J Health Econ
· 2024 Dec · PMID 39260047
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E-cigarette licensure laws (ELLs) require retailers to obtain a state license to sell e-cigarettes over the counter. This study is the first to comprehensively explore the effect of ELL adoption on youth tobacco product...E-cigarette licensure laws (ELLs) require retailers to obtain a state license to sell e-cigarettes over the counter. This study is the first to comprehensively explore the effect of ELL adoption on youth tobacco product use. Using data from the State Youth Risk Behavior Survey (YRBS) and a difference-in-differences approach, we find no evidence that ELL adoption reduces youth ENDS use. The precision of our estimates allows us to rule out, with 95 % confidence, ELL-induced declines in prior-month, frequent, and everyday youth ENDS use of more than 0.7, 0.3, and 0.4 percentage points, respectively. The pattern of null findings persists when we examine ELLs that impose higher penalties for retailer non-compliance, higher renewable licensure fees, and criminal in addition to civil penalties. We conclude that ELLs have only limited success in curbing access to ENDS among youths.
We study competing hospitals' incentives for quality provision in a dynamic setting where healthcare is an experience good. In our model, the utility a patient derives from choosing a particular provider depends on a sub...We study competing hospitals' incentives for quality provision in a dynamic setting where healthcare is an experience good. In our model, the utility a patient derives from choosing a particular provider depends on a subjective component specific to the match between the patient and the provider, which can only be learned through experience. We find that the experience-good nature of healthcare can either reinforce or dampen the demand responsiveness to quality and the hospitals' incentives for quality provision, depending on two key factors: the shape of the distribution of match-specific utilities and the cost relationship between quality provision and treatment volume. We establish conditions under which ignoring the experience dimension of healthcare leads to inaccurate assessments of the competitiveness of hospital markets.
We study the effects of health insurance coverage on agricultural production decisions, examining the causal relationships by exploiting a health care reform and providing a theoretical framework to elucidate underlying...We study the effects of health insurance coverage on agricultural production decisions, examining the causal relationships by exploiting a health care reform and providing a theoretical framework to elucidate underlying mechanisms. We find that the reform led to long-run increases in total cultivation investments and output, accompanied by a shift in households' cultivation portfolio towards riskier crops. We explain these findings using a model of agricultural investment, highlighting the important roles of health insurance in mitigating background medical expenditure risks and enhancing health. We also find that the reform improved households' financial well-being through reduced debts and defaults on loans.
In a randomized controlled trial conducted in three waves over 2.5 years and involving nearly 700 customer-service representatives (CSRs) from a Canadian government service agency, we studied how providing CSRs with repe...In a randomized controlled trial conducted in three waves over 2.5 years and involving nearly 700 customer-service representatives (CSRs) from a Canadian government service agency, we studied how providing CSRs with repeated performance feedback, with or without peer comparison, affected their subsequent organ donor registration rates. The feedback resulted in a 25 % increase in daily signups compared to otherwise equivalent encouragements and reminders. Adding benchmark information about peer performance did not amplify or diminish this effect. We observed increased registration rates for both high and low performers. A post-intervention survey indicates that CSRs in all conditions found the information included in the treatments helpful and motivating, and that signing up organ donors makes their job more meaningful. We also found suggestive evidence that performance feedback with benchmark information was the most motivating and created the least pressure to perform.
Smart R, Powell D, Pacula RL
… +3 more, Peet E, Abouk R, Davis CS
J Health Econ
· 2024 Sep · PMID 39043099
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Despite efforts to expand naloxone access, opioid-related overdoses remain a significant contributor to mortality. We study state efforts to expand naloxone distribution through pharmacies by reducing the non-monetary co...Despite efforts to expand naloxone access, opioid-related overdoses remain a significant contributor to mortality. We study state efforts to expand naloxone distribution through pharmacies by reducing the non-monetary costs to prescribers, dispensers, and/or potential recipients of naloxone. We find that laws that only address liability costs have small and insignificant effects on the volume of naloxone dispensed through pharmacies. In contrast, we estimate large effects of laws removing the need for patients to obtain prescriptions from traditional prescribers (e.g., primary care physicians): laws authorizing non-patient-specific prescription distribution and laws granting pharmacists prescriptive authority. We test whether areas designated as primary care shortage areas-where it would be costlier to obtain a prescription-were disproportionately impacted. Shortage areas experienced sharper growth in pharmacy naloxone dispensing in states adopting prescriptive authority policies. These gains were primarily due to those facing low out-of-pocket costs, suggesting that price barriers also must be addressed to increase naloxone purchases.
Health expenditure data almost always include extreme values, implying that the underlying distribution has heavy tails. This may result in infinite variances as well as higher-order moments and bias the commonly used le...Health expenditure data almost always include extreme values, implying that the underlying distribution has heavy tails. This may result in infinite variances as well as higher-order moments and bias the commonly used least squares methods. To accommodate extreme values, we propose an estimation method that recovers the right tail of health expenditure distributions. It extends the popular two-part model to develop a novel three-part model. We apply the proposed method to claims data from one of the biggest German private health insurers. Our findings show that the estimated age gradient in health care spending differs substantially from the standard least squares method.
This paper examines the influence of housing wealth on fertility outcomes through a regression discontinuity design based on a 2006 Chinese housing-market policy. Our analysis reveals that the positive impact of this pol...This paper examines the influence of housing wealth on fertility outcomes through a regression discontinuity design based on a 2006 Chinese housing-market policy. Our analysis reveals that the positive impact of this policy on housing wealth significantly enhances the likelihood of fertility by 7.3 %. Our result implies that a 1 % increase in housing wealth can raise the fertility rate by 0.18 %. Furthermore, we observe that children born subsequent to the positive housing wealth shock exhibit improved health, not only at birth but also over the long term. Lastly, we present suggestive evidence suggesting that both parental pre-birth time allocation and parental health may help explain the documented positive effects of housing wealth on fertility rates.
This study assesses the impact of financial incentives on hygienic latrine ownership by poor/near-poor households in Vietnam. Rural communes were randomly assigned to a control group and three treatment arm groups: (T1)...This study assesses the impact of financial incentives on hygienic latrine ownership by poor/near-poor households in Vietnam. Rural communes were randomly assigned to a control group and three treatment arm groups: (T1) a rebate for households that installed a hygienic latrine; (T2) a financial reward for commune governments if the proportion of hygienic latrines in their commune increased by 30 percentage points; (T3) both a household rebate and a commune reward. We find a strong and positive effect from the household rebate (treatment arms 1 and 3) but an insignificant effect from the commune reward (treatment arm 2) on household ownership of a septic tank latrine. Our analysis provides suggestive evidence that microcredit is a channel through which a rebate encourages the installation of septic tank latrines. We also find that treatment arm 3 increases people's knowledge regarding sanitation and the availability of water and soap for handwashing within households.
Alcohol control policies are implemented to reduce alcoholism and related harms around the globe. This work examines the effects of a policy that restricted when alcohol could be purchased on child outcomes in Russia. To...Alcohol control policies are implemented to reduce alcoholism and related harms around the globe. This work examines the effects of a policy that restricted when alcohol could be purchased on child outcomes in Russia. To identify causal impacts, I exploit variation in the timing and severity of the restriction, which was implemented in Russian states between 2005 and 2010. Utilizing household survey data and a difference-in-differences estimation approach, I find that the policy has improved children's physical health, with younger children being more affected, and additionally has decreased a variety of risky behavior indicators. Potential mechanisms for these effects include alcohol consumption, parental employment, household income, family stability, and time use. This work demonstrates that policies controlling parental substance access can have important effects on child health.
J Health Econ
· 2024 Sep · PMID 38944945
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Health plans for the poor increasingly limit access to specialty hospitals. We investigate the role of adverse selection in generating this equilibrium among private plans in Medicaid. Studying a network change, we find...Health plans for the poor increasingly limit access to specialty hospitals. We investigate the role of adverse selection in generating this equilibrium among private plans in Medicaid. Studying a network change, we find that covering a top cancer hospital causes severe adverse selection, increasing demand for a plan by 50% among enrollees with cancer versus no impact for others. Medicaid's fixed insurer payments make offsetting this selection, and the contract distortions it induces, challenging, requiring either infeasibly high payment rates or near-perfect risk adjustment. By contrast, a small explicit bonus for covering the hospital is sufficient to make coverage profitable.
Is the education-health gradient inflated because both education and health are associated with unobserved socio-emotional skills? We find that the gradient in health behaviors and outcomes is reduced by about 15 to 50%...Is the education-health gradient inflated because both education and health are associated with unobserved socio-emotional skills? We find that the gradient in health behaviors and outcomes is reduced by about 15 to 50% from accounting for fine-grained personality facets and up to another 50% from Locus of Control. Traditional aggregated Big-Five scales, however, have a much smaller contribution to the gradient. We use sibling-fixed effects to net out the contribution from genes and shared childhood environment, decomposing the gradient into its components with an order-invariant method. We rely on a large survey (N = 28,261) linked to high-quality Danish administrative registers with information on parental background and objectively measured diagnoses and care use. Accounting for Locus of Control yields the strongest gradient reduction in self-rated health status and objective diagnoses (30%-50%), and in health behaviors the most important factor is Extraversion, a skill that has been shown to be malleable in interventions.
Demand-side cost-sharing reduces moral hazard in healthcare but increases exposure to out-of-pocket expenditure. We introduce a structural microsimulation model to evaluate both total and out-of-pocket expenditure for di...Demand-side cost-sharing reduces moral hazard in healthcare but increases exposure to out-of-pocket expenditure. We introduce a structural microsimulation model to evaluate both total and out-of-pocket expenditure for different cost-sharing schemes. We use a Bayesian mixture model to capture the healthcare expenditure distributions across different age-gender categories. We estimate the model using Dutch data and simulate outcomes for a number of policies. The model suggests that for a deductible of 300 euros shifting the starting point of the deductible away from zero to 400 euros leads to an average 4% reduction in healthcare expenditure and 47% lower out-of-pocket payments.
J Health Econ
· 2024 Sep · PMID 38861907
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Private equity is an increasing presence in US healthcare, with unclear consequences. Leveraging unique data sources and difference-in-differences designs, we examine the largest private equity hospital takeover in histo...Private equity is an increasing presence in US healthcare, with unclear consequences. Leveraging unique data sources and difference-in-differences designs, we examine the largest private equity hospital takeover in history. The affected hospital chain sharply shifts its advertising strategy and pursues joint ventures with ambulatory surgery centers. Inpatient throughput is increased by allowing more patient transfers, and crucially, capturing more patients through the emergency department. The hospitals also manage shorter, less treatment-intensive stays for admitted patients. Outpatient surgical care volume declines, but remaining cases focus on higher complexity procedures. Importantly, behavior changes persist even after private equity divests.
J Health Econ
· 2024 Jun · PMID 38833959
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Healthcare is often free at the point-of-care so that price does not deter patients. However, the dis-utility from waiting for care that often occurs could also lead to deterrence. I investigate responses in the volume a...Healthcare is often free at the point-of-care so that price does not deter patients. However, the dis-utility from waiting for care that often occurs could also lead to deterrence. I investigate responses in the volume and types of patients that demand emergency care when predicted waiting times quasi-randomly change. I leverage a discontinuity to compare emergency sites with similar predicted wait times but with different apparent wait times displayed to patients. I use impulse response functions estimated by local projections to estimate effects of predicted wait times on patient demand for care. An additional thirty minutes of predicted wait time results in 15% fewer waiting patients at urgent cares and 2% fewer waiting patients at emergency departments within three hours of display. Patients that stop using emergency care are also triaged as healthier. However, at very high predicted wait times, there are reductions in demand for all patients including sicker patients.
Armand A, Augsburg B, Bancalari A
… +1 more, Kameshwara KK
J Health Econ
· 2024 Jun · PMID 38805882
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We investigate how religion concordance influences the effectiveness of preventive health campaigns. Conducted during the early stages of the COVID-19 pandemic in two major Indian cities marked by Hindu-Muslim tensions,...We investigate how religion concordance influences the effectiveness of preventive health campaigns. Conducted during the early stages of the COVID-19 pandemic in two major Indian cities marked by Hindu-Muslim tensions, we randomly assigned a representative sample of slum residents to receive either a physician-delivered information campaign promoting health-related preventive practices, or uninformative control messages on their mobile phones. Messages, introduced by a local citizen (the sender), were cross-randomized to start with a greeting signaling either a Hindu or a Muslim identity, manipulating religion concordance between sender and receiver. We found that doctor messages increased compliance with recommended practices and beliefs in their efficacy. Our findings suggest that the campaign's impact is primarily driven by shared religion between sender and receiver, leading to increased message engagement and compliance with recommended practices. Additionally, we observe that religion concordance helps protect against misinformation.
O'Neill S, Grieve R, Singh K
… +2 more, Dutt V, Powell-Jackson T
J Health Econ
· 2024 Jun · PMID 38805881
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Childhood vaccinations are among the most cost-effective health interventions. Yet, in India, where immunisation services are widely available free of charge, a substantial proportion of children remain unvaccinated. We...Childhood vaccinations are among the most cost-effective health interventions. Yet, in India, where immunisation services are widely available free of charge, a substantial proportion of children remain unvaccinated. We revisit households 30 months after a randomised experiment of a health information intervention designed to educate mothers on the benefits of child vaccination in Uttar Pradesh, India. We find that the large short-term effects on the uptake of diphtheria-pertussis-tetanus and measles vaccination were sustained at 30 months, suggesting the intervention did not simply bring forward vaccinations. We apply causal forests and find that the intervention increased vaccination uptake, but that there was substantial variation in the magnitude of the estimated effects. We conclude that characterising those who benefited most and conversely those who benefited least provides policy-makers with insights on how the intervention worked, and how the targeting of households could be improved.
J Health Econ
· 2024 May · PMID 38763530
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Prior research has found that a high level of residential racial segregation, or the degree to which racial/ethnic groups are isolated from one another, is associated with worsened infant health outcomes, particularly am...Prior research has found that a high level of residential racial segregation, or the degree to which racial/ethnic groups are isolated from one another, is associated with worsened infant health outcomes, particularly among non-Hispanic (NH) Black infant populations. However, because exposure to segregation is non-random, it is unclear whether and to what extent segregation is causally linked to infant health. To overcome this empirical limitation, we leverage exogenous variation in the placement of railroad tracks in the 19th century to predict contemporary segregation, an approach first introduced by Ananat (2011). In alignment with prior literature, we find that residential segregation has statistically significant associations with negative birth outcomes among Black infant populations in the area. Using OLS methods underestimates the negative impacts of segregation on infant health. We fail to detect comparable effects on health outcomes among NH White infant populations. Further, we identify several key mechanisms by which residential segregation could influence health outcomes among Black infant populations, including lower access to prenatal care during the first trimester, higher levels of anti-Black prejudice, greater transportation barriers, and increased food insecurity. Given that poor birth outcomes have adverse effects on adults' health and well-being, the findings suggest that in-utero exposure to residential segregation could have important implications for Black-White inequality over the life course.
J Health Econ
· 2024 Jun · PMID 38754342
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We examine whether a friend or older sibling's teen pregnancy impacts one's own sexual behavior. Employing an event study design and rich retrospective data on sexual activity, we find that those who observe a peer's tee...We examine whether a friend or older sibling's teen pregnancy impacts one's own sexual behavior. Employing an event study design and rich retrospective data on sexual activity, we find that those who observe a peer's teen pregnancy change sexual behavior after the pregnancy ends to put themselves at lower risk of their own teen pregnancy; specifically, they are less likely to have unprotected sex and have fewer sexual partners in the year following the end of the teen pregnancy. We find that females are more likely to change their sexual behavior compared to males, and the effects are primarily driven by peer live births, as opposed to other pregnancies. Ultimately, we find a slight decline in the likelihood of one's own teen pregnancy, though estimates are noisy. Our work suggests that education campaigns that provide a realistic portrayal of teen parenthood may be an effective tool for impacting teen behavior.
J Health Econ
· 2024 Jun · PMID 38749331
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We estimate a dynamic structural model of labor supply, retirement, and informal caregiving to study short and long-term costs of informal caregiving in Germany. Incorporating labor market frictions and the German tax an...We estimate a dynamic structural model of labor supply, retirement, and informal caregiving to study short and long-term costs of informal caregiving in Germany. Incorporating labor market frictions and the German tax and benefit system, we find that in the absence of Germany's public long-term insurance scheme, informal elderly care has adverse and persistent effects on labor market outcomes and, thus, negatively affects lifetime earnings and future pension benefits. These consequences of caregiving are heterogeneous and depend on age, previous earnings, and institutional regulations. Policy simulations suggest that while public long-term care insurance policies are fiscally costly and induce negative labor market effects, they can largely offset the personal costs of caregiving and increase welfare, especially for low-income individuals.
J Health Econ
· 2024 May · PMID 38723461
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This paper investigates the influence of gifts - monetary and in-kind payments - from drug firms to US physicians on prescription behavior and drug costs. Using causal models and machine learning, we estimate physicians'...This paper investigates the influence of gifts - monetary and in-kind payments - from drug firms to US physicians on prescription behavior and drug costs. Using causal models and machine learning, we estimate physicians' heterogeneous responses to payments on antidiabetic prescriptions. We find that payments lead to increased prescription of brand drugs, resulting in a cost rise of $23 per dollar value of transfer received. Paid physicians show higher responses when they treat higher proportions of patients receiving a government-funded low-income subsidy that lowers out-of-pocket drug costs. We estimate that introducing a national gift ban would reduce diabetes drug costs by 2%.