Dissertations / Theses on the topic 'Health economics'

In Chapter 1 of this thesis we examine two key empirical questions in public economics by exploiting the 2009 Polish tax reforms. First, we estimate the degree of substitution between employment and self-employment tax bases – on the extensive margin. In particular, we quantify the impact of changes in the differential in rates of taxation between the two tax bases on the propensity of taxpayers to declare any positive level of employment or self-employment income. Second, we contribute to the literature on elasticities of taxable income on the intensive margin – the responsiveness of taxable income to changes in marginal tax rates – by providing estimates which are more likely to be robust to changes in year-to-year income dynamics than previous estimates. To identify these effects, we exploit variation in marginal and total tax rates around the 2009 reforms which occurs independently of an individual’s position in the income distribution as a result of joint reporting with a spouse. At the same time, to obtain the extensive-margin responses, we exploit the uniqueness of the 2009 Polish tax reforms, which left the tax schedule un-changed for some types of self-employment while changing the tax schedule for the employed. The baseline estimates of the intensive-margin elasticities are around 0.2-0.3 for the employed and around 0.5-0.7 for the self-employed. The estimates jointly make possible the decomposition of the deadweight losses of the tax reform into intensive and extensive-margin responses, with the contribution of the extensive margin found to be around 7% of the total. In Chapter 2, we examine the optimal non-linear taxation in an environment in which individuals have the option of engaging in either employment or self-employment activity. We build on the estimates from Chapter 1 to calibrate an extension of the classic Mirrleesian model which allows for extensive-margin transitions between employment and self-employment. The results help rationalise the preferential tax treatment of self-employment income versus employment income given in certain tax systems. They also illustrate the ways in which the possibility of extensive-margin transitions between tax bases moderate the incentive to give such preferential treatment. Based on the parameterisation here, the presence of the extensive-margin ap- pears to have a limited impact on the optimal marginal and total tax rates faced by the employed and self-employed. This, together with the earlier decomposition of deadweight losses in Chapter 1 by types of response, points towards a limited role of the extensive margin as a consideration for optimal-tax design, at least as far as the employment and self-employment tax bases are concerned. Chapter 3 turns to a fundamental question in health economics: how do health states change over the life-cycle, and how does the risk of adverse health-shocks change over the life-cycle? Most economic models of individuals’ behaviour over the life-cycle, to the extent to which they incorporate a measure of health risk, assume a simplified unidimensional measure of health. We contribute to this literature by estimating a flexible dynamic factor model of health and health risk over an individual’s life using the rich health data from the Health and Retirement Study (HRS). We find that the many potentially collinear health indicators found in the HRS can broadly be summarized into four underlying factors. Three of these correspond to what may be termed subjective health measures, such as self-reported mobility, while a fourth corresponds to objective measures, including the number of overnight hospital stays, doctor visits and medical spending. The persistence of these underlying factors and the variance of their shocks are estimated as parameters of a vector auto-regressive process. We obtain results about the deterministic evolution of the health factors with age, the level of risk relating to each health measure, as well as heterogeneity by level of education. These are intended as building blocks of an ongoing project concerning the optimal design of disability insurance, given the health risks faced by individuals.

Thesis (Ph. D.) -- University of Maryland, College Park, 2009.
Thesis research directed by: Dept. of Economics. Title from t.p. of PDF. Includes bibliographical references. Published by UMI Dissertation Services, Ann Arbor, Mich. Also available in paper.

Over the past two decades, a growing body of literature within health economics has provided evidence of the impact of fetal conditions on individual’s health and economic outcomes over the entire life course. This dissertation contributes to the field of health economics by investigating the effects of two distinct types of public policies, antimalarial interventions in sub-Saharan Africa and medical marijuana laws in the United States, on early-life health. Chapter 1 adds to the increased understanding of the impact of in utero exposure to large-scale interventions to combat endemic diseases by examining the effects of antimalarial interventions aimed at preventing and controlling malaria in pregnancy on birth outcomes. Since the year 2000, a coordinated international effort against malaria has led to a significant scale-up of intervention coverage across sub-Saharan Africa. One of the objectives of this undertaking was to improve maternal and early-life health. This chapter investigates the effect of access to malaria prevention and control measures, including insecticide-treated nets, intermittent preventive treatment in pregnancy, indoor residual spraying, and artemisinin-based combination therapy, on birth weight. I exploit the geographic and time variation in the rollout of antimalarial interventions in sub-Saharan Africa across regions with different levels of initial malaria prevalence to analyze 277,245 live births in 22 countries from 2000 to 2013 in a continuous difference-in-differences estimation framework and find that the diffusion of intermittent preventive treatment among pregnant women contributed to the reduction of low birth weight incidence in sub-Saharan Africa. I do not find other antimalarial interventions to be associated with significant improvements in birth outcomes. Chapter 2 provides an investigation focused on examining the impact of medical marijuana laws in the United States on birth outcomes. As of June 2017, medical marijuana laws which liberalize the cultivation, possession, and use of cannabis for allowable medical purposes have been adopted by 29 states and the District of Columbia. The expansion of state-level legislation allowing for medical marijuana use has fueled an ongoing debate regarding drug policy. Despite a growing interest in investigating and quantifying both direct and indirect effects of marijuana liberalization policies, little is known about how they affect early-life health. Using data on the entire universe of births in the U.S. between 1990 and 2013 and a difference-in-differences research design, I find no evidence to support the hypothesis that medical marijuana laws have a negative impact on birth weight and gestation, however I also find that medical marijuana laws are associated with reductions in Apgar scores.

Thesis (Ph. D.)--University of Kentucky, 2007.
Title from document title page (viewed on April 1, 2008). Document formatted into pages; contains: vii, 137 p. : ill. (some col.). Includes abstract and vita. Includes bibliographical references (p. 129-136).

This dissertation explores situational differences in physician behavior based on detailed electronic hospital records, shedding light on previously unobservable determinants of treatment decisions and processes.
Economics

Thesis: Ph. D., Massachusetts Institute of Technology, Department of Economics, 2016.
"June 2016." Cataloged from PDF version of thesis.
Includes bibliographical references (pages 135-144).
The first chapter explores strategic insurer pricing in response to consumer inertia. A growing literature has documented evidence that consumers in health insurance markets are inertial, or behave as though they face substantial switching costs in choosing a health insurance plan. I investigate whether the private firms that provide prescription drug insurance through Medicare Part D exploit this inertia when setting prices. I first document descriptive evidence consistent with insurers initially setting low prices in order to "invest" in future demand before later raising prices to "harvest" inertial consumers. I then apply a two-step estimation approach following Bajari, Benkard and Levin (2007) to explore the implications of these invest and harvest incentives for equilibrium pricing, finding that on net, demand inertia reduces equilibrium prices (i.e. the invest incentive dominates the harvest incentive). Finally, I evaluate welfare consequences of policies that could be used to constrain insurers' ability to conduct such "invest-then-harvest" pricing patterns. I find, for example, that a policy change to cap premium increases would improve consumer welfare by both lowering average premiums and smoothing prices over time. Motivated by prior work on market size spurring innovation, the second chapter (co-authored with Manuel Hermosilla) explores the role of increased downstream demand in facilitating interfirm cooperation in the pharmaceutical industry, where licensing is a common form of collaboration between upstream innovators and downstream commercializers. We propose a simple model of licensing with heterogeneous match quality which predicts that positive demand shocks will increase the likelihood of licensing and improve match quality by reducing the relative importance of transaction costs. We then use the differential impacts of the introduction of Medicare Part D across drug categories 'targeting different ages of consumers as a source of variation in demand, and document empirical evidence consistent with the model. Using US county-level data on physician stock from the Area Resource File, the third chapter is devoted to uncovering and understanding the differential effects of medical schools on the supply of physician across regions. I use a difference-in-difference framework to compare changes in physician supply in areas closer to new medical school entries with regions further away. I find that a new medical school increased the physician supply by one to three times the county average level in the county where the medical school was located, relative to other counties. The broader regional effect was smaller but still substantial - a new medical school increased physician supply by one fourth to two thirds of the sample average in counties within 50 miles, relative to counties farther away. When tracking the effect over time, I find that a new medical school had the same impact in the year of entry and in the following 20 years, which indicates that most of the impacts could be attributed to the immediate responses. I find no effect on the physician supply in most of the pre-entry years, which supports the identifying assumption that locations of new medical schools were not correlated with other underlying determinants of physician supply.
by Yufei Wu.
Supply response to consumer inertia: strategic pricing in Medicare Part D -- Market size and innovation: the intermediary role of technology licensing -- Regional impacts of new medical school entries on the supply of physicians.
Ph. D.

Thesis (Ph. D.)--University of California, San Diego, 2009.
Title from first page of PDF file (viewed June 16, 2009). Available via ProQuest Digital Dissertations. Vita. Includes bibliographical references (p. 101-113).

Le résumé en français n'a pas été communiqué par l'auteur
This thesis investigates several topics in health economics, and each of the three chapters is a self-contained paper. It aims to contribute to the design of health care systems and provides suggestions to policy makers. The first two chapters comes from my job market paper entitled "Reference Dependent Decisions on Noncommunicable Diseases: Prevention, Treatment and Optimal Health Insurance". In Chapter 1, I develop a reference dependent theory that accounts for people’s decisions on their prevention and treatment of noncommunicable diseases. Patients are predicted to have the same willingness to pay for the treatment of NCDs, and to go bankrupt if the willingness to pay exceeds their income.It imposes more realistic assumptions of health decisions, and the reference dependent theory better fits people’s decision patterns regarding NCDs. It also leads to different policy implications regarding the design of social insurance. Chapter 2 is the application of the theory in the design of social health insurance. It investigates how individuals with reference dependent preferences respond to various forms of social insurance. It shows that health insurance with copays can either encourage or discourage prevention, even when the efforts are not observable to the insurance provider. Moreover, deductible insurance is found to be financially unfeasible with ex-post moral hazard. The chapter then derives the analytical results of optimal social health insurance with the presence of ex-ante and ex-post moral hazard. The inverse relationship between income and prevention serves as a justification of redistribution. The third chapter, co-authored with Catarina Goulão, studies the impact of patient mobility on different health care systems that compete using waiting time and price respectively. We use a Hotelling model with two regions with different types of public health care systems to study the impact of patient mobility on their interaction, and on the regional welfare. We first characterize the autarky scenarios where patient mobility is no allowed, and shows that price and waiting time have different welfare impacts on regional welfare. We then explore equilibrium price and waiting time if patient mobility is allowed, and compare with the autarky scenario, and discuss the possible impacts on regional welfare

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Essa tese de doutorado se divide em três artigos. O primeiro artigo tem como objetivo analisar o impacto das restrições ao fumo nos EUA na qualidade dos nascimentos. Por qualidade dos nascimentos entende-se saúde do recém nascido. O segundo artigo estuda o impacto da introdução do divórcio unilateral no peso infantil. E o último artigo se propõe a identificar quais os impactos dos empréstidos do BNDES aos frigoríficos brasileiros para os consumidores finais e produtores primários.

La tesi si concentra su tre diverse problematiche largamente dibattute nell’Economia Sanitaria: la relazione tra obesità e conseguenze sul mercato del lavoro, azzardo morale causato dall’assicurazione sanitaria su comportamenti legati alla salute e la valutazione di un’iniziativa di assistenza per coinvolgere e mantenere in cura individui marginalizzati affetti da HIV. Il primo capitolo, “Wages and Weight in Europe: Evidence using Quantile Regression Model”, studia l’aspetto economico del crescente tasso di obesità in Europa, esaminando la relazione tra obesità e salari utilizzando dati per nove Paesi ottenuti dall’European Community Household Panel (ECHP) nel periodo 1998-2001. L’apporto originale rispetto alla letteratura esistente consiste nell’approccio della Regressione Quantilica per caratterizzare l’impatto eterogeneo dell’obesità su diversi punti della distribuzione salariale. I nostri risultati mostrano che i) l’evidenza ottenuta dalle regressioni sulla media nascondono gran parte dell’eterogeneità poiché la relazione tra obesità e salari differisce tra Paesi e quantili salariali, e ii) aspetti culturali, ambientali o istituzionali non sono in grado di spiegare le differenze tra Paesi, lasciando spazio all’ipotesi di un puro effetto di discriminazione nei confronti degli obesi nel mercato del lavoro. Il secondo capitolo, “Does Health Insurance make you fat?”, esamina se l’assicurazione sanitaria causa azzardo morale nei comportamenti associati al peso corporeo. Le spese per le cure sanitarie tra gli obesi, sono maggiori rispetto a quelle degli individui con peso corporeo regolare, e in assenza di premi assicurativi che tengono conto del rischio, gli individui sono protetti dai maggiori costi per le cure mediche associate all’obesità. Comunque, anche quando i premi dell’assicurazione sanitaria tengono conto del rischio, gli individui possono adottare scelte inefficienti rispetto ai comportamenti alimentari e all’attività fisica che portano all’obesità. In questo capitolo sviluppiamo un semplice modello teorico a due periodi in cui gli individui decidono quante risorse allocare per il consumo, risparmio e cure preventive per caratterizzare le esternalità dell’assicurazione sanitaria e mostriamo come l’effetto di azzardo morale può essere neutralizzato dall’avversione al rischio. Utilizziamo dati dal National Longitudinal Survey of Youth (NLSY) per il periodo 1989-2004 per stimare empiricamente il modello ed esaminare la relazione tra assicurazione sanitaria offerta dal datore di lavoro e peso corporeo, così come la relazione tra assicurazione sanitaria e attività fisica. Troviamo scarsa evidenza empirica per supportare l’esistenza di importanti esternalità in questo mercato, mettendo in discussione l’opportunità di un intervento governativo in risposta ai crescenti tassi di obesità. Il terzo capitolo, “Does Retention in Care Increase Life Expectancy? Cost-Effectiveness Analysis of an Outreach Program”, è un’analisi costi benefici di strategie utilizzate per coinvolgere e mantenere in cura individui marginalizzati affetti da HIV negli Stati Uniti. L’Outreach Initiative (2004-2006), finanziata da Special Programs of National Significance (SPNS) è la principale fonte di dati per questa analisi. Abbiamo sviluppato un modello Markov per predirre le aspettative di vita dei partecipanti al programma basato su cambiamenti sul CD4 count, viral load, AIDS e aderenza a Highly Active Anti-Retroviral Therapy (HAART), avvenuti durante sei mesi di partecipazione al programma. Attraverso dati estrapolati dalla letteratura clinica, confrontiamo questo gruppo di intervento con un ipotetico gruppo di controllo e i nostri risultati mostrano come i partecipanti al programma hanno 1.415 anni di vita attesi in più rispetto ai non partecipanti, tenendo conto della qualità della vita. Incorporando i costi del programma nel modello, otteniamo che ciascun anno addizionale di vita costa $4,718 per individuo. Colmando il vuoto sulla ricerca nell’HIV/AIDS sui costi e gli effetti di lungo periodo degli interventi di assistenza, questo risultato suggerisce che il programma è altamente conveniente, in termini di costi-benefici, secondo i valori definiti dal World Health Organization (WHO) per l’analisi costi-benefici.
The thesis focuses on three different issues largely debated in the literature on health economics: the relationship between obesity and labor market outcomes, the moral hazard on health related behaviours caused by health insurance and the evaluation of an outreach initiative to engage and retain underserved individuals affected by HIV in primary care. The first chapter, “Wages and Weight in Europe: Evidence using Quantile Regression Model” studies the economic side of the increasing rate of obesity by examining the relationship between obesity and wages using data for nine countries from the European Community Household Panel (ECHP) over the period 1998-2001. We improve upon the existing literature by adopting a Quantile Regression approach to characterize the heterogenous impact of obesity at different points of the wage distribution. Our results show that i) the evidence obtained from mean regression and pooled analysis hides a significant amount of heterogeneity as the relationship between obesity and wages differs across countries and wages quantiles and ii) cultural, environmental or institutional settings do not seem to be able to explain differences among countries, leaving room for a pure discriminatory effect hypothesis. The second chapter, “Does Health Insurance make you fat?”, examines whether health insurance causes moral hazard in health behaviors associated with body weight. Health care expenditures among the obese are higher than those of normal weight individuals, and, in the absence of risk-rated premiums, individuals will be shielded from the incremental medical care costs associated with obesity. However, even when health insurance premiums are risk rated, individuals may make inefficient decisions with respect to eating and physical activity that lead to obesity. In this chapter, we develop a simple two period theoretical model of consumption, saving and preventive effort to characterize the health insurance externalities and show how the moral hazard effect can be neutralized by risk aversion. We use data from the National Longitudinal Survey of Youth (NLSY) over the period 1989-2004 to empirically estimate the model and examine the relationship between employer-sponsored health insurance coverage and body weight as well as the relationship between health insurance and physical activity. We find little evidence to support the existence of important externalities in this market, questioning the desirability of government intervention as a response to rising rates of obesity. The third chapter, “Does Retention in Care Increase Life Expectancy? Cost-Effectiveness Analysis of an Outreach Program”, is a cost-effectiveness analysis of strategies used to engage and retain underserved HIV positive individuals in primary care in the US. The Outreach Initiative (2004-2006), funded by the Special Programs of National Significance (SPNS) served as the primary data source for this analysis. We developed a Markov model to predict the life expectancy of program participants based on changes in CD4 count, viral load, AIDS status, and Highly Active Anti-Retroviral Therapy (HAART) adherence that occurred during six months of program participation. Through data extrapolated from clinical literature, we compare this intervention group to a hypothetical control group and found that program participants were predicted to live 1.415 year longer than non-participants, adjusting for quality of life. By incorporating program costs into the model, within the base-case scenario, each additional life-year gained costs $4,718 per person. Filling the void in HIV/AIDS research on costs and long term impacts of outreach interventions, this result suggests that the program is highly cost effective, according to the World Health Organization (WHO) thresholds for cost effectiveness analysis.

In the first chapter we develop a theoretical model investigating food consumption and body weight with a novel assumption regarding human caloric expenditure (i.e. metabolism), in order to investigate why individuals can be rationally trapped in an excessive weight equilibrium and why they struggle to lose weight even when offered incentives for weight-loss. This assumption allows the theoretical model to have multiple equilibria and to provide an explanation for why losing weight is so difficult even in the presence of incentives, without relying on rational addiction, time-inconsistency preferences or bounded rationality. In addition to this result we are able to characterize under which circumstances a temporary incentive can create a persistent weight loss. In the second chapter we investigate the possible contributions that social norms and peer effects had on the spread of obesity. In recent literature peer effects and social norms have been characterized as important pathways for the biological and behavioral spread of body weight, along with decreased food prices and physical activity. We add to this literature by proposing a novel concept of social norm related to what we define as social distortion in weight perception. The theoretical model shows that, in equilibrium, the effect of an increase in peers' weight on i's weight is unrelated to health concerns while it is mainly associated with social concerns. Using regional data from England we prove that such social component is significant in influencing individual weight. In the last chapter we investigate the relationship between body weight and employment probability. Using a semi-parametric regression we show that men and women employment probability do not follow a linear relationship with body mass index (BMI) but rather an inverted U-shaped one, peaking at a BMI way over the clinical threshold for overweight.

In the first chapter we develop a theoretical model investigating food consumption and body weight with a novel assumption regarding human caloric expenditure (i.e. metabolism), in order to investigate why individuals can be rationally trapped in an excessive weight equilibrium and why they struggle to lose weight even when offered incentives for weight-loss. This assumption allows the theoretical model to have multiple equilibria and to provide an explanation for why losing weight is so difficult even in the presence of incentives, without relying on rational addiction, time-inconsistency preferences or bounded rationality. In addition to this result we are able to characterize under which circumstances a temporary incentive can create a persistent weight loss. In the second chapter we investigate the possible contributions that social norms and peer effects had on the spread of obesity. In recent literature peer effects and social norms have been characterized as important pathways for the biological and behavioral spread of body weight, along with decreased food prices and physical activity. We add to this literature by proposing a novel concept of social norm related to what we define as social distortion in weight perception. The theoretical model shows that, in equilibrium, the effect of an increase in peers' weight on i's weight is unrelated to health concerns while it is mainly associated with social concerns. Using regional data from England we prove that such social component is significant in influencing individual weight. In the last chapter we investigate the relationship between body weight and employment probability. Using a semi-parametric regression we show that men and women employment probability do not follow a linear relationship with body mass index (BMI) but rather an inverted U-shaped one, peaking at a BMI way over the clinical threshold for overweight.

Australia has decades of public policy experience attempting to overcome the disparities in health outcomes facing Aboriginal and Torres Strait Islander (Indigenous) Australians. Significant resources have accompanied these policy initiatives, however, Indigenous Australians continue to bear a heavier burden of death, disease, disability and economic hardship than other Australians. Despite the policy experience of Australia and widespread support for initiatives to overcome Indigenous disadvantage, there is little consensus on the best means to actually do so. Working to ensure that available resources are used in their most effective way possible is vital to improving the health of Australia’s Indigenous populations. At its broadest level, health economics is the study of the choices made in the allocation of scarce resources to improve the health status of populations and service delivery. Notwithstanding the political, moral and economic importance of the issue, there remains limited health economic research in the field of Indigenous health nor is there a developed evidence base to provide guidance to policy-makers looking to invest in cost-effective interventions. Further, health economic methods have been criticised as potentially inappropriate for the area of Indigenous health. Current methods for economic evaluation tend to adopt a reductionist approach based on a cost per health outcome paradigm and are potentially insensitive to the outcomes and processes that Indigenous people see to be of value to their health and health care on three broad and related levels. First, Indigenous conceptions of health have been shown to differ from the biomedical notions which tend to underlie the reductionist approach of health economic evaluations. Second, a central tenet of Indigenous health care is community ownership and control of healthcare services. As such there is value associated with how well services achieve engagement with communities which may also be missed through a reductionist health economic approach. Third, social determinants of health have also been demonstrated to be particularly important to the health outcomes of Indigenous Australians but again have tended to lie outside the domain of traditional economic evaluation methods. Potentially because of these and other difficulties, resource allocation decisions in the field of Indigenous health have been made without a strong economic evidence-base and have instead seemingly relied on rights-based arguments promoting investment based on the sizeable need that these communities face. While there is no denying the stark disadvantage facing Australia’s Indigenous populations, such rights-based arguments provide little guidance on how much to invest or on trade-offs between different policy options or individual service components. Further, the weight attributed to such arguments has tended to vary according to the prevailing political climate. Health economic approaches on the other hand, can provide evidence based on value that can transcend politics and lay the foundation for rational priority-setting that maximises the health of target populations. Ignoring the realities of resource scarcity in the sector will not allow policy interventions to maximise the health outcomes for Australia’s Indigenous communities. Health economic methods such as discrete choice experiments (DCEs) and contingent valuation studies have been used to value factors outside of traditional economic evaluations in other fields yet have been largely untested in Australian Indigenous populations. Such techniques potentially represent a direct means through which to incorporate Indigenous values and preferences into the evaluation and design of health programs and ultimately a mechanism for the sector to demonstrate the value and impact that properly designed services can have. There is limited empirical understanding of the role of culturally-specific healthcare providers in terms of the service use patterns of these communities and overcoming the barriers that face Indigenous Australians attempting to access health services. Examining these issues through an economic lens is likely to provide a level of guidance to policy-makers that is currently absent from Indigenous health policy in Australia. This thesis explores these issues through a mixed-methods approach investigating the application and merits of a variety of health economic methods in these populations. Chapter 1 introduces the major issues in the field and provides an overview of the published literature carried out to date. Chapter 2 presents a more detailed investigation of the economic evaluation literature with a systematic review of published economic evaluations investigating health interventions in Indigenous populations around the world. The review finds relatively limited economic evaluation of health care interventions for Indigenous populations in Australia or globally, however, what has been done has demonstrated the potential for cost-effective interventions in these populations. Almost no consideration of alternative conceptions of health or Indigenous-specific values were found through the review. Chapter 3 examines this issue further, investigating the use of health-related quality of life (HRQoL) instruments in these populations, one of the most direct method to incorporate Indigenous conceptions of health into evaluations of health programs, through a systematic review of the use of these instruments in Indigenous populations around the world. The review found that while HRQoL instruments have been used to elicit the quality of life of Indigenous populations their use was relatively limited, as was evidence of the validation of these instruments in these population groups. The evidence that does exist suggests that some Indigenous populations potentially conceptualise these issues fundamentally differently to populations in which these tools have been designed and validated. Chapter 4 discusses the findings of the reviews presented in Chapters 2 and 3 in light of the Australian policy context. The chapter argues that the policy environment has emphasised rights-based rather than economic arguments in resource allocation decisions that has left room for efficiency and equity improvements in the way that resource allocation decisions are made in the field of Indigenous health. Given this, the chapter calls for further work to investigate the service utilisation of Indigenous populations and the role of culturally-specific healthcare providers and incorporate Indigenous values to value programs to improve Indigenous health including through contingent valuation and discrete choice experiment methodologies. Chapter 5 takes up the first of these issues with an analysis of the healthcare expenditure of a cohort of Indigenous and non-Indigenous Australians at high-risk of cardiovascular disease to investigate the relative service utilisation of the two groups. The analysis finds that when individuals are engaged with care providers, culturally-specific providers were providing equivalent care to mainstream providers in non-remote areas and factors other than patient Aboriginality seem to be more important in determining the healthcare expenditure of these high-risk patients. The chapter also highlights problems with current data collections in the field that acts to obscure analysis of service utilisation patterns of Indigenous Australians, particularly in remote areas, and comparisons between the relative service use of Indigenous and non-Indigenous Australians. Chapter 6 further investigates the role of culturally-specific service providers through a DCE attempting to value the cultural component of a fall-prevention service. The chapter presents the findings of a DCE carried out in a cohort of older Aboriginal people receiving a culturally-specific fall-prevention intervention. The chapter demonstrates that DCEs provide a potential means to incorporate the preferences of Indigenous communities into the design and evaluation of health services. A value for the cultural component of the service was derived through the DCE and the relative importance of different barriers to care to the decision-making of the participants were investigated. Chapter 7 presents the findings of a contingent valuation study investigating the value that the Australian community places on holding a driver licence as an example of a social determinant that has been shown to be associated with positive health outcomes in Indigenous populations. The analysis finds contingent valuation techniques can provide a means to value social determinants of health that lie outside traditional health economic evaluations and to value broader policy interventions to improve living standards. Chapter 8 puts forward the main findings of this thesis arguing that the health economics field has an important role to play in improving the health of Australia’s Indigenous populations. Appropriate targeting of available resources is essential to close the gap in health outcomes between Indigenous and non-Indigenous Australians. Economic research is vital to build an evidence-base for policy makers looking to invest in cost-effective policy options and this needs to be based on factors that Indigenous communities consider important to their health and healthcare. Potential for economic evaluation of programs needs to be a key consideration in resource allocation decisions in the field. These need to be robust enough to incorporate the factors that are important to Indigenous Australians. The role of culturally-specific providers needs to be better understood as do the different components that make up such a service. Finally, incorporating social determinants of health into the health policy environment remains crucial in the field of Indigenous health. Given the political, moral and economic importance of overcoming the disparities faced by Australia’s Aboriginal and Torres Strait Islander communities, the relative lack of health economic research in the sector is a failing of the field in Australia. Building an economic evidence base will assist those working in the sector to demonstrate the value of appropriately designed, culturally acceptable healthcare services and decision-makers in the field to move beyond rights-based arguments for funding decisions. Collectively this will enable a system of rational priority-setting in the sector whereby the health impacts derived from scarce resources are maximised.

This dissertation presents three papers applying health economics to the study of risky behaviors. The first uses data from the 1979 National Longitudinal Survey of Youth to examine the relationship between adverse events and risky behaviors among adolescents. Substance use responses to experiencing either of two adverse events--violent crime victimization or death of a non-family member one felt close to--explain 6.7 percent of first cigarette use, and 14.3 percent of first use of illegal drugs other than marijuana. Analyses of exercise, a positive coping mechanism, find shock-responses consistent with a coping-response, but not with rational, time-inconsistent, or non-rational drivers considered here. I conclude that distressing events lead to risky behaviors, with a coping response contributing to this effect.

Dans le premier chapitre, co-écrit avec James Hammitt, nous proposons une relation théorique entre la propension à payer entre la réduction de petits risques de mortalité, la réduction de risques, la probabilité de survivre et le revenu. En plus, nous proposons une valeur de la vie statistique qui prend en compte la qualité des réponses. En utilisant une enquête de préférences déclarées dirigée à un échantillon représentatif de la population française nous explorons de combien et pourquoi les répondants s'éloignent des prédictions de la théorie de l'utilité espérée. On trouve que 40% des répondants se comporte comme la théorie d’utilité espérée prédit. Nos spécifications préférées estiment une valeur statistique de la vie entre 2.2 et 3.4 millions d’euro pour un adulte et 6 millions d’euro pour un enfant. Le deuxième chapitre s'intéresse à l'impact d'une campagne d'information de santé publique en France sur le comportement d'achat des consommateurs. Les motivations économiques derrière l'intervention publique dans le domaine de la santé et la nutrition sont partiellement soutenues par l'idée que les consommateurs ne disposent pas de l'information suffisante pour la prise d'une bonne décision. Dans cet article je prends comme étude de cas les maladies de tubes neurales, une maladie neurologique qui affecte 1 sur 1000 nouveaux née en France chaque année. J'utilise une méthode quasi expérimentale pour mesurer l'impact de la campagne d'information française sur la consommation d'acide folique à l'aide d'une approche réduite. Je combine une base de données très détaillée concernant les achats de nourriture avec une base de données de macro et micro nutriments. La stratégie d'identification consiste à exploiter la variation dans la nécessité de l'information concernant l'acide folique parmi les foyers: ceux qui sont en train de concevoir un bébé ou qui désirent en concevoir l'utilisent, tandis que ceux qui ne sont pas en train de concevoir ne l'utilisent pas. En outre, je fais une estimation structurelle de la demande de nourriture et de nutriments afin de capturer les changements potentiels des préférences qui auraient été causées par l'intervention. Les résultats suggèrent que la campagne d'information a eu un impact positif sur les préférences d'acide folique des foyers en risque et qu'elle a aidé à augmenter la disponibilité d'acide folique dans ces foyers. Finalement, en collaboration avec Jorge Florez-Acosta, nous identifions les coûts d'achat des consommateurs à l'aide d'une approche structurelle en utilisant une base de données des achats de nourriture des foyers français. Les coûts d'achat représentent les coûts réels ou perçus de visiter un nouveau magasin. Nous présentons un modèle de demande pour des magasins et des biens multiples qui représentent le problème d'optimisation du nombre de visite en termes de coûts d'achat individuels. Cette règle détermine si un consommateur visiterait un ou plusieurs magasins durant une période d'achat déterminée. Ensuite, nous estimons les paramètres du modèle et la distribution des coûts d'achat. Nous quantifions les coûts d'achat moyens par magasin visité. Ces coûts ont deux composantes : un coût moyen d'achat fixe et un coût moyen de transport par déplacement. Nous montrons que les consommateurs en capacité de visiter trois ou plus de magasins ont des coûts d'achat inférieurs à zéro, ce qui explique la faible proportion de consommateurs visitant trois ou plus de magasins présents dans notre base de données. Une fois les coûts d'achat sont pris en compte, la théorie montre que des pratiques, supposé, pro-concurrentiel peuvent réduire le bien-être et motiver l'intervention publique. Tels résultats théoriques n'ont toujours pas été testés empiriquement. Cet article représente un premier pas dans cette direction
Le résumé en anglais n'a pas été communiqué par l'auteur

En este trabajo, se aplican herramientas de la Economía Conductual al sector de la salud. En primer lugar, el mercado de Planes Médicos genera una distancia temporal entre la firma del contrato y la prestación de los servicios médicos contratados. Por lo tanto, los consumidores a la hora de decidir firmar un contrato de servicios médicos están obligados a crear previsiones para elegir. Es natural suponer que los consumidores carecen de los conocimientos y sofisticación para predecir con precisión sus necesidades futuras, pues las predicciones de demanda de servicios médicos requieren un considerable nivel de conocimientos y un suficiente acceso a la información. Por lo tanto, las decisiones en este mercado dependen de manera importante de las creencias de los consumidores, sin hablar de la multiplicidad de creencias existente. En el capítulo 2 se estudia dicho mercado cuando los consumidores tienen creencias sesgadas sobre la probabilidad de su estado de salud futuro. Es decir, que sobre o subestiman el riesgo de contraer una enfermedad Se deducen las implicaciones que tienen las creencias sesgada sobre los Planes Médicos públicos y privados. Se encuentra que cuando los consumidores mantienen creencias sesgadas, los proveedores privados pueden capitalizar tales sesgos. Estos sesgos son una de las posibles explicaciones a la contratación de Planes Médicos que proporcionan niveles de tratamiento distintos a los eficientes. Se explora la interacción entre los proveedores de planes públicos y privados. Para ello se derivan los contratos óptimos de un proveedor público y se demuestra que las creencias sesgadas dan lugar a la entrada de proveedores privados, que aprovechan los sesgos para obtener ganancias estrictamente positivas. También se analiza cómo reacciona el proveedor público a la presencia de los proveedores privados. En segundo lugar, se estudia la elección de proveedores de servicios médicos (médicos, hospitales o planes de salud), la cual implica un proceso de recopilación de información y un mecanismo para estimar y evaluar la calidad de dichos proveedores. Estos procesos también están sujetos a sesgos. Específicamente, en el tercer y cuarto capítulo del presente trabajo se analizan las fuentes de información que los clientes utilizan para hacer juicios sobre la calidad de los médicos. Nos centramos en la manera en que esto afecta a la calidad de los médicos. Es decir, en los capítulos 3 y 4 se estudian las elecciones de calidad y precios de doctores que operan en un mercado donde los consumidores basan sus decisiones en anécdotas. Los consumidores se percatan de la existencia de únicamente algunos de los médicos en el mercado y estiman sus habilidades tomando una muestra entre los pacientes anteriores de cada médico. Estas decisiones basadas en anécdotas tienen dos peculiaridades: un exceso de confianza en muestras pequeñas y la limitada disponibilidad de información. Se encuentra que, a mayor disponibilidad de información, mayor diferenciación en calidad y menor el nivel de calidad promedio en el mercado. La aplicación de modelos económicos tradicionales, basados en la maximización de la utilidad por parte de consumidores perfectamente informados ha contribuido grandemente en el diseño e implementación de políticas públicas en el sector salud. Sin embargo, la aplicación de herramientas de la Economía Conductual puede ser fructífera para profundizar en el análisis de sector salud. El presente trabajo es un intento de contribuir con algunas ideas al desarrollo de una comprensión más completa de algunas situaciones en el sector de la salud que se caracterizan, al menos parcialmente, por involucrar sesgos conductuales.
In this work, we apply Behavioral Economic models and tools to the healthcare sector. First, the Health Plan market naturally generates a time gap between the acceptance of the Health Plan contract and the delivery of the contracted services. Therefore, in decisions regarding the signing of Health Plan contracts consumers are required to create forecasts to choose their supplier. It is natural to assume that consumers lack the knowledge and apparatus to accurately predict their future needs for medical services, as predictions of such ilk demand a considerable level of expertise and access to relevant information. Therefore, decisions in this market depend to a large extent on the beliefs hold by consumers. Moreover, consumers are very diverse in terms of such beliefs. In chapter 2 we study the Health Plan market in presence of consumers with biased beliefs on the likelihood of their future health status. That is, they over or underestimate the probability for them to contract a disease. We derive the implications of biased risk-of-disease estimations on the private and public healthcare systems. We find that when consumers hold biased beliefs, private providers can capitalize on such biases. Biased beliefs then become relevant as they could be a reason to offer Health Plan contracts that provide treatment quantities that differ from efficient levels. We explore the interaction that arises between private and public healthcare provision under such circumstances. For this we compute the contracts offered by a public provider and show that the presence of biased beliefs create room for the entrance of private providers, who take advantage of consumers biases to make strictly positive profits. We also analyze how the public provider reacts to the presence of private providers. Second, the choice of medical services providers (physicians, hospitals or Health Plans) involves a process of gathering information and a mechanism for estimating and evaluating the quality of said providers. These processes and mechanisms are also subject to behavioral biases. Specifically, in the third and fourth chapter of the present work we analyze the sources of information that consumers use to make judgments about the quality of physicians. We mainly focus in the manners in which the environment affects the physicians' choice of quality. Namely, in chapters 3 and 4 we study the ability choices and pricing strategies of physicians who operate in a market where consumers base their decisions on anecdotes. The consumers are aware of only some of the physicians in the market and estimate their abilities by taking a sample from the patients a given physician has previously treated. Consumers' decisions based on anecdotal evidence entail two hindrances: an over-reliance on small samples and the limited availability of information. In this setting, situations arise where physicians have incentives to choose low levels of ability even when it is costless. More information availability leads to more ability differentiation and a lower average ability level. The application of traditional economic models relying on rational, utility-maximizing agents with perfect information, has greatly contributed to the design and implementation of public policy in healthcare. Yet, we belief that the application of the tools from Behavioral Economics can be fruitful in further advancing the analysis of healthcare markets and institutions, particularly when one considers the peculiarities inherent to the sector. The present work is an attempt to contribute with some insights that could be helpful in developing a fuller understanding of some situations in the healthcare market which we believe to be shaped, at least partially, by behavioral biases.

Thesis (Ph. D.) -- University of Maryland, College Park, 2009.
Thesis research directed by: Dept. of Economics. Title from t.p. of PDF. Includes bibliographical references. Published by UMI Dissertation Services, Ann Arbor, Mich. Also available in paper.

This thesis consists of three chapters. The first chapter explores the effects of prenatal nutritional deficiency on depression in adulthood. It is well established that maternal behaviour during pregnancy has a lasting effect on the child for years to come. Studies show that in utero nutritional shocks can have prolonged effects on health and labour market outcomes later in life of the offspring. In this paper I investigate whether such nutritional deficiencies during gestation can have an extended impact on mental health in adulthood. Using the fourth wave of Indonesian Family Life Survey (IFLS), I find that Muslim individuals who were potentially exposed to Ramadan in the first and third trimester have significantly higher scores on the depression scale than those who were not exposed. This effect is particularly significant among Muslim males who were exposed in the first trimester and Muslim females who were exposed in the third trimester. Similar effects of exposure are also found on the probability of being depressed in the Muslim population. The absence of such impact of exposure in the non-Muslim population suggests that nutritional deficiencies during the gestation period can have lasting effects on mental health and may increase the possibility of developing depression later in life. Next, the literature on socioeconomic health inequality uses individuals' socioeconomic rank (p) to develop the concentration index. In the second chapter of the thesis, I construct an alternative framework by directly using individuals' income level (y) to rank them and develop stochastic dominance conditions to investigate whether this method leads to the same conclusion as using the socioeconomic ranks (p). Using World Health Survey data for five South Asian countries, I conclude that using the socioeconomic ranks (p) and income levels (y) to rank individuals lead to different results in dominance tests adjusted for different equivalence scales. Lastly, to address the arbitrariness problem of the health concentration index's value caused by assuming the existence of a ratio-scaled variable, Makdissi and Yazbeck (2014) adopted a counting approach to measure health inequality. In the third chapter of the thesis, I apply this counting approach in a two-fold way. Firstly, I estimate the values of population health status and health inequality in United States using the National Health Interview Survey (2010) data. Then, assuming increased government expenditure on health awareness, I simulate the effects such policy interventions and see what improvements in the public health can be achieved. Also, I propose the count-approach incremental cost effectiveness ratio (C-ICER) which is a simple measure to assess the cost effectiveness of public health awareness campaigns.

The correct level of public funding of sexual health services, particularly contraception and abortion (fertility control) remains controversial. As with other services, decision making requires appropriate evidence. This thesis, by reviewing current policy, identified two questions pertinent to decision makers in the English NHS, namely what is the cost and benefit of improving access to abortion and contraception. By critiquing current theory, as illustrated by the National Institute of Health and Clinical Evidence technology appraisal methods, it set out a new theory of evidence quality, defined according to its usefulness in decision making. General recommendations for economic evaluation were then deduced for dealing with uncertainty and measuring benefit, defined as the extent of fulfilment in decision makers' goals. In the empirical part of the thesis firstly, qualitative methods showed the range of measures of benefit, including access and user choice. Secondly, a systematic review of economic evaluations in fertility control showed their inadequacy in addressing the policy questions and made recommendations for economic evaluations specific to fertility control. Two economic evaluations were then conducted to examine the cost and consequences of improved access to contraception and abortion methods according to women's preferences. The first showed that greater choice of contraceptive methods could save up to £500 million over 15 years and reduce the annual number of unintended pregnancies by about 55,000 and annual number of abortions by about 22,000. The second showed that reducing the mean gestational age at abortion by about 9 days could increase the percentage of abortions within 10 weeks and save about £9 million over 15 years. Allowing women to choose medical abortion would produce greater savings. Sensitivity analyses largely supported these findings. Finally, limitations of the theoretical and empirical parts were discussed and recommendations for economic evaluation generally and specific to fertility control made.

High birth weight (also known as macrosomia) is a problem that has as of yet received little attention by health researchers, in particular, health economists. High birth weight is a concern mostly due to the increased difficulties it presents during birth for both the mother and the baby but there is also concern that high birth weight may continue to present negative effects later in the baby’s life. Many factors have been attributed as risk factors for high birth weight including mother’s age, ethnicity, parity, obesity, weight gain during pregnancy, infant gender, and gestation length. However, there is a dearth of careful analysis dedicated to determining the extent of causality of these risk factors where endogeneity concerns are present. In this thesis, I examine various issues surrounding high birth weight. I describe the situation in New Zealand (Chapter 2) to see if our experience with high birth weight reflects that found in international research. I analyse the relationship between socio-economic status and high birth weight (Chapter 3) to explore whether high socio-economic status has a unique effect on high birth weight compared to other health disorders in which it generally helps alleviate the incidence. I further investigate the relationship between obesity and high birth weight (Chapter 4) in an attempt to disentangle the causal effect of obesity on high birth weight risk from the mere correlation that has been well documented. I explore the possibility of vitamin and mineral supplements taken during pregnancy being a risk factor for high birth weight (Chapter 5), then address the potential endogeneity issues to identify a causal impact. Finally, I return to the definition of high birth weight (Chapter 6) and consider the optimal way to define the “problematic” weight threshold and whether this threshold should depend on gestation length or the ethnicity of the mother. My findings suggest that in New Zealand, the incidence of macrosomia varies by the ethnicity and weight group of the mother and the gender of the infant. Socio-economic status does seem to affect high birth weight risk but the nature of the relationship is complex. Obesity only appears to have a significant causal effect on high birth weight risk for women who are morbidly obese, but even for these women conventional estimation that disregards the endogeneity of obesity greatly exaggerates the effect. There does appear to be a correlation between iron supplementation and high birth weight risk but the relationship does not withstand controlling for endogeneity. My findings indicate that the currently accepted threshold used to define macrosomia is justified as it does consistently predict adverse health outcomes. However, flexible definitions which consider different grades of macrosomia or different thresholds for different ethnicities could improve on the current definition.

This dissertation consists of three essays. The first essay examines the unintended consequence of Medicare pay-for-performance programs. I find evidence that the CMS case mix adjustment formula for patient experience measures in the Hospital Value-based Purchasing Program (HVBP) over-corrects (under-corrects) for the effect of patient health status on favorable survey responses for surgical (obstetric) patients, which creates scope for hospital to risk select patients on the basis of health status. Using inpatient discharge data from Pennsylvania and Maryland, I find that average patient severity increased among surgical patients and decreased among obstetric patients after the HVBP took effect. In addition, I find weak evidence of an increase in patient experience measures as a result of the HVBP, but no such effect is found for clinical process measures.

In the second essay, I estimate the short-term effect of depression on labor market outcomes using data from the 2004-2009 Medical Expenditure Panel Survey. After accounting for the endogeneity of depression through a correlated random effects panel data specification, I find that depression reduces the contemporaneous probability of employment by 2.6 percentage points. I do not find evidence of a causal relationship between depression and hourly wages or weekly hours worked. In addition, I examine the effect of depression on work impairment and found that depression increases annual work loss days by about 1.4 days (33 percent), which implies that the annual aggregate productivity loses due to depression range from $700 million to 1.4 billion in 2009 USD.

In the third essay, I investigate the health impacts of unconventional natural gas development of Marcellus shale in Pennsylvania between 2001 and 2013. Through a multivariate regression analysis that compares changes in hospitalization rates over time for air pollution-sensitive disease in counties with unconventional gas wells to changes in hospitalization rates in non-well counties, I find significant associations between shale gas development and hospitalizations for acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), asthma, pneumonia, and upper respiratory infections (URI). These adverse effects on health are consistent with higher levels of air pollution resulting from unconventional natural gas development.

Thesis advisor: Claudia Olivetti
Injuries and violence are a major public health issue and represent a threat to individual wellbeing, productivity, and societal development at large. In recent years, the public health approach to reduce violence and injury has become crucial in guiding research and public policy. Governmental and nongovernmental organizations are strengthening data collection and surveillance systems to promote research and inform policy making. Yet the idea that violence and injuries can be prevented through systematic monitoring and research is still a novel one. The three essays that comprise this dissertation make advancements in this direction focusing on the United States. The first two chapters focus on child safety, examining the issues of bullying and firearm violence at school. The third chapter expands on the topic of gun violence examining the impact of firearm legislation on the broader problem of suicide deaths. From a methodological point of view, this dissertation combines economic models with a public health approach employing both structural estimation techniques and a quasi-experimental approach. While quasi-experimental methods are effective in uncovering broad causal relationships between legislative changes and outcome measures, structural estimation methods are essential when interested in recovering deep preference parameters and performing counterfactual policy analysis. As such, this dissertation represents an example of multidisciplinary work combining Economics and Public Health, and highlights the importance of employing diverse methodologies to uncover crucial behavioral patterns and their policy implications. The first essay, titled Is School Bullying Contagious?, uses a nationwide cross-section of students to uncover peer effects in adolescent bullying behavior at school. Victimization at school has been linked to a number of adverse effects for child development and well-being, including depression, higher drop-out risk, and lower earnings during adulthood. While understanding social interactions in bullying behavior is essential to designing effective policies, previous empirical work has overlooked the impact of classmates’ behavior on the individual inclination for bullying. This essay estimates a structural model of bullying with social interactions where the individual bullying effort depends on the average effort among classmates. The model controls for individual and family characteristics, classmates’ characteristics, as well as classroom unobservable factors. The results present strong evidence of peer effects in a large number of bullying behaviors. Considering a median classroom of 20 students with five bullies, the introduction of a new bully would spawn two additional bullies due to peer influences. This suggests that social interactions can be targeted to reduce the prevalence of bullying. In particular, counter-factual policy experiments indicate that schools may achieve sizable reductions in the number of bullies by spreading them out over classrooms. The second essay, titled Gun Laws and School Safety, is joint with Summer Hawkins and Christopher Baum. Motivated by the documented link between school safety and psychological well-being, this essay examines the impact of state-level gun control on adolescent school safety. The analysis uses data on 926,639 adolescents from 45 states in the 1999-2015 Youth Risk Behavior Surveys. Students self-reported on weapon carrying at school, the number of times they had been threatened or injured with a weapon at school, the number of school days missed due to feeling unsafe, and weapon carrying at any location. For each state and year, 133 gun laws were combined into an index of gun control strength. Difference-in-differences logistic regressions were used to evaluate the impact of stricter gun laws on binary measures of school safety. Each regression controlled for individual and state characteristics, as well as year and state fixed effects. An interquartile-range (IQR) increase in the index (i.e. a 15-point increase corresponding to a strengthening of gun control) was associated with a 0.8 percentage point decrease in the probability of weapon threats at school (p=0.038) and a 1.2 percentage point decrease in the probability of missing school due to feeling unsafe (p=0.004). While we did not find a significant impact of gun laws on weapon carrying at school, an IQR increase in the index was associated with a 2-percentage point decrease in the probability of carrying weapons at any location (p=0.002). Our results suggest that the adoption of stricter state gun laws may improve school climate and subjective perceptions of safety. The third essay, joint with Summer Hawkins and Christopher Baum, is titled Gun Laws and Firearm Suicides. Between 2005 and 2015, suicide rates have been steadily increasing in the US, with firearm suicides representing over half of all suicides and the primary cause of firearm mortality. As such, firearm suicides represent an urgent policy matter and a prompt policy response is required. Using a 10-year-long panel of the 50 states, we investigated whether stricter gun laws may reduce firearm suicides, possibly by reducing firearm availability. As a reduction in firearm availability may simply result in a substitution towards alternative suicide methods, we further explored whether stricter gun laws are associated with an increase in non-firearm suicides. We analyzed 2005-2015 National Vital Statistics System mortality files from the 50 states, with 212,804 firearm suicides and 206,795 non-firearm suicides. We measured the strength of state-level gun control using an index that combines 133 different laws. We conducted difference-in-differences regression models to assess whether changes in the index were associated with changes in the number of firearm and non-firearm suicides. We found that implementing an additional gun law would result in a decrease in the number of firearm-related suicides by 2 to 4 percentage points. In addition, significant interactions between the gun score and demographic characteristics suggest that the effectiveness of stronger gun laws is the highest among individuals age 20 to 49, but seems to be null among black individuals. Although we found no overall association between a stricter gun law environment and non-firearm suicides, stricter gun laws seem to increase non-firearm suicides among white and black individuals, suggesting that additional policy actions are required to prevent suicides in these groups. Our findings are robust to controlling for demographic characteristics, state time-varying characteristics, state and year fixed effects, as well as state-specific time trends. We also provide graphical evidence that trends in suicide rates were not dependent on the level of strength of gun control, supporting the parallel trend assumption and a causal interpretation of our estimates
Thesis (PhD) — Boston College, 2018
Submitted to: Boston College. Graduate School of Arts and Sciences
Discipline: Economics

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Conselho Nacional de Desenvolvimento Científico e Tecnológico
Esta tese estuda três tópicos em economia da saúde usando dados do Brasil. O primeiro ensaio investiga o efeito do baixo peso ao nascer sobre a mortalidade infantil. Entender esta relação é importante para o desenho da política que tem como objetivo reduzir a taxa de mortalidade infantil. Porém, é muito pouco conhecido sobre este tópico em países em desenvolvimento e as estimações de países ricos poderiam pouca validade externa para as economias em desenvolvimento. A estratégia empírica para isolar o efeito do baixo peso de outros determinantes da mortalidade infantil usa variação entre irmãos gêmeos. Os resultados indicam que os bebes que nascem com baixo peso têm maiores taxas de mortalidade no primeiro ano de vida. Estes efeitos são maiores que aqueles de estudos para Estados Unidos e a Noruega. O segundo ensaio fornece as primeiras estimações das externalidades locais do desmatamento na saúde infantil. A queima de floresta libera uma grande variedade de contaminantes, alguns dos quais são conhecidos como perigosos para a saúde. Estimações convencionais dos custos do desmatamento raramente incorporam os efeitos na saúde da poluição gerada pelo desmatamento. Para identificação econométrica, usam-se as grandes e heterogêneas reduções no desmatamento ao longo da Amazônia brasileira gerada por uma política de conservação. Os resultados principais indicam que esta política levou a reduções na incidência do baixo peso ao nascer e a prematuridade. Estes resultados são maiores para meninos. Conjuntamente, estes resultados fornecem justificativas adicionais para controlar o desmatamento. Finalmente, o terceiro ensaio estima o efeito de um aumento na oferta de médicos sobre as hospitalizações em crianças. É uma posição amplamente difundida que gastar recursos em aumentar a disponibilidade de médicos é uma maneira eficaz de melhorar a saúde infantil. Porém, há muito pouca investigação cuidadosa documentando a importância quantitativa dos médicos na saúde das crianças. Este estudo aproveita um aumento drástico no número de médicos induzido pelo programa Mais Médicos para preencher esta lacuna. Os resultados indicam que a introdução desse programa está associado a reduções estatisticamente significantes nas hospitalizações sensíveis à atenção primaria somente em áreas pobres. As estimações indicam que a política levou a uma queda de 4.8 por cento neste tipo de hospitalizações em crianças.
This thesis studies three topics on health economics using Brazilian data. In the first essay, we study the effects of low birth weight on infant mortality. Understanding such a relationship is important for the development of policies aimed at reducing the incidence of infant mortality. However, it is little known about this topic in developing countries and estimates from rich economies may have limited external validity to the developing world. Our empirical strategy to isolate the effect of low birth weight from other determinants of infant mortality exploits within-twin variation. The results indicate that lower birth weight babies exhibit higher rates of mortality within one year of birth. The effects are much larger than those derived from the US and Norwegian context. The second essay provides the first estimates of the local externalities of deforestation in infant health. The burning of forest releases a wide range of contaminants, some of which are known to be hazardous for health. Traditional estimates of the costs of deforestation rarely incorporate the health effects of pollution generated by deforestation. For identification, we use the large and heterogeneous reductions in deforestation across sites in the Brazilian Amazon generated by a conservation policy. The findings suggest that deforestation control policy led to reductions in the incidence of low birth weight and prematurity. This is especially true for boys. Collectively, these results provide additional justification for controlling deforestation. Finally, the third essay estimates the effect of increased supply of physicians on child hospitalizations. It is a widely held position that spending resources on increasing the availability of physicians is an effective way to improve child health. However, there is very little rigorous investigation documenting the quantitative importance of physicians for child health. Our empirical strategy exploits a dramatic increase in the number of physicians generated by the Mais Medico program to fill this gap. The results suggest that program implementation is associated with statistically significant reductions in avoidable, ambulatory sensitive hospitalizations only in poor areas. Our estimates indicate that policy lead to a fall of 4.8 percent in avoidable child hospitalizations. Together, the three essays contribute to a better understanding about vi the causes of poor health in early life using data from Brazilian, a rapidly emerging economy.

Economics
Ph.D.
My dissertation covers three loosely related topics in health and education economics that focus on examining factors that may affect children’s and young adults’ health capital and human capital accumulation. The first essay examines the effect of state-level full parity mental illness law implementation on mental illness among college-aged individuals and human capital accumulation in college. It is important to consider spill-overs to these educational outcomes, as previous research shows that mental illness impedes college performance. I utilize administrative data on completed suicides and grade point average, and survey data on reported mental illness days and decision to drop-out of college between 1998 and 2008 in differences-in-differences (DD) analysis to uncover causal effects of state-level parity laws. Following the passage of a state-level full parity law, I find that the suicide rate reduces, the propensity to report any poor mental health day reduces, college GPA increases, and the propensity to drop out of college does not change. The second essay investigates the effects of family size on child health. This essay is a joint study with Kabir Dasgupta. In this study, we use matched mother-child data from the National Longitudinal Surveys to study the effects of family size on child health. Focusing on excess body weight indicators as children’s health outcome of interest, we examine the effects of exogenous variations in family size generated by twin births and parental preference for mixed sex composition of their children. We find no significant empirical support in favor of the quantity-quality trade-off theory in instrumental variable regression analysis. This result is further substantiated when we make use of the panel aspects of the data to study child health outcomes of arrival of younger siblings at later parities. The third essay estimates the causal effect of being born out of wedlock on a child’s health outcome and early academic achievements. Specifically, the study uses rich panel data from the National Longitudinal Survey of Youth 1979 (NLSY79) and the Children of the NLSY79 (NLSY79-child), coupled with a sibling fixed-effects model to address omitted variable bias attributable to unobserved family characteristics. The study findings suggest that the results from the OLS models have been driven by unobserved family effects, because the significance of the results disappear for the sibling fixed-effects models. Also, due to the large confidence intervals, and the signs changing for some of the regression coefficients, I cannot conclusively state whether being born to a married mother has no significant impact on children’s health and education.
Temple University--Theses

Economics
Ph.D.
This dissertation consists of three essays in health economics. The first chapter estimates changes in sexually transmitted disease rates for young adults in the United States following the Affordable Care Act’s dependent coverage mandate; a provision that allows dependents to remain covered under their parents’ health insurance plans until the age of 26. This study is the first to analyze changes in reported chlamydia and gonorrhea rates resulting from the dependent coverage mandate. Utilizing a difference-in-differences framework coupled with administrative data from the Centers for Disease Control and Prevention, I find that reported chlamydia rates increased for males and females ages 20-24 relative to comparison groups of males and females ages 15-19 and 25-29 following the mandate. I also find evidence of an increase in gonorrhea rates for females in this age group. I find no evidence that the mandate induced ex ante moral hazard. The second chapter estimates the relationship between state-level factors and the passage of electronic cigarette regulation. E-cigarettes are controversial products. They may help addicted smokers to consume nicotine in a less harmful manner or to quit tobacco cigarettes entirely, but these products may also entice youth into smoking. This controversy complicates e-cigarette regulation as any regulation may lead to health improvements for some populations and health declines for other populations. Using data from 2007 to 2016, we examine factors that are plausibly linked with U.S. state e-cigarette regulations. We find that less conservative states are more likely to regulate e-cigarettes and that states with stronger tobacco lobbies are less likely to regulate e-cigarettes. This information can help policymakers as they determine how best to promote public health through regulation. The third chapter estimates the effect of changes in the number of family planning clinics on county-level fertility rates. Results suggest that increasing the number of clinics in a county decreases the fertility rate by .3 percent. These results are likely biased downward due to the inclusion of multiple types of clinics (i.e., fertility and contraceptive).
Temple University--Theses

Il Capitolo 1 focalizza l'attenzione sui problemi di "reporting bias" legati all'indicatore di salute auto-riportato. Questo capitolo mostra che in Europa differenze di genere e differenze regionali possono solo parzialmente essere spiegate dalle differenze nella prevalenza delle varie condizioni croniche. Eppure, una parte non trascurabile di queste differenze è dovuta ad altre cause, che possono includere differenze nel modo in cui lo stato di salute viene riportato. Lo strumento delle "anchoring vignettes" è utilizzato per comprendere se e come le donne e gli uomini che vivono in diverse regioni d'Europa riportano differentemente il livello di salute relativo a vari "domini". L'analisi è basata sulla seconda Release della prima (2004) wave della Survey of Health, Ageing and Retirement in Europe (SHARE). Questa indagine è ideale per lo scopo in quanto contiene informazioni circa misure soggettive dello stato di salute e misure più oggettive (come ospedalizzazione e "grip strength"), come anche informazioni dettagliate circa condizioni croniche. La seconda Release dei dati contiene anche l'uso di "vignettes" in questionari assegnati ad un campione casuale di rispondenti. Le "vignettes" risultano essere utili per identificare differenze regionali e di genere nelle "response scales". Dopo aver corretto queste differenze, le variazioni regionali e di genere nelle stato di salute riportato risultano entrambe ridotte, seppure non del tutto eliminate. I risultati suggeriscono che le differenze nelle "response styles" devono essere prese in considerazione quando si utilizza lo salute auto-riportato in studi socio-economici. Non tenerne conto pu\`o condurre a risultati fuorvianti. Focalizzando l'attenzione su una specifica condizione cronica, l'ipertensione, il Capitolo 2 studia la relazione tra compliance medica e outcome sanitari (ospedalizzazione e mortalità) utilizzando un panel di pazienti che risiedono in un'Autorità Sanitaria Locale italiana. Questi dati consentono di seguire i pazienti attraverso tutti i loro accessi ai servizi sanitari pubblici. I risultati mostrano che gli outcome sanitari migliorano decisamente quando i pazienti sono più "compliant" alla terapia. Inoltre, è possibile inferire importanti informazioni circa il ruolo che il co-payment ha sulla compliance, e di conseguenza sugli outcome sanitari, esplorando due esperimenti naturali verificatisi durante il periodo qui analizzato. I risultati mostrano che il co-payment ha forti effetti sulla compliance, e che questi effetti sono immediati. Il Capitolo 3 estende l'analisi della relazione tra salute e trattamento sanitario fornita nel Capitolo 2. Infatti, considerando la semplice correlazione tra salute e trattamento sanitario non necessariamente fornisce la risposta adeguata, a causa della simultaneità nelle componenti inosservate del deterioramento della salute. In questo capitolo, si utilizza un dataset in cui informazioni molto dettagliate circa il consumo farmaceutico, l'ospedalizzazione e la mortalità sono collezionate nel tempo per un campione di individui affetti da ipertensione. L'ipertensione è una condizione cronica e asintomatica di cui soffre una larga parte della popolazione adulta. Tutte queste variabili sono fortemente dipendenti l'una dall'altra. Per analizzare l'informazione contenuta in tali variabili, viene proposto l'impiego di un modello a fattori dinamico, in cui il trattamento medico e la mortalità siano in principio tutti guidati dallo stato di salute latente. La dinamica viene introdotta nel modello includendo l'effetto del trattamento medico passato sullo stato di salute corrente. Il modello è stimato tramite Massima Verosimiglianza Simulata. Coerentemente con i risultati presenti finora in letteratura, i risultati indicano che una migliore condizione di salute è associata con un minore trattamento medico. Inoltre, il consumo farmaceutico nel periodo precedente ha effetti positivi sullo stato di salute corrente. Questo è consistente con il fatto che non seguire la terapia medica oggi può risultare in una peggiore condizione di salute domani. Nonostante questo, assumere più pastiglie di quanto necessario non migliora ulteriormente la stato di salute. Questi risultati hanno importanti implicazioni in termini di policy. Infatti, i risultati suggeriscono che politiche mirate ad aumentare la consapevolezza delle malattie legate all'ipertensione e l'importanza della cura dell'alta pressione possono aiutare non poco a ridurre i rischi cardiovascolari, e la conseguente ospedalizzazione e mortalità. Ci si attende che questo abbia implicazioni positive sia per la larga parte di popolazione adulta affetta da ipertensione sia per gli stessi Servizi Sanitari Nazionali.
Chapter 1 focuses on the issue of reporting bias in self-rated health. This chapter shows that gender and regional differences in self-rated health in Europe are only partly explained by differences in the prevalence of the various chronic conditions. However, a non-negligible part of these differences is due to other causes, which may include differences in reporting own health. The tool of "anchoring vignettes" is employed to understand whether and how women and men living in different regions differently report levels in a number of health components or domains. The analysis is based on Release~2 of the first (2004) wave of the Survey of Health, Ageing and Retirement in Europe (SHARE). This survey is ideal for the purpose because it contains information on subjective measures of health (such as self-rated health) and more objective measures (such as hospitalization and interviewer-measured grip strength), as well as detailed information on chronic health conditions. Release 2 of the data also includes the use of vignettes in self-administered questionnaires given to a randomly selected subsample of respondents. Vignettes are found to help identifying gender and regional differences in response scales. After correcting for these differences, both gender and regional variation in reported health is substantially reduced, although not entirely eliminated. The results suggest that differences in response styles should be taken into account when using self-assessment of health in socio-economic studies. Failing to do so may lead to misleading conclusions. Focusing on a specific chronic condition, hypertension, Chapter 2 studies the relationship between medical compliance and health outcomes (hospitalization and mortality rates) using a large panel of patients residing in a local health authority in Italy. These data allow to follow individual patients through all their accesses to public health care services until they either die or leave the local health authority. The results show that health outcomes clearly improve when patients become more compliant to drug therapy. At the same time, it is possible to infer valuable information on the role that drug co-payment can have on compliance, and as a consequence on health outcomes, by exploiting the presence of two natural experiments during the period of analysis. The results show that drug co-payment has a strong effect on compliance, and that this effect is immediate. Chapter 3 improves the analysis of the relationship between health and medical care provided in Chapter 2. In fact, looking at the raw correlation between medical care and health cannot be expected to give the right answer, because of simultaneity through the unobservable components of deterioration. In this chapter, it is used a dataset where very detailed information about medical drug use, hospitalization, and mortality, is collected over time for a sample of individuals suffering from hypertension, a chronic asymptomatic pathology affecting a large share of the adult population. All those variables are expected to be strongly dependent on each other. For analysing the amount of information embedded in such variables, a dynamic factor model is proposed, where medical treatments and mortality may all in principle be driven by latent individual stock of health. Dynamics is introduced by including the effects of lagged treatment on latent health. The model is estimated by Maximum Simulated Likelihood (MSL). In line with findings provided so far in the literature, the results indicate that better health is associated to lower medical treatments. In addition, lagged medical drug use is found to have positive effects on current health. This is consistent with the fact that not taking the medication today may result in poorer health tomorrow. Nonetheless, taking more pills than needed cannot improve health. These findings have important policy implications. In fact, the results suggest that policies aimed at improving awareness of hypertensive diseases and the importance of the treatment of high blood pressure may help reduce cardiovascular risks, and consequent hospitalization and mortality. This is expected to have positive implications both for the large share of adult population suffering from hypertension and for the National Health Systems themselves.

The present doctoral thesis is based on three different essays on health economics. Even though the topics differ across the three chapters, they share two main features: i) they are all based on micro analyses and ii) they all aim to explain some specific aspects of the pharmaceutical market. In particular, the first two chapters shed light on the nexus between regulation and drug Innovation, while the third presents an econometric analysis of the demand of production factors in the Italian pharmaceutical industry. It is worth noticing that the first and the third chapter both present an empirical analysis based on novel and ad hoc datasets. The first chapter Pharmaceutical industry, drug quality and regulation. Evidence from US and Italy, co-authored by Vincenzo Atella and Jay Bhattacharya, studies the interactions existing between pharmaceutical companies and regulators and how these interactions affect the quality (i.e. ex post efficacy) of the drug delivered to the market. This contribution is the first attempt, to our knowledge, to provide an empirical assessment of the nexus between regulation and the pairs price, efficacy realized in drug market. In particular, the goal is to analyze the effects on drug price and drug quality of the two most common regulatory regimes in the pharmaceutical market: Minimum Efficacy Standards (MES) and Price Controls (PC). Following Besanko, Donnenfeld, and White [5], we develop a very simple model of adverse selection where a pharmaceutical company can charge different prices to a heterogeneous group of buyers for its (innovative) drug, and we evaluate the properties of the equilibria under the two regimes. We model consumer heterogeneity stemming from differences in the willingness-to-pay for drug quality, measured through ex-post efficacy. The theoretical analysis provides two main results. First, the average drug quality delivered is higher under the MES regime than in the PC regime or a in combination of the two regimes. Second, PC regulation reduces the difference in terms of high-low quality drug prices. The empirical analysis has been conducted on a common sample of drugs available both in Italy and in US. Drug quality has been measured using data from Tufts - New England Medical Center - Cost Effectiveness Analysis Registry that allows to compare cost-effectiveness of a broad range of interventions (among which drugs are the most studied) using standardized cost-utility ratios. Despite its simplicity, the theoretical model produces testable predictions that are corroborated by the empirical analysis. The chapter Information and regulation in drug market explores the trade-off faced by the pharmaceutical firms whether to innovate or not and the related problem of designing a regulatory framework that provides incentives for firms to produce breakthrough drug rather than incremental modifications to the existing pharmaceutical product lines (the so-called me-too drugs). We consider the interaction between the innovative firm and the regulator when the innovative process is assumed to be stochastic. The relationship between the regulated price and the efficacy of the entrant drug is established through a bargaining approach. The model suggests that regulators should apply a value-based approach to pricing in order to relate the price to the incremental therapeutic benefit delivered to patients. In light of this purpose, the regulator should use her bargaining power to penalize the production of me-too drugs and incentivate firm’s innovative effort acknowledging higher prices to more effective drug. Finally, the third chapter How variable is labor input in the Italian manufacturing: the case of the pharmaceutical industry analyzes the labor demand in the Italian manufacturing, using firmlevel data on pharmaceutical industry. The Italian pharmaceutical industry is characterized by the existence of long-term labor contracts, and this fact suggests to consider labor as quasi-fixed input. In order to characterize firms’ behavior we base our analysis on the restricted Generalized Leontief cost function. The choice of this flexible functional form is due to its ability to capture the input substitution patterns in presence of more than one quasi-fixed input. Therefore demand and substitution elasticities are estimated with respect to two different theoretical models: the first, QFI(1), with capital as quasi-fixed input and the second, QFI(2), with two quasi-fixed inputs, capital and labor. The choice among the two alternative specifications is based on an elasticity comparison criterion, since the two models are not nested. Our results confirm the a priori on the labor market rigidity and point out the high heterogeneity between the firms, even controlling for size and nationality.

Choice experiments (CEs) are commonly used in applied economics to value non-market goods or to overcome market imperfections. In a CE, participants are asked to choose between two or more multi-attribute hypothetical descriptions of the good. These stated preferences are then used to estimate the marginal utility of changes in the composition of the good. This PhD thesis aims to contribute to the base of knowledge on the applications of stated preference methods in health economics. The thesis consists of three independent papers. All the studies have in common that they feature a choice experiment. However, regarding content, various policy-relevant questions in health economics are addressed. The first paper investigates heterogeneity in patients’ willingness to wait (WTW) for changes in time and risk attributes of kidney transplantation and examined how heterogeneity in WTW can be mapped with observable characteristics of the patients. Using mixed logit models in WTW-space, we find evidence of heterogeneity in WTW for attributes of kidney transplantation. We demonstrate that younger patients are willing to wait longer for a transplant with the better-expected outcome. Moreover, patients with longer duration of dialysis are willing to wait longer for a better-quality organ. The implication for transplant practice is that accounting patients' preferences in kidney allocation algorithm may improve patients’ satisfaction and the donor-receiver matching process. The second paper explores whether there is a link between cognitive ability, choice consistency, and WTW, using heteroskedastic multinomial logit, generalised multinomial logit models, and the same data set as in the first paper. A higher cognitive ability tended to result in more consistent choices, and consistency resulted in a lower WTW for changes in the multi-attribute content of kidney transplantation. The paper highlighted the importance of incorporating a cognitive ability test in CEs to determine the consistency of choice responses. The third paper investigates whether individuals aggregate multi-attribute information when completing choice tasks in CEs. An existing CE survey concerned with preferences for personalisation of chronic pain self-management programmes in the UK is used to explore attributes aggregation (AA) in multi-attribute choices. We develop a framework in which individuals restructure the multi-attribute information into a meta-attribute (e.g., convert non-monetary attributes into a single quality dimension) before making their decisions. We find evidence of AA when responding to CEs, with the probability of adopting AA greater for homogenous information. AA is more prevalent amongst participants who adopted a quick and click strategy (shorter response time), more likely to occur for later positioned choice tasks (potentially due to fatigue effect), leads to improvements in model fit and has implications for welfare estimates. Our results underline the importance of accounting individuals’ information processing rules when modelling multi-attribute choices.

Three essays form this thesis which addresses the effectiveness of interventions aimed at attaining two health Millennium Development Goals (MDG) set by the United Nations: a 2/3rds reduction by 2015 of 1990 child mortality rates (MDG4) and 3/4th reduction of 1990 maternal mortality rates by the same date (MDG5). The first chapter assesses the relative efficiency of 85 countries at using these interventions for the reduction of child and maternal mortality. It teases out the extent to which mortality reduction is a result of the interventions themselves as opposed to the context in which they are implemented. A three step procedure which includes Data Envelopment Analysis indicates that efficiency is mainly driven by context. Chapter 2 addresses the association between the 2000-2008 rates of change of interventions and the rate of change of mortality. It uses finite mixture modeling to take account of the possibility that there may be underlying heterogeneity in the mortality reduction functions of the 32 sub-Saharan African countries studied. Results support this hypothesis and show that an intervention may exhibit increasing returns to scale in some countries and decreasing returns to scale in others. Chapter 3 assesses the link between interventions and mortality rates and examines cost minimizing scenarios for attaining MDG4 and MDG5 in 27 sub-Saharan African countries. Lagged data on interventions predicts mortality rates (by OLS) to take into account the potential reverse causality between the two. Results indicate that achieving MDG mortality targets at the least possible cost invariably requires very substantive increases in medical human resources, yet training physicians has not been the main objective of public health organizations. Furthermore, improving the context in which interventions are implemented - increasing female literacy or effectiveness of political stability- allows countries to reach mortality targets with substantially lower levels of interventions (including, much lower levels of physician density).

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Economics, 2005.
Includes bibliographical references.
This thesis exploits a major overhaul in the U.S. Department of Veterans Affairs health care system to answer various questions about publicly-provided health care. The VA restructuring involved the adoption of a capitated payment system and treatment methods based on the managed care model. This reorganization was accompanied by a major expansion in the population eligible to receive VA care. Chapter one analyzes both the efficiency of providing public health care in a managed care setting and the effectiveness of expanding coverage to healthier and wealthier populations. I estimate that between 35 and 70 percent of new take-up of VA care was the result of individuals dropping private health insurance. While utilization of services increased, estimates indicate that the policy change did not result in net health improvements. Regions providing more care to healthier, newly-eligible veterans experienced bigger reductions in hospital care and larger increases in outpatient services for previously-eligible veterans. This shift away from specialty care may help to explain the aggregate health declines. Chapter two examines the impact of the introduction of a VA-sponsored drug benefit on Medicare-eligible veterans. Results suggest that a drug benefit does not result in changes in the quantity of drugs consumed, but does lead to an increase in spending and a shift in who pays for the prescriptions. The benefit appears to have a larger effect on lower-income individuals. Results also show suggestive evidence of positive health effects as a result of the drug benefit, an outcome which could be cost-saving in the long run.
(cont.) Chapter three utilizes the change in government health care coverage for veterans to test whether employer-provided insurance leads to inefficiencies in the labor market, and the degree to which such inefficiencies might be alleviated by expanding public health insurance programs. We examine the impact of health care coverage on labor force participation and retirement by comparing veterans and non-veterans before and after the VA expansion. Results indicate that workers are significantly more likely to cease working as a result of becoming eligible for public insurance, and are also more likely to move to part-time work.
by Melissa Ann Boyle.
Ph.D.