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We investigate the effect of the COVID-19 pandemic on self-employed people’s mental health. Using representative longitudinal survey data from Germany, we reveal differential effects by gender: whereas self-employed women experienced a substantial deterioration in their mental health, self-employed men displayed no significant changes up to early 2021. Financial losses are important in explaining these differences. In addition, we find larger mental health responses among self-employed women who were directly affected by government-imposed restrictions and bore an increased childcare burden due to school and daycare closures. We also find that self-employed individuals who are more resilient coped better with the crisis., CEPA Discussion Papers; 46

The focus of this paper is on the trade-off between cost efficiency and access in the choice of the optimal mix of public and private provision in universal health systems. We model a simple health care market in which the regulator acts as a third payer. Patients need one unit of medical service and differ in the severity of illness. A private and a public hospital are available. The private manager internalizes profits, and has an incentive both to refuse to treat costly patients and to exert effort in cost reduction. The public manager does not internalize profits, and has no incentive to reduce costs or to dump costly patients. We show that, when a relatively efficient effort in cost reduction is available, it is optimal to buy part of the services from the private hospital. This may be the case for procedures that are easier to standardize, such as elective surgery. Since the regulator acts as an insurer for the whole population, a public hospital has to be used as a last resort facility. Imposing a no-dumping constraint on the private hospital is not always optimal since eliciting effort and truthful revelation of costs may become more difficult.

Upcoding—manipulation of patient diagnoses in order to game payment systems—has gained significant attention following the introduction of risk adjustment into US insurance markets. We provide new evidence that enrollees in private Medicare plans generate 6% to 16% higher diagnosis-based risk scores than they would generate under fee-for-service Medicare, where diagnoses do not affect payments. Our estimates imply upcoding generates billions of dollars in excess public spending annually and significant consumer choice distortions. We show that coding intensity increases with vertical integration, reflecting a principal-agent problem faced by insurers, who desire more intense coding from the physicians with whom they contract.

Compensating wages for workplace fatality and accident risks are used to infer the value of a statistical life (VSL), which in turn is used to assess the benefits of human health and safety regulations. The estimation of these wage differentials, however, has been plagued by measurement error and omitted variables. This paper employs the first quasi-experimental design within a labor market setting to overcome such limitations in the ex-tant literature. Specifically, randomly assigned, exogenous federal safety inspections are used to instrument for plant-level risks and combined with confidential U.S. Census data on manufacturing employment to estimate the VSL using a difference-in-differences framework. The VSL is estimated to be between $2 and $4 million ($2011), suggesting prior studies may substantially overstate the value workers place on safety, and therefore, the benefits of health and safety regulations.

Several European countries have followed the USA in introducing prospective payment for hospitals with the expectation of achieving cost efficiency gains. This article examines whether theoretical expectations of cost efficiency gains can be empirically confirmed. In contrast to previous studies, the analysis of hospitals in Switzerland provides a comparison of a retrospective per diem payment system with a prospective global budget and a payment per patient case system. Using a sample of approximately 90 public financed Swiss hospitals during the years 2004–2009 and Bayesian inference of a standard and a random parameter frontier model, cost efficiency gains are found, particularly with payment per patient case. Prospective payment, designed to put hospitals at operating risk, is more effective in terms of cost reduction than the retrospective alternative. However, hospitals are heterogeneous with respect to their production technologies, making a random parameter frontier model the superior specification for Switzerland.

We study how people form and revise health risk beliefs based on food safety information. In an online experiment, subjects stated their perceived risk of contracting a foodborne illness before and after receiving information about the population average risk and the eating habits of the average consumer. Precautionary effort in handling and preparing food reduced prior risk beliefs, but did not affect the belief revision process. About one quarter of subjects either fully ignored the information provided or revised their beliefs inconsistently with the Bayesian learning hypothesis. We find several factors related to the subjects’ numerical skills that explain information refusal and inconsistent belief revisions and discuss them in the context of health risks.

We investigate how the economic consequences of the pandemic, and of the government-mandated measures to contain its spread, affect the self-employed – particularly women – in Germany. For our analysis, we use representative, real-time survey data in which respondents were asked about their situation during the COVID-19 pandemic. Our findings indicate that among the self-employed, who generally face a higher likelihood of income losses due to COVID-19 than employees, women are 35% more likely to experience income losses than their male counterparts. Conversely, we do not find a comparable gender gap among employees. Our results further suggest that the gender gap among the self-employed is largely explained by the fact that women disproportionately work in industries that are more severely affected by the COVID-19 pandemic. Our analysis of potential mechanisms reveals that women are significantly more likely to be impacted by government-imposed restrictions, i.e. the regulation of opening hours. We conclude that future policy measures intending to mitigate the consequences of such shocks should account for this considerable variation in economic hardship., CEPA Discussion Papers; 27

Although the elderly are more vulnerable to COVID-19, the empirical evidence suggests that they do not behave more cautiously in the pandemic than younger individuals. This theoretical model argues that some individuals might not comply with the COVID-19 measures to reassure themselves that they are not vulnerable, and that the incentives for such self-signaling can be stronger for the elderly. The results suggest that communication strategies emphasizing the dangers of COVID-19 could backfire and reduce compliance among the elderly.

This chapter summarises the role of EU actions in supporting health care policies in the EU Member States, both looking at implemented actions and describing current priorities for the future. It argues that these coordinated actions can be beneficial for EU Member States by helping them to avoid duplication of effort and to attain economies of scale. Moreover, data sharing with proper safeguards can unleash vast amount of "learning what works" both for medical treatments and for healthcare sustainability measures. The need for this common learning appears ever more urgent while facing the health and economic consequences of the present pandemic.

Labor market policy tools such as training and sanctions are commonly used to help bring workers back to work. By analogy to medical treatments, the individual exposure to these tools may have side effects. We study effects on health using individual-level population registers on labor market events outcomes, drug prescriptions and sickness absence, comparing outcomes before and after exposure to training and sanctions. We find that training improves cardiovascular and mental health and lowers sickness absence. The results suggest that this is not due to improved employment prospects but rather to instantaneous features of participation such as, perhaps, the adoption of a more rigorous daily routine. Unemployment benefits sanctions cause a short-run deterioration of mental health, possibly due higher stress levels, but this tapers out quickly., CEPA Discussion Papers, 22

In this paper we determine the cost of fatalities resulting from road traffic injuries (RTIs) in South Africa. We express the costs in terms of reduced life expectancy and years of potential life lost (YPLL). Our main data source is the Injury Mortality Survey, a retrospective descriptive study carried out in 2009 in South Africa. Using the mortality rates by sex and age from the mortuary data we calculate actual life expectancy at birth. In our counterfactual analysis we assume a reduction of 15% reduction per year in road fatalities for a period of 10 years. A comparison of the estimated actual and counterfactual life expectancies suggests that the average gain in life expectancy at birth would be 0.58 years. Since the overwhelming majority of road traffic fatalities are male (75.7%), there is a considerable gender difference. Men would gain 0.85 years while women would gain 0.30 years in life expectancy, closing the gender gap in life expectancy by about 14%. We then discuss how a reduction in RTIs could be achieved. South Africa’s legislation already covers all important aspects of road safety (e.g. seat belt use, drink driving restrictions, speed limits, infrastructure improvements), however, enforcement is relatively weak and should be improved. There are a raft of measures that have been well researched in other countries, most interventions aim to modify the behaviour of road users and have been found to be cost effective. In addition to stricter enforcement, evidence from social science suggests that compliance could be increased through a change in social norms regarding road usage. published

This paper uses the 1918 influenza pandemic as a natural experiment to examine whether air pollution affects susceptibility to infectious disease. The empirical analysis combines the sharp timing of the pandemic with large cross-city differences in baseline pollution measures based on coal-fired electricity generating capacity for a sample 183 American cities. The findings suggest that air pollution exacerbated the impact of the pandemic. Proximity to World War I military bases and baseline city health conditions also contributed to pandemic severity. The effects of air pollution are quantitatively important. Had coal-fired capacity in above-median cities been reduced to the median level, 3,400-5,860 pandemic-related infant deaths and 15,575-23,686 pandemic-related all-age deaths would have been averted. These results highlight the complementarity between air pollution and infectious disease on health, and suggest that there may be large co-benefits associated with pollution abatement policies.

The Affordable Care Act's taxes, subsidies, and regulations significantly alter terms of trade in both goods and factor markets. We use a multi-sector (intra-national) trade model to predict and quantify consequences of the Affordable Care Act for the incidence of health insurance coverage and patterns of labor usage. If and when the new exchange plans are competitive with employer-sponsored insurance (ESI), our model suggests that more than 20 million people will leave ESI as a consequence of the law. Behavioral changes that are captured in the model could add about 3 million participants to the new exchange plans: beyond those that would participate solely as the result of employer decisions to stop offering coverage and beyond those who would have been uninsured. Industries and regions will grow, decline, and change coverage on the basis of their relative demand for skilled labor.

This study considers the effects of the kingpin strategy, an approach to fighting organized crime in which law-enforcement efforts focus on capturing the leaders of criminal organizations, on community violence in the context of Mexico's drug war. Newly constructed historical data on drug-trafficking organizations' areas of operation at the municipality level and monthly homicide data allow us to control for a rich set of fixed effects and to leverage variation in the timing of kingpin captures to estimate their effects. This analysis indicates that kingpin captures cause large and sustained increases to the homicide rate in the municipality of capture and smaller but significant effects on other municipalities where the kingpin's organization has a presence, supporting the notion that removing kingpins can have destabilizing effects throughout an organization that are accompanied by escalations in violence. We also find reductions in homicides in municipalities surrounding the municipality where kingpins are captured.

This study examines the effect of abolishing user fees from the maternal and child health (MCH) services on child quantity and quality in South Africa in the post-apartheid era. Exploiting exogenous variation in exposure to the policy effect, we find that the policy resulted in lower fertility in households and greater educational attainment of children a decade later. The absence of the effects among children not subject to the policy eliminates channels through heterogeneous preexisting trends or unobserved concurrent changes. The important policy implications are (i) the theoretical predictions of the child quantity-quality tradeoff model characterize reproductive behavior among parents in developing countries; and (ii) MCH policy serves as a motivating force underlying the demographic transition and human capital development.

Increased competition from the Internet has raised a concern of product quality for online prescription drugs. The Food and Drug Administration (FDA) prohibits the importation of unapproved drugs into the US and the National Association of Boards of Pharmacy (NABP) emphasizes their illegality and cites examples of unsafe drugs from rogue pharmacies. An investigation by the Department of Justice (DOJ) revealed that Google was allowing unapproved Canadian pharmacies to advertise on their search engine and target US consumers. Because of heightened concern to protect consumers, Google agreed to ban non-NABP-certified pharmacies from their sponsored search listings in February 2010 and settled with the DOJ in August 2011. We study how the ban on non-NABP-certified pharmacies from sponsored search listings affects consumer search on the Internet.Using click-through data from comScore, we find that non-NABP-certified pharmacies receive fewer clicks after the ban, and this effect is heterogeneous. In particular, pharmacies not certified by the NABP, but certified by other sources (other-certified sites), experience a reduction in total clicks, and some of their lost paid clicks are replaced by organic clicks. These effects do not change significantly after the DOJ settlement. In contrast, pharmacies not certified by any of the four major certification agencies suffer a greater reduction in both paid and organic clicks, and the reduction was exacerbated after the DOJ settlement. These results suggest that the ban has increased the search cost for other-certified sites, but at least some consumers overcome the search cost by switching from paid to organic links. In addition to search cost, the ban may have increased concerns for uncertified sites and discouraged consumers from reaching them via both paid and organic links.

This paper investigates how legal cannabis access affects student performance. Identification comes from an exceptional policy introduced in the city of Maastricht in the Netherlands that discriminated access via licensed cannabis shops based on an individual's nationality. We apply a difference-in-difference approach using administrative panel data on course grades of local students enrolled at Maastricht University before and during the partial cannabis prohibition. We find that the academic performance of students who are no longer legally permitted to buy cannabis substantially increases. Grade improvements are driven by younger students and the effects are stronger for women and low performers. In line with how cannabis consumption affects cognitive functioning, we find that performance gains are larger for courses that require more numerical/mathematical skills. Our investigation of underlying channels using course evaluations suggests that performance gains are driven by an improved understanding of the material rather than changes in students' study effort.

One in twelve Americans suffers from asthma and its annual costs are estimated to exceed $50 billion. Simultaneously, the root causes of the disease remain unknown. A recent hypothesis speculates that maternal vitamin D levels during pregnancy affect the probability the fetus later develops asthma. In two large-scale studies, we test this hypothesis using a natural experiment afforded by historical variation in sunlight, a major source of vitamin D. Specifically, holding the birth location and month fixed, we see how exogenous within-location variation in sunlight across birth years affects the probability of asthma onset. We show that this measurement of sunlight correlates with actual exposure, and consistent with pre-existing results from the fetal development literature, we find substantial and highly significant evidence in both datasets that increased sunlight during the second trimester lowers the subsequent probability of asthma. Our results suggest policies designed to augment vitamin D levels in pregnant women, the large majority of whom are vitamin D insufficient, could be very cost-effective.

Beginning in the mid-2000s, the incidence of drug shortages rose, especially for generic injectable drugs such as anesthetics and chemotherapy treatments. We examine whether reimbursement changes contributed to the shortages, focusing on a reduction in Medicare Part B reimbursement to providers for drugs. We hypothesize that lower reimbursement put downward pressure on manufacturers' prices, which reduced manufacturers' incentives to invest in capacity, reliability, and new launches. We show that after the policy change, shortages rose more for drugs with higher shares of patients insured by Medicare, greater decreases in provider reimbursement, and greater decreases in manufacturer prices. (JEL H51, 118, L1, L65)

Iodine deficiency is the leading cause of preventable mental retardation in the world today. The condition, which was common in the developed world until the introduction of iodized salt in the 1920s, is connected to low iodine levels in the soil and water. We examine the impact of salt iodization on cognitive outcomes in the United States by taking advantage of this natural geographic variation. Salt was iodized over a short period of time beginning in 1924. We use military data collected during World War I and World War II to compare outcomes of cohorts born before and after iodization in localities that were naturally poor and rich in iodine. We find that for the one-quarter of the population most deficient in iodine this intervention raised intelligence quotient (IQ) by approximately one standard deviation. Our results can explain roughly one decade’s worth of the upward trend in IQ in the United States (the Flynn effect). We also document a large increase in thyroid-related deaths following the countrywide adoption of iodized salt, which affected mostly older individuals in localities with high prevalence of iodine deficiency.

There is widespread concern that major cities and their inhabitants are highly vulnerable to transit strikes. Governments in many countries have addressed this concern by limiting the right of transit workers to strike. Whether or not this can be justified depends, in turn, on whether strikes by transit workers implicate the safety or health of urban populations and impose disproportionate costs on non-involved third parties. We use time series and cross-sectional variation in powerful registry data in order to quantify the effects of public transit strikes in five population-relevant domains: traffic volumes, travel times, accident risk, pollution emissions, and health. The context of our study are the five largest cities in Germany, allowing us to exploit 71 public transit strikes over the period from 2002 to 2011. Generalized difference-in-differences models suggest that strikes lead to a significant increase in car traffic, congestion, accident risk and air pollution. There is also evidence for a substantial increase in accident-related injuries and pollution-related health problems. The third party congestion costs of public transit strikes exceed the private costs of struck employers by at least a factor of four.

We study the effect of birth weight on long-run outcomes, including permanent income, income across various stages of the lifecycle, education, social benefits take-up, and adult mortality. For this purpose, we have linked a unique dataset on nearly all Swedish twins born between 1926- 1958, containing information on birth weight, to administrative records spanning nearly entire life time lab or market histories. We find that birth weight positively affects permanent income and income across large parts of the life cycle, although there is some evidence of a fade out after age 50. Our results indicate that lower birth weight children are more likely to avail of social insurance programs such as unemployment and sickness insurance and that birth weight matters for adult mortality. We supplement our main analysis with more recent data, which enables us to study how the impact of birth weight on income and education of young adults has changed across cohorts born almost 50 years apart.

Economists think of medical innovation as a valuable but risky good, producing health benefits but increasing financial risk. This perspective overlooks how innovation can lower physical risks borne by healthy patients facing the prospect of future disease. We present an alternative framework that accounts for all these aspects of value and links them to the value of health insurance. We show that any innovation worth buying reduces overall risk, thereby generating positive insurance value on its own. We conduct two empirical exercises to assess the significance of our insights. First, we calculate that conventional methods underestimate the value of historical health gains by 30-80%. Second, we examine a large set of medical technologies and calculate that insurance value on average adds 100% to the conventional valuation of those treatments. Moreover, we find that the physical risk-reduction value of these technologies is ten times greater than the financial risk they pose and the corresponding value of health insurance that insures this financial risk. Our analysis also suggests standard methods disproportionately undervalue treatments for the most severe illnesses, where physical risk to consumers is most costly.

Purpose The purpose of this paper is to investigate how socioeconomic status and demographic factors were associated with child malnutrition as well as how these factors accounted for socioeconomic inequality of child malnutrition in Bangladesh during 2007-2011. Design/methodology/approach Data of this study come from two cross-sectional rounds (2007 and 2011) of the Bangladesh Demographic and Health Survey. This paper uses ordinary least square models to estimate the correlates of child malnutrition. The study further uses the concentration curve and the concentration index to estimate socioeconomic inequality of child malnutrition in Bangladesh. Finally, the decomposition method is used to explain socioeconomic inequality of child malnutrition in the study period. Findings Regression analysis indicates that child’s age, breast feeding, child’s birth order, the number of under-five child in the household, household wealth and parental education were strongly correlated with child malnutrition in Bangladesh. This study finds that absolute level of child malnourishment slightly decreased between 2007 and 2011, but socioeconomic inequality increased during this period. Children from the poorest household endured the burden of malnourishment more than those from the wealthiest households. The level of inequality also increased among the rural children, although it remained stagnant among the urban children. Decomposition analysis highlights that parental education had a significant negative relation with the average level of malnutrition, but its role was primarily centred among children from wealthier households. Practical implications An approach linking the ministry of health and education with other ministries may speed up the reduction of inequalities in social determinants of childhood undernourishment. Most importantly, there is a need for comprehensive government policies to reduce growing economic inequality and increase the relative income of the poor in Bangladesh. Originality/value This study is the first of its kind to apply the decomposition method to explain the socioeconomic inequality of child malnutrition in Bangladesh. This paper presents an enriched understanding of socioeconomic inequality of child malnutrition in Bangladesh during 2007-2011.

Die Beitragssatzentwicklung in der Gesetzlichen Krankenversicherung (GKV) und der Sozialen Pflegeversicherung (SPV) wird analytisch in einen Demographieeffekt, einen Ausgabenniveaueffekt und einen Einkommenseffekt aufgeteilt. Empirisch zeigt sich, dass der reine Demographieeffekt vor allem mittelfristig in beiden Sozialversicherungszweigen eine bedeutende Rolle spielt. Allerdings ist aufgrund des steileren Verlaufes der Ausgabenprofile die Beitragssatz erhA¶hende Wirkung des Demographieeffektes in der SPV weitaus grA¶AŸer als in der GKV. So wird mittel- und langfristig die Beitragssatzentwicklung der SPV vor allem durch die demographische Entwicklung getrieben, wA¤hrend diese in der GKV nur mittelfristig zu einer VerschA¤rfung der finanziellen Belastung fA¼hrt. In der Krankenversicherung wird der Beitragssatz hauptsA¤chlich vom Ausgabenniveaueffekt determiniert, der in der SPV aufgrund des Teilkaskocharakters mit vorgegebenen Leistungspauschalen eine untergeordnete Rolle spielt. In einem Pauschalbeitragssystem reduziert sich die Wirkung des Demographieeffektes, wA¤hrend die Bedeutung des Ausgabenniveaueffektes unverA¤ndert bleibt und der Einkommenseffekt gA¤nzlich verschwindet. Eine hA¶here FertilitA¤tsrate fA¼hrt aufgrund der zunehmenden Ausgaben fA¼r Kinder kurzfristig zu einem stA¤rkeren Anstieg des Beitragssatzes in der GKV. Bis 2060 wird diese BeitragssatzerhA¶hung allerdings durch die zunehmende Anzahl von Beitragszahlern ausgeglichen, und es kommt zu einer geringen Beitragssatzentlastung.

This study investigates dynamic incentives to select patients for hospitals that are remunerated according to a prospective payment system of the diagnosis-related group (DRG) type. Using a model with patients differing in severity within a DRG, we show that price dynamics depend on the extent of hospital altruism and the relation between patients' severity and benefit. Upwards and downwards price movements over time are both possible. In a steady state, DRG prices are unlikely to give optimal incentives to treat patients. Depending on the level of altruism, too few or too many patients are treated. DRG pricing may also give incentives to treat low-severity patients even though high-severity patients should be treated. Copyright © 2016 John Wiley & Sons, Ltd.

Motivated by current topics in health economics, we apply the theory of salience to consumer policy. If a government intends to encourage healthier diets without harming consumers by raising taxes, it could initiate information campaigns which focus consumers’ attention either on the healthiness of one item or the unhealthiness of the other item. According to our approach, both campaigns work, but it is more efficient to proclaim the unhealthiness of one product in order to present it as a “ bad.” Our findings imply that comparative advertisement is particularly efficient for entrant firms into established markets.

Bans on retail tobacco displays, of the type proposed by New York's Mayor Bloomberg in March 2013, have been operative in several economies since 2001. Despite an enormous number of studies in public health journals using attitudinal data, we can find no population-based econometric studies of the type normally used in Economics. This paper attempts to fill that gap by using data from the annual Canadian Tobacco Use Monitoring Surveys. These data afford an ideal opportunity to study events of this type given that each of Canada's provinces implemented display bans at various points between 2003 and 2009. We use difference-in-differences methods to study three behaviors following the introduction of bans: participation in smoking, the intensity of smoking and quit intentions. A critical element of the study concerns the treatment of contraband tobacco. Our estimates provide little support for the hypothesis that behaviors changed significantly following the bans, although there is evidence that the ban reduced smoking intensity among youth.

In recent years many countries of the European Union (EU) have implemented comprehensive smoking bans to reduce exposure to tobacco smoke in public places and all indoor workplaces. Despite the intense public debate, research on the impact of smoking regulation on health, particularly within the workplace, is still very limited. In this paper, we use a Diff-in-Diff approach and comparable micro-data – for a large number of European countries – to evaluate the impact of national comprehensive smoking bans on both perceived workers' health and presence of respiratory problems within workplaces. Results show that the introduction of comprehensive smoking bans has a significant effect on workers' perceived health, particularly on the probability of exposure to smoke and fumes, also controlling for risk exposure. We also highlight some unintended effects of smoking bans in terms of mental distress, which counteract the positive impact on risk exposure and physical health. The impact across countries is shown to vary with the degree of strictness of the bans.

We study how the optimal public provision of health care depends on whether or not individuals have an option to seek publicly financed treatment in other regions. We find that, relative to the first-best solution, the government has an incentive to over-provide health care to low-income individuals. When cross-border health care takes place, this incentive is solely explained by that over-provision facilitates redistribution. The reason why more health care facilitates redistribution is that high-ability individuals mimicking low-ability individuals benefit the least from health care when health and labor supply are complements. Without cross-border health care, higher demand for health care among high-income individuals also contributes to the over-provision given that high-income individuals do not work considerably less than low-income individuals and that the government cannot discriminate between the income groups by giving them different access to health care.

The standard Medicare Part D drug insurance contract is non-linear—with reduced subsidies in a coverage gap—resulting in a dynamic purchase problem. We consider enrolees who arrived near the gap early in the year and show that they should expect to enter the gap with high probability, implying that, under a benchmark model with neoclassical preferences, the gap should impact them very little. We find that these enrolees have flat spending in a period before the doughnut hole and a large spending drop in the gap, providing evidence against the benchmark model. We structurally estimate behavioural dynamic drug purchase models and find that a price salience model where enrolees do not incorporate future prices into their decision-making at all fits the data best. For a nationally representative sample, full price salience would decrease enrolee spending by 31%. Entirely eliminating the gap would increase insurer spending 27%, compared to 7% for generic-drug-only gap coverage.

An informer sequentially collects and disseminates information through costly research to persuade an evaluator to approve an activity. Payoffs and control rights are split between informer and evaluator depending on the organizational rules governing the approval process. The welfare benchmark corresponds to Wald’s classic solution for a statistician with payoff equal to the sum of informer and evaluator. Organizations with different commitment power of informer and evaluator are compared from a positive and normative perspective. Granting authority to the informer is socially optimal when information acquisition is sufficiently costly. The analysis is applied to the regulatory process for drug approval. (JEL D82, D83, I18, L51, L65, O31)

This article analyzes co-regulation as a policy instrument that makes it possible to achieve synergy between public support and private efforts in the food sector to improve the nutritional quality of the food offer. Our objective is to demonstrate the interest and the limits, as well as the conditions of the efficiency of this instrument, through the empirical analysis of the French voluntary agreements for nutritional improvements (charters) implemented in the framework of the French National Nutrition and Health Program (PNNS). We propose an interpretative model of the policy action on the nutritional quality of the food offer set out in the PNNS and we carry out new indicators of success to assess the efficiency of voluntary agreements in the food sector., Cet article analyse la co-régulation en tant qu’instrument politique permettant de réaliser une synergie entre les initiatives publiques et les efforts privés dans le secteur alimentaire pour améliorer la qualité nutritionnelle de l’offre alimentaire. Notre objectif est de démontrer l’intérêt et les limites, ainsi que les conditions d’efficience de cet instrument, à travers l’analyse empirique des accords volontaires français d’amélioration nutritionnelle (chartes) mis en place dans le cadre du Programme National Nutrition et Santé. (PNNS). Nous proposons un modèle interprétatif de l’action politique sur la qualité nutritionnelle de l’offre alimentaire définie dans le PNNS et nous présentons de nouveaux indicateurs de succès pour évaluer l’efficience des accords volontaires dans le secteur alimentaire.

Healthcare providers’ response to payment incentives may have consequences for both fiscal spending and patient health. This paper studies the effects of a change in the payment scheme for hospitals in Norway. In 2010, payments for patients discharged on the day of admission were substantially decreased, while payments for stays lasting longer than one day were increased. This gave hospitals incentives to shift patients from one-day stays to two-day stays, or to decrease the admission of one-day stays. I study hospital responses by exploiting the variable size of price changes across diagnoses in a difference-in-differences framework. I find no evidence that hospitals respond to price changes, and capacity constraints do not appear to explain this finding. Results imply that the current payment policy yields little scope for policymakers to affect the healthcare spending and treatment choices. Denne artikkelen studerer effektene av en endring i finansieringssystemet for norske sykehus. I 2010 ble sykehusenes kompensasjon for dagbehandling drastisk redusert, mens kompensasjonen for døgnbehandling ble økt. Dette ga sykehusene insentiver til å flytte pasienter fra dagbehandling til døgnbehandling, eller til å redusere antall dagbehandlinger. Slike tilpasninger til økonomiske insentiver kan ha konsekvenser både for offentlige finanser og for pasienters helse. Artikkelen utnytter variasjon mellom diagnosegrupper i størrelsen på marginalgevinsten av å legge inn pasienten for å undersøke om sykehus responderer på insentivendringene. Resultatene viser at sykehus ikke responderer på endringene i insentiver, og det ser ikke ut til at mangel på ledige sengeplasser forklarer hvorfor pasienter ikke flyttes fra dagbehandling til døgnbehandling. Disse funnene indikerer at dagens finansieringsmodell gir lite rom for at økonomiske insentiver kan påvirke behandlingsvalg og ressursbruk i helsetjenesten

In several countries, some healthcare providers combine public service with practice in their own facilities (dual-job practitioners). According to the existing literature, they are viewed as cream-skimming profitable (low-severity) public patients to the benefit of private practice, causing cost of treatment in the public sector to increase. If true, this is particularly problematic when public provider payment is prospective. However, two facts seem to be neglected. First, cream skimming involves effort and thus does not occur in all circumstances. Second, public providers might have an incentive to select patients too, resulting in dumping of the least profitable (high-severity) patients on the private sector. Thus, average cost of treatment in public hospitals does not have to increase, and might even decrease. This paper derives the conditions under which both creaming and dumping are predicted to occur.

We study choice over prescription insurance plans by the elderly using government administrative data to evaluate how these choices evolve over time. We find large “foregone savings” from not choosing the lowest cost plan that has grown over time. We develop a structural framework to decompose the changes in “foregone welfare” from inconsistent choices into choice set changes and choice function changes from a fixed choice set. We find that foregone welfare increases over time due primarily to changes in plan characteristics such as premiums and out-of-pocket costs; we estimate little learning at either the individual or cohort level. (JEL G22, H51, I13, I18, J14)

We study the impact of a Canadian prenatal nutrition program on child health at birth. The objective of the “oeuf-lait-orange” (eggs–milk–oranges) (OLO) program is to reduce the incidence of prematurity and low birth weight by providing a specific food basket and nutritional guidance to pregnant women in situations of poverty. Our identification strategy exploits exogenous variations in access to the program caused by the progressive implementation of the program. Using detailed administrative birth records for over 1.5 million newborns, we find that the program significantly increased the birth weight of treated children by 69.8 g and reduced the probability of low birth weight by 3.6 percentage points. W also find that prematurity decreased by 2.2 percentage points and gestation increased by 1.5 days, but these effects are generally not significant. While the cost of the program is equivalent to the comparable United States Supplemental Nutrition Program for Women, Infants and Children (WIC), the food basket is simpler and the gains on birth weight are larger.

Occupational licensing laws have been relaxed in a large number of U.S. states to give nurse practitioners the ability to perform more tasks without the supervision of medical doctors. We investigate how these regulations may affect wages, employment, costs, and quality of providing certain types of medical services. We find that when only physicians are allowed to prescribe controlled substances that this is associated with a reduction in nurse practitioner wages, and increases in physician wages suggesting some substitution among these occupations. Furthermore, our estimates show that prescription restrictions lead to a reduction in hours worked by nurse practitioners and are associated with increases in physician hours worked. Our analysis of insurance claims data shows that the more rigid regulations increase the price of a well-child medical exam by 3 to 16 %. However, our analysis finds no evidence that the changes in regulatory policy are reflected in outcomes such as infant mortality rates or malpractice premiums. Overall, our results suggest that these more restrictive state licensing practices are associated with changes in wages and employment patterns, and also increase the costs of routine medical care, but do not seem to influence health care quality.

This paper estimates the effects of post-and-hold laws on alcohol consumption and price. Post-and-hold laws require alcohol wholesalers to provide a list of prices to the state, which can be reviewed by retailers, competitors and the public. These laws were generally enacted at the end of prohibition with the intention of limiting alcohol consumption by raising prices. The laws may also have the unintended consequence of protecting small retailers. Recently, several large retailers have argued in court that these laws are counter to the Sherman Act, which limits anti-competitive behavior. This paper follows the recent paper by Cooper and Wright (2012) and adds new data and new statistical tests. Both difference-in–difference models and synthetic control models are employed. The estimation results provide no persuasive evidence of an effect of post-and-hold laws on the consumption of either beer, wine, or spirits. There is also no persuasive evidence that the laws increase the prices of these products. One possible explanation of this null effect is that the wholesale markets for alcohol are so highly regulated that post-and-hold laws have no discernable marginal effect. The empirical results presented in this paper do support alcohol excise taxes as effective means of reducing alcohol consumption.

This paper assesses the long-run toll taken by a large-scale technological disaster on welfare, well-being and mental health. We estimate the causal effect of the 1986 Chernobyl catastrophe after 20 years by linking geographic variation in radioactive fallout to respondents of a nationally representative survey in Ukraine according to their place of residence in 1986. We exclude individuals who were exposed to high levels of radiation—about 4% of the population. Instead, we focus on the remaining majority of Ukrainians who received subclinical radiation doses; we find large and persistent psychological effects of this nuclear disaster. Affected individuals exhibit poorer subjective well-being, higher depression rates and lower subjective survival probabilities; they rely more on governmental transfers as source of subsistence. We estimate the aggregate annual welfare loss at 2–6% of Ukraine's GDP highlighting previously ignored externalities of large-scale catastrophes.

One of the consequences of rapid economic growth and industrialization in the developing world has been deterioration in environmental conditions and air quality. While air pollution is a serious threat to health in most developing countries, environmental regulations are rare and the determination to address the problem is weak due to ongoing pressures to sustain robust economic growth. Under these constraints, natural gas, as a clean, abundant, and highly-efficient source of energy, has emerged as an increasingly attractive source of fuel, which could address some of the environmental and health challenges faced by these countries without undermining their economies. In this paper, we examine the impact of air pollution on infant mortality in Turkey using variation across provinces and over time in the adoption of natural gas as a cleaner fuel. Our results indicate that the expansion of natural gas infrastructure has caused a significant decrease in the rate of infant mortality in Turkey. In particular, a one-percentage point increase in the rate of subscriptions to natural gas services would cause the infant mortality rate to decline by 4 percent, which could result in 348 infant lives saved in 2011 alone. These results are robust to a large number of specifications. Finally, we use supplemental data on total particulate matter and sulfur dioxide to produce direct estimates of the effects of these pollutants on infant mortality using natural gas expansion as an instrument. Our elasticity estimates from the instrumental variable analysis are 1.25 for particulate matter and 0.63 for sulfur dioxide.

We estimate the effect of proximity to two sports facilities in Columbus, OH, on residential property values. Results from a spatial hedonic model indicate that the presence of sports facilities in Columbus have a significant, positive, and distance-decaying effect on surrounding residential housing values, supporting the idea that professional sports facilities generate intangible benefits in the local economy. Ordinary least square (OLS) overestimates the hedonic model parameters compared with maximum likelihood and spatial two-stage least squares, suggesting that spatial autocorrelation plays an important role in this setting.

In light of the shortage of healthcare professionals, many developing countries operate a defacto two-tiered system of healthcare provision, in which Community Health Workers (CHWs) supplement service provision by fully qualified physicians. CHWs are relatively inexpensive to train but can treat only a limited range of medical conditions. This paper explicitly models a two-tiered structure of healthcare provision and characterizes the optimal allocation of resources between training doctors and CHWs, and implications for population health outcomes. We analyze how medical migration alters resource allocation and population health outcomes, shifting resources towards training CHWs. In the model, migration stimulates health care provision at the lower end of the illness severity spectrum, improving health outcomes for those patients; sufferers of relatively severe medical conditions who can only be treated by doctors are made worse off. It is further shown that donor countries must be reimbursed by more than the training cost of emigrating physicians in order to restore aggregate population health to the pre-migration level, assuming that there are increasing marginal costs in involved in replacing migrating physicians.

The consequences of tobacco control policies for individual welfare are difficult to assess, even more so when related consumption choices challenge people's willpower. We therefore evaluate the impact of smoking bans and cigarette prices on subjective well-being by analyzing data for 40 European countries and regions between 1990 and 2011. We exploit the staggered introduction of bans and apply an imputation strategy to study the effect of anti-smoking policies on people with different propensities to smoke. We find that higher cigarette prices reduce the life satisfaction of likely smokers. Overall, smoking bans are barely related to subjective well-being, but increase the life satisfaction of smokers who would like to quit smoking. The latter finding is consistent with cue-triggered models of addiction and the idea of bans as self-control devices.

A substantial economics literature documents that tighter alcohol controls reduce alcohol related harms, but far less is known about mechanisms. We use the universe of Canadian mortality records to document that Canada's Minimum Legal Drinking Age (MLDA) significantly reduces mortality rates of young men but has much smaller effects on women. Using drinking data that are far more detailed than in prior work, we document that the MLDA substantially reduces 'extreme' drinking among men but not women. Our results suggest that alcohol control efforts targeting young adults should focus on reducing extreme drinking behavior.

Regulation fostering Managed Care alternatives in health insurance is spreading. This work reports on an experiment designed to measure the amounts of compensation asked by the Swiss population (in terms of reduced premiums) for Managed-Care type restrictions in the provision of health care. It finds that restrictions on the freedom of physician choice would require an average compensation of more than one-third of the premium, while generic substitution even meets with a small willingness to pay. Marked preference heterogeneity is an argument against regulation imposing uniformity of contract in Swiss social health insurance.

We explore time trends in the labor force participation of veterans and non-veterans and investigate whether they are consistent with a rising role for the Department of Veterans Affairs' Disability Compensation (DC) program, which pays benefits to veterans with service-connected disabilities and has grown rapidly since 2000. Using 35 years of March CPS data, we find that veterans' labor force participation declined over time in a way that coincides closely with DC growth and that veterans have become more sensitive to economic shocks. Our findings suggest that DC program growth has contributed to recent declines in veterans' labor force participation.

As health insurance becomes available outside of the employment relationship as a result of the Affordable Care Act (ACA), the cost of applying for Social Security Disability Insurance (SSDI)—potentially going without health insurance coverage during a waiting period totaling 29 months from disability onset —will decline for many people with employer-sponsored health insurance. At the same time, the value of SSDI and Supplemental Security Income (SSI) participation will decline for individuals who otherwise lacked access to health insurance. We study the 2006 Massachusetts health insurance reform to estimate the potential effects of the ACA on SSDI and SSI applications.

Many severe health risks in developing countries could be substantially reduced with access to appropriate preventive measures. However, the associated costs are often high enough to restrict access among poor households, and free provision through public health campaigns is often not financially feasible. We describe findings from the first large-scale cluster randomized controlled trial in a developing country context that evaluates the uptake of a health-protecting technology, insecticide-treated bednets (ITNs), through micro-consumer loans, as compared to free distribution and control conditions. Numerous studies have shown that widespread, regular use of ITNs is one the most effective preventive measures against malaria. However, ownership rates remain very low in most malarious areas, including our study areas in rural Orissa (India). Despite the un-subsidized price, 52 percent of sample households purchased at least one ITN, leading to 16 percent of individuals using a treated net the previous night, relative to only 2 percent in control areas where nets were not offered for sale. However, the increase fell significantly short of the 47 percent previous-night usage rate achieved with free distribution. Most strikingly, we find that neither micro-loans nor free distribution led to improvements in malaria and anemia prevalence, measured using blood tests. We examine and rule out several plausible explanations for this latter finding. We conjecture that insufficient ITN coverage is the most likely explanation, and discuss implications for public health policy.