment and engage in cost-conscious, value-based neurosurgical decision-making.
    Keywords: access to information; elective surgical procedures; health care costs; neurosurgery
    JEL: J1
    Date: 2022–06–01
  20. By: Bellés Obrero, Cristina (Barcelona Institute of Economics); Rice, Caoimhe T. (University of York); Castello, Judit Vall (University of Barcelona)
    Abstract: This paper investigates the causal link between healthcare access and the help-seeking behavior of intimate partner violence (IPV) victims. Healthcare access can be an important entry point for screening or detecting IPV. Doctors are required by law to report any injuries to a judge if they suspect they are the result of a crime and can inform and direct victims to IPV services. We exploit the 2012 reform in Spain that removed access to the public healthcare system for undocumented immigrants. We use court reports and protection order requests from the Judicial Branch of the Spanish government to perform a difference-in-differences approach, comparing the help-seeking behavior of foreign and Spanish women before and after the reform. We find that the impact of the reform was immediate; foreign women's IPV reporting and application for protection orders decreased by 12%. This effect is entirely driven by regions with stronger enforcement of the reform. We show suggestive evidence that the reform left the underlying levels of IPV incidence unaffected. Instead, the results are driven by a reduction in injury reports by medical centers. Our findings are important given the increase in migration flows globally as well as for current debates on granting/limiting access to healthcare for marginalized groups.
    Keywords: healthcare access, intimate partner violence, reporting, undocumented immigrants
    JEL: I10 I12 I14 I31
    Date: 2023–03
  21. By: Amanda Dahlstrand
    Abstract: Digital platforms are transforming services by making the physical distance between provider and user less relevant. I quantify the potential gains this flexibility offers in the context of digital primary care in Sweden, harnessing nationwide conditional random assignment between 200, 000 patients and 150 doctors. I evaluate causal effects of matching patients of varying risks to doctors with different skills and assess counterfactual policies compared to random assignment. Matching patients at high risk of avoidable hospitalizations to doctors skilled at triaging reduces avoidable hospitalizations by 20% on aggregate - without affecting other adverse outcomes, such as counter-guideline antibiotics prescriptions. Conversely, matching the best triaging doctors to the richest patients leads to more avoidable hospitalizations, since the most vulnerable patients are often the poorest. Hence, remote matching can sever the link between local area income and service quality in favor of a needs-based assignment, improving the effectiveness and equity of service provision.
    Keywords: skills, labor markets, health and inequality
    Date: 2022–12–07
  22. By: Bhattacharyya, Bhaskar; Mandal, Biswajit; Sengupta, Sarbajit
    Abstract: Using data from NFHS-4, this study examines the progressiveness of out-of-pocket spending and health financing methods used in the case of institutional delivery in India. We used concentration indices to arrive at some intriguing results. Applying Multinomial Logit Model we focus on how various socio-economic factors play crucial role in making choice among alternative distress financing options. Unlike other studies, we find that as women get older, they often arrange for money by selling jewelries for health purpose. This is equally true for women with a secondary education. They also rely on other strategies like saving and selling. In case of different social division in Indian society, the SCs and the OBCs are found to be more susceptible to distress financing. In spite of some government initiatives like Janani Suraksha Yojana (JSY) the problem of out- of- pocket expenditure related distress has not been reduced substantially. In our opinion this is a policy failure. In order to address this problem a concerted effort from both demand and supply side should be made available.
    Keywords: Out- of- pocket expenditure, distress financing, institutional delivery
    JEL: I12 I13 I14 I15 I18
    Date: 2022
  23. By: Carrasco Azzini, Giuseppe; Conti, Valentina; Holleman, Cindy; Smulders, Mark
    Abstract: After decreasing for nearly a decade, hunger is once again on the rise. The major drivers behind this reversal – especially in low- and middle-income countries – are conflict, climate extremes and variability, and economic downturns. This crisis – exacerbated by the economic shocks stemming from the COVID-19 pandemic containment measures – underlines the urgent need to transform food systems for food security, improved nutrition and affordable healthy diets. This prompted FAO, the International Fund for Agricultural Development (IFAD), the United Nations Children’s Fund (UNICEF), the World Food Programme (WFP) and the World Health Organization (WHO) to focus the theme of The State of Food Security and Nutrition in the World 2021 on possible transformative pathways and portfolios of policies to achieve these objectives. This paper analyses 136 case studies received from a call for best practices in transforming food systems to improve the affordability of healthy diets and build resilience to the major drivers of food security and nutrition. These can help countries formulate context-specific portfolios of policies, investments and laws that integrate different sectors – environmental, health and social protection, among others – to move from siloed approaches to integrated food systems solutions. The findings in this brief have been adapted from the FAO report "The State of Food Security and Nutrition in the World 2021 – Transforming food systems for food security, improved nutrition and affordable healthy diets for all" (
    Keywords: Agricultural and Food Policy, Food Consumption/Nutrition/Food Safety
    Date: 2022–10–26
  24. By: Vuong, Quan-Hoang; La, Viet-Phuong; Le, Tam-Tri; Hoang, Giang; Jin, Ruining; Quang-Loc, Nguyen; Vuong, Thu-Trang; Nguyen, Minh-Hoang
    Abstract: Bribing doctors for preferential treatment is rampant in the healthcare system of developing countries like Vietnam. Although bribery raises the out-of-pocket expenditures of patients, it is so common to be deemed an “envelope culture.” Given the little understanding of the underlying mechanism of the culture, this study employed the mindsponge theory for reasoning the mental processes of both patients and doctors for why they embrace the “envelope culture” and used the Bayesian Mindsponge Framework (BMF) analytics to validate our reasoning. Analyzing responses from 1042 Vietnamese patients, we discovered that bribing doctors can help patients reduce the destitution risk induced by treatment. Such effect of doctor bribery remains consistent among patients that have to pay high daily costs (e.g., accommodation and subsistence fees) regardless of their employment status. Nevertheless, for patients with no or unstable jobs, their risks of destitution increase if they have to pay more thank-you money. These findings suggest that doctor bribery is an adaptive strategy for patients in an environment where the healthcare supply cannot meet the actual demand. Moreover, healthcare equity is greatly exacerbated due to the envelope culture, as vulnerable individuals are exposed to a greater threat of poverty. At the same time, those with good economic conditions get preferential treatment by paying a higher amount of thank-you money. Healthcare workers’ ethics must be the top priority for an equitable and proper healthcare system.
    Date: 2023–02–22
  25. By: Mylène Lagarde (London School of Economics and Political Science); Carlos Riumallo Herl (Erasmus University Rotterdam)
    Abstract: We study the power of social incentives to increase individuals' investment in preventive health using small financial incentives with group conditionality. In a field experiment in El Salvador, we compare those to equivalent individual incentives. Despite the uncertainty about others’ behavior, group incentives are as effective as individual ones and double the demand for prevention. They achieve these effects by increasing communication, peer pressure, and coordination between members to reduce information asymmetry and address behavioral barriers that limit prevention take-up. Incentives leveraging social interactions may act on both present bias and inaccurate beliefs that limit investment in health services.
    JEL: C93 D91 I12
    Date: 2023–03–03
  26. By: Dubois, Pierre; Majewska, Gosia; Reig, Valentina
    Abstract: Drug shortages are a problem widely documented around the world. We develop a simple method allowing to identify shortage events and their intensity using sales data at a national level. In the case of prescription drugs, shortages occur when the quantities supplied do not meet demand at regulated prices. Using sales data only, shortages that are driven by supply shocks affect only the lower distribution of sales quantities and can be identified using a demand prediction model estimated on sales observed above a given quantile threshold. We can then measure the likelihood and the magnitude of shortage events. We provide evidence that lower French prices increase the likelihood and magnitude of shortages in France. However, higher prices in the UK seem to have positive spillover effects on reducing the likelihood of shortages, while a negative one when shortages happen and there is competition for scarce resources internationally. Finally, we provide evidence on the heterogeneous effects of shortage reductions achievable through higher regulated prices in France.
    Keywords: Drug Shortages; Prices; Regulation; Econometrics.
    JEL: L5 L65 I18
    Date: 2023–03–10
  27. By: Keith M. Drake; Thomas McGuire
    Abstract: In agreements settling patent challenges in the drug industry, the plaintiff brand commonly licenses the defendant generic to sell prior to patent expiry. Some agreements require the generic to pay the brand royalties. Despite the superficial flow of profits, royalty terms may function as part of an anticompetitive “reverse payment” made to the generic in exchange for delayed entry. Typically, the brand launches its own authorized generic (AG) during the first-to-file generic’s 180-day exclusivity period so there are two initial generic competitors. A royalty structure that deters the brand’s AG launch reduces the number of entrants to one, conveying net value to the generic and potentially inducing it to delay its entry. Our simple model shows that royalties usually have no place in a brand-generic agreement between rational actors. However, when royalties are conditioned on the brand’s AG launch, a range of royalty rates exists that both conveys net value to the generic and deters the brand from rationally introducing an AG. Declining royalty terms in a brand’s settlement with a first-to-file generic thus raise a red flag that the agreement is a pay-for-delay. Although the numbers are small, empirical analysis based on publicly available materials corroborates this conclusion.
    JEL: D22 D43 K21 L41
    Date: 2023–03
  28. By: Joan Costa-i-Font; Cristina Vilaplana-Prieto
    Abstract: We examine the extent to which exposure to higher relative COVID-19 mortality (RM), influences health system trust (HST), and whether changes in HST influence the perceived ease of compliance with pandemic restrictions during the COVID-19 pandemic. Drawing on evidence from two representative surveys covering all regions of 28 European countries before and after the first COVID-19 wave and using a difference in differences strategy together with Coarsened Exact Matching (CEM), we document that living in a region with higher RM during the first wave of the pandemic increased HST. However, the effect is driven by individuals over 45 years of age, and the opposite is true among younger cohorts. We find that a higher HST reduces the costs of complying with COVID-19 restrictions, but only so long as excess mortality does not exceed the average by more than 20%, at which point the ease of complying with COVID-19 restrictions significantly declines, offsetting the positive effect of trust in the healthcare system. Our interpretation of the estimates is that RM is interpreted as a risk signal among those over 45, and as a signal of health-care system failure among younger age individuals.
    Keywords: healthcare system trust, mortality, lockdown, Eurobarometer, difference in differences, Covid-19
    JEL: I13 Z10
    Date: 2023
  29. By: Aslim, Erkmen Giray (Grand Valley State University); Fu, Wei (University of Pennsylvania); Tekin, Erdal (American University); You, Shijun (Lehigh University)
    Abstract: This paper examines the impact of COVID-19 vaccination on food insecurity in the United States, using data from the Household Pulse Survey. Our primary research design exploits variation in vaccine eligibility across states over time as an instrumental variable to address the endogeneity of vaccination decision. We find that vaccination had a substantial impact on food hardship by reducing the likelihood of food insecurity by 24%, with even stronger effects among minority and financially disadvantaged populations. Our results are robust to alternative specifications and the use of regression discontinuity as an alternative identification strategy. We also show that vaccine eligibility had a positive spillover impact on food assistance programs, specifically by reducing participation in the Supplemental Nutrition Assistance Program (SNAP), which suggests that vaccination policy can be effective in alleviating the fiscal burden of the pandemic on the government. Furthermore, our analysis indicates that vaccinated individuals exhibit increased financial optimism, as measured by expectations about future loss of employment and income as well as ability to make mortgage and debt payments. Based on the point estimates, the implied elasticity of food insecurity with respect to financial optimism is between -0.57 and -0.86. Our findings suggest that the COVID-19 vaccination program has implications that extend beyond the direct health benefits. Taken together, our results underscore the critical role of medical innovations and health interventions in improving economic optimism and food security, especially among vulnerable populations, during public health crises.
    Keywords: food insecurity, food stamps, vaccination, financial optimism, COVID-19
    JEL: I14 I18
    Date: 2023–03
  30. By: Andor, Mark Andreas; Bauer, Thomas K.; Eßer, Jana; Schmidt, Christoph M.; Tomberg, Lukas
    Abstract: This study investigates the different cognitive and non-cognitive characteristics associated with individuals' willingness to get vaccinated against Covid-19 and their actual vaccination status. Our empirical analysis is based on data obtained from three survey waves of about 2, 000 individuals living in the German state of North Rhine-Westphalia. We find that individuals with a high level of trait reactance display a significantly lower willingness to get vaccinated. They also tend to get inoculated later or never. Moreover, neuroticism, locus of control, and risk literacy appear to be associated with the willingness to get vaccinated, but these results are less pronounced and less robust. Our results indicate that vaccination campaigns and policies could be improved by specifically addressing those with a high level of trait reactance.
    Keywords: Covid-19, vaccination, psychological traits, risk literacy, health literacy
    JEL: D91 H0 I12 I18
    Date: 2023
  31. By: Hupkau, Claudia; Ruiz-valenzuela, Jenifer; Isphording, Ingo E.; Machin, Stephen
    Abstract: This paper studies spill-over effects of parental labour market shocks at two time points in the Covid-19 crisis: right after its onset in April 2020, and in January 2021. We use rich data from the UK to look at the consequences of immediate and persistent shocks that hit parents’ economic livelihoods. These negative labour market shocks have substantially larger impacts when suffered by fathers than by mothers. Children of fathers that suffered the most severe shocks - earnings dropping to zero - are the ones that are consistently impacted. In April 2020, they were 10 percentage points less likely to have received additional paid learning resources, but their fathers were spending about 30 more minutes per day helping them with school work. However, by January 2021, this latter association switches sign, as the negative spill-over onto children’s education occurred for those fathers facing more persistent, negative labour market shocks as the crisis progressed. The paper discusses potential mechanisms driving these results, finding a sustained deterioration of household finances and a worsening of father’s mental health to be factors at play.
    Keywords: job loss; job insecurity; child outcomes; COVID-19; parental investments
    JEL: J63 J65 I20
    Date: 2023–06–01
  32. By: Contini, Dalit (University of Turin); Di Tommaso, Maria Laura (University of Turin); Muratori, Caterina (University of Torino); Piazzalunga, Daniela (University of Trento); Schiavon, Lucia (University of Torino)
    Abstract: This paper estimates the effect of a full year of the COVID-19 pandemic on school performance, focusing on students at the end of upper secondary school who are about to enter the labour market or start university without having had the opportunity to recover. Using longitudinal data from standardised tests for the student population nationwide, we use difference-in-differences models to analyse the performance of two cohorts of students in Italy: a cohort that has never been exposed to the pandemic and a cohort that graduated in 2021. We find that the pandemic had a huge negative impact on students' performance in mathematics and reading (approximately 0.4 s.d. in both domains). Low-achieving pupils suffered the most, increasing the gap between strong and poor performers. The relative position of girls improved compared to boys. Different from the findings from the existing literature, inequalities by parental education remained largely unchanged.
    Keywords: COVID-19, school closure, learning loss, standardised tests, inequality
    JEL: I21 I24 I18 I28
    Date: 2023–03
  33. By: Giorgio Fabbri; Salvatore Federico; Davide Fiaschi; Fausto Gozzi
    Abstract: We propose a model, which nests a susceptible-infected-recovered-deceased (SIRD) model of epidemic into a dynamic macroeconomic equilibrium framework with agents’ mobility. The latter affect both their income and their probability of infecting and being infected. Strategic complementarities among individual mobility choices drive the evolution of aggregate economic activity, while infection externalities caused by individual mobility affect disease diffusion. The continuum of rational forward-looking agents coordinates on the Nash equilibrium of a discrete time, finite-state, infinite-horizon Mean Field Game. We prove the existence of an equilibrium and provide a recursive construction method for the search of an equilibrium(a), which also guides our numerical investigations. We calibrate the model by using Italian experience on COVID-19 epidemic and we discuss policy implications.
    Keywords: mean field game, strategic complementarities, ESIRD, COVID-19
    JEL: E1 H0 I1 C72 C73 C62
    Date: 2022–11

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