Showing papers in "Health Economics in 2008"

The measurement of efficiency and productivity of health care delivery

Abstract: The measurement of efficiency and productivity of health service delivery has become a small industry. This is a review of 317 published papers on frontier efficiency measurement. The techniques used are mainly based on non-parametric data envelopment analysis, but there is increasing use of parametric techniques, such as stochastic frontier analysis. Applications to hospitals and other health care organizations and areas are reviewed and summarised, and some meta-type analysis undertaken. Cautious conclusions are that public provision may be potentially more efficient than private, in certain settings. The paper also considers conceptualizations of efficiency, and points to dangers and opportunities in generating such information. Finally, some criteria for assessing the use and usefulness of efficiency studies are established, with a view to helping both researchers and those assessing whether or not to act upon published results.

Informal and formal care among single-living elderly in Europe

Abstract: The aims of this study were to analyse (1) whether informal care, provided by children or grandchildren to their elderly parents, and formal care are substitutes or complements, and (2) whether this relationship differs across Europe. The analyses were based on cross-sectional data from the newly developed SHARE (Survey of Health, Ageing, and Retirement in Europe) database. We found (1) that informal and formal home care are substitutes, while informal care is a complement to doctor and hospital visits, and (2) that these relationships in some cases differ according to a European north-south gradient. Instrumental variable methods were used and the results highlight the importance of accounting for the endogeneity of informal care.

Does reporting heterogeneity bias the measurement of health disparities

Abstract: Heterogeneity in reporting of health by socio-economic and demographic characteristics potentially biases the measurement of health disparities. We use anchoring vignettes to identify socio-demographic differences in the reporting of health in Indonesia, India and China. Homogeneous reporting by socio-demographic group is rejected and correcting for reporting heterogeneity tends to reduce slightly estimated disparities in health by education (not China) and to increase those by income. But the method does not reveal substantial reporting bias in measures of health disparities.

Coping with health‐care costs: implications for the measurement of catastrophic expenditures and poverty

Abstract: In the absence of formal health insurance, we argue that the strategies households adopt to finance health care have important implications for the measurement and interpretation of how health payments impact on consumption and poverty. Given data on source of finance, we propose to (a) approximate the relative impact of health payments on current consumption with a 'coping'-adjusted health expenditure ratio, (b) uncover poverty that is 'hidden' because total household expenditure is inflated by financial coping strategies and (c) identify poverty that is 'transient' because necessary consumption is temporarily sacrificed to pay for health care. Measures that ignore coping strategies not only overstate the risk to current consumption and exaggerate the scale of catastrophic payments but also overlook the long-run burden of health payments. Nationally representative data from India reveal that coping strategies finance as much as three-quarters of the cost of inpatient care. Payments for inpatient care exceed 10% of total household expenditure for around 30% of hospitalized households but less than 4% sacrifice more than 10% of current consumption to accommodate this spending.Ignoring health payments leads to underestimate poverty by 7-8% points among hospitalized households; 80% of this adjustment is hidden poverty due to coping.

Adolescent depression: diagnosis, treatment, and educational attainment

Abstract: In this paper, I use nationally representative longitudinal data to examine adolescent depression and educational attainment. First, I examine the individual, family, and community-level determinants of adolescent depression, diagnosis, and treatment. I find that male and minority adolescents who score high on depression scales are less likely to be diagnosed as depressed or receive treatment than female and non-Hispanic white adolescents. Additionally, I find several community-level variables to be important determinants of depression, diagnosis, and treatment. Second, I examine the importance of adolescent depression for educational attainment. Although it is uncontroversial to expect a negative relationship, most previous research uses cross-sectional data, making it difficult to adequately determine the magnitude of the effect. I find that depressive symptoms are related to educational attainment along multiple margins: dropping out of high school, college enrollment, and college type. These relationships are only found for adolescent females, and there are several interesting results across income groups. Overall, these findings suggest that further attempts to diagnose and treat adolescents with depressive symptoms are needed and that additional treatment options may be required to combat the important relationship between adolescent depression and human capital accumulation for females.

Explaining the characteristics of the power (CRRA) utility family.

Abstract: The power family, also known as the family of constant relative risk aversion (CRRA), is the most widely used parametric family for fitting utility functions to data. Its characteristics have, however, been little understood, and have led to numerous misunderstandings. This paper explains these characteristics in a manner accessible to a wide audience.

Do nutrition labels improve dietary outcomes

Abstract: The disclosure of nutritional characteristics of most packaged foods became mandatory in the United States with the implementation of the Nutrition Labeling and Education Act (NLEA) in 1994. Under the NLEA regulations, a ‘Nutrition Facts’ panel displays information on nutrients such as calories, total and saturated fats, cholesterol, and sodium in a standardized format. By providing nutrition information in a credible, distinctive, and easy-to-read format, the new label was expected to help consumers choose healthier, more nutritious diets. This paper examines whether the disclosure of nutrition information through the mandatory labels impacted consumer diets. Assessing the dietary effects of labeling is problematic due to the confounding of the label effect with unobserved label user characteristics. This self-selection problem is addressed by exploiting the fact that the NLEA exempts away-from-home foods from mandatory labeling. Difference-in-differences models that account for zero away-from-home intakes suggest that the labels increase fiber and iron intakes of label users compared with label nonusers. In comparison, a model that does not account for self-selection implies significant label effects for all but two of the 13 nutrients that are listed on the label. Published in 2007 by John Wiley & Sons, Ltd.

Hospital ownership and quality of care: what explains the different results in the literature?

Abstract: This systematic review examines what factors explain the diversity of findings regarding hospital ownership and quality. We identified 31 observational studies written in English since 1990 that used multivariate analysis to examine quality of care at nonfederal general acute, short-stay US hospitals. We find that pooled estimates of ownership effects are sensitive to the subset of studies included and the extent of overlap among hospitals analyzed in the underlying studies. Ownership does appear to be systematically related to differences in quality among hospitals in several contexts. Whether studies find for-profit and government-controlled hospitals to have higher mortality rates or rates of adverse events than their nonprofit counterparts depends on data sources, time period, and region covered. Policymakers should be aware of the underlying reasons for conflicting evidence in this literature, and the strengths and weaknesses of meta-analytic synthesis. The 'true' effect of ownership appears to depend on institutional context, including differences across regions, markets, and over time.

Health and labour force participation of older people in Europe: What do objective health indicators add to the analysis?

Abstract: This paper studies labour force participation of older individuals in 11 European countries. The data are drawn from the new Survey of Health, Ageing and Retirement in Europe (SHARE). We examine the value added of objective health indicators in relation to potentially endogenous self-reported health. We approach the endogeneity of self-reported health as an omitted variables problem. In line with the literature on the reliability of self-reported health ambiguous results are obtained. In some countries self-reported health does a fairly good job and controlling for objective health indicators does not add much to the analysis. In other countries, however, the results show that objective health indicators add significantly to the analysis and that self-reported health is endogenous due to omitted objective health indicators. These latter results illustrate the multi-dimensional nature of health and the need to control for objective health indicators when analysing the relation between health status and labour force participation. This makes an instrumental variables approach to deal with the endogeneity of self-reported health less appropriate.

Cost and technical efficiency of German hospitals: does ownership matter?

Abstract: This paper is the first to investigate both the technical and cost efficiency of more than 1500 German general hospitals. More specifically, it deals with the question how hospital efficiency varies with ownership, patient structure, and other exogenous factors, which are neither inputs to nor outputs of the production process. The empirical results for the years from 2001 to 2003 indicate that private and non-profit hospitals are on average less cost efficient and less technically efficient than publicly owned hospitals. The hospital rankings based on estimated efficiency scores turn out to be negatively correlated with average length of stay, which is highest in private hospitals. The results are derived by conducting a Stochastic Frontier Analysis assuming both Cobb-Douglas and translog production technologies and using a newly available and multifaceted administrative German data set.

Valuing reductions in on-the-job illness: 'presenteeism' from managerial and economic perspectives.

Abstract: This paper reports on a study of manager perceptions of the cost to employers of on-the-job employee illness, sometimes termed ‘presenteeism,’ for various types of jobs. Using methods developed previously, the authors analyzed data from a survey of more than 800 US managers to determine the characteristics of various jobs and the relationship of those characteristics to the manager's view of the cost to the firm of absenteeism and presenteeism. Jobs with characteristics that suggest unusually high cost (relative to wages) were similar in terms of their ‘absenteeism multipliers’ and their ‘presenteeism multipliers.’ Jobs with high values of team production, high requirements for timely output, and high difficulties of substitution for absent or impaired workers had significantly higher indicators of cost for both absenteeism and presenteeism, although substitution was somewhat less important for presenteeism. Copyright © 2007 John Wiley & Sons, Ltd.

Healthy, wealthy and insured? The role of self-assessed health in the demand for private health insurance.

Abstract: Both adverse selection and moral hazard models predict a positive relationship between risk and insurance; yet the most common finding in empirical studies of insurance is that of a negative correlation. In this paper, we investigate the relationship between ex ante risk and private health insurance using Australian data. The institutional features of the Australian system make the effects of asymmetric information more readily identifiable than in most other countries. We find a strong positive association between self-assessed health and private health cover. By applying the Lokshin and Ravallion (J. Econ. Behav. Organ 2005; 56:141-172) technique we identify the factors responsible for this result and recover the conventional negative relationship predicted by adverse selection when using more objective indicators of health. Our results also provide support for the hypothesis that self-assessed health captures individual traits not necessarily related to risk of health expenditures, in particular, attitudes towards risk. Specifically, we find that those persons who engage in risk-taking behaviours are simultaneously less likely to be in good health and less likely to buy insurance.

Youth smoking, cigarette prices, and anti-smoking sentiment.

Abstract: In this paper, we develop a new direct measure of state anti-smoking sentiment and merge it with micro-data on youth smoking in 1992 and 2000. The empirical results from the cross-sectional models show two consistent patterns: after controlling for differences in state anti-smoking sentiment, the price of cigarettes has a weak and statistically, insignificant influence on smoking participation, and state anti-smoking sentiment appears to have a potentially important influence on youth smoking participation. The cross-sectional results are corroborated by results from the discrete time hazard models of smoking initiation that include state-fixed effects. However, there is evidence of price-responsiveness in the conditional cigarette demand by youth and young adult smokers. Copyright © 2007 John Wiley & Sons, Ltd.

Genetic information, obesity, and labor market outcomes.

Abstract: SUMMARY Economists have argued that obesity may lead to worse labor market outcomes, especially for women. Empirical methods to test this hypothesis have not thus far adequately controlled for the endogeneity of obesity. We use variation in genotype to predict variation in phenotype (obesity). Genetic information from specific genes linked to obesity in the biomedical literature provides strong exogenous variation in the body mass index and thus can be used as instrumental variables. These genes predict swings in weight of between 5 and 20 pounds for persons between five and six feet tall. We use additional genetic information to control for omitted variables correlated with both obesity and labor market outcomes. We analyzed data from the third wave of the Add Health data set, when respondents are in their mid-twenties. Results from our preferred models show no effect of lagged obesity on the probability of employment or on wages, for either men or women. This paper shows the potential of using genetic information in social sciences. Copyright r 2008 John Wiley & Sons, Ltd. Received 8 October 2007; Revised 23 April 2008; Accepted 29 April 2008

Should the capability approach be applied in Health Economics

Abstract: This editorial questions the implications of the capability approach for health economics. Two specific issues are considered: the evaluative space of capablities (as opposed to health or utility) and the decision-making principle of maximisation. The paper argues that the capability approach can provide a richer evaluative space enabling improved evaluation of many interventions. It also argues that more thought is needed about the decision-making principles both within the capability approach and within health economics more generally. Specifically, researchers should analyse equity-oriented principles such as equalisation and a 'decent minimum' of capability, rather than presuming that the goal must be the maximisation of capability.

Hospital financial condition and the quality of patient care.

Abstract: Concerns about deficiencies in the quality of care delivered in US hospitals grew during a time period when an increasing number of hospitals were experiencing financial problems. Our study examines a six-year longitudinal database of general acute care hospitals in 11 states to assess the relationship between hospital financial condition and quality of care. We evaluate two measures of financial performance: operating margin and a broader profitability measure that encompasses both operating and non-operating sources of income. Our model specification allows for gradual adjustments in quality-enhancing activities and recognizes that current realizations of patient quality may affect future financial performance. Empirical results suggest that there is a relationship between financial performance and quality of care, but not as strong as suggested in earlier research. Overall, our results suggest that deep financial problems that go beyond the patient care side of business may be important to prompting quality problems.

What is the relationship between income inequality and health? Evidence from the BHPS.

Abstract: Income inequality hypotheses propose that income differentials and/or income distributions have a detrimental effect on health. This previously well accepted relationship between inequality and health has recently come under scrutiny; some claim that it is a statistical artefact, arguing that aggregate level data are not sophisticated enough to adequately test for (and discriminate between) their existence. Supporters argue that it is a question of estimating the relationship using, amongst other things, an appropriate geographical scale. This paper adds to the debate by estimating the relationship between income inequality and health using individual panel data, exploring the relationship at the regional as well as the national level, while attempting to discriminate between the competing hypotheses. Pooled, random and fixed effects ordered probit models are exploited to estimate the relationship between self-reported health and household income, income inequality and relative income. While the estimating regressions find support for the absolute income hypothesis, there is no support for the income inequality hypothesis or relative income hypothesis, and as such we argue that there is limited evidence of an effect of income inequality on health within Britain.

Eliciting the demand for long-term care coverage: a discrete choice modelling analysis.

Abstract: We evaluate the demand for long-term care (LTC) insurance prospects in a stated preference context, by means of the results of a choice experiment carried out on a representative sample of the Emilia-Romagna population. In this paper, these methods are first of all used in order to assess the relative importance of the characteristics that define hypothetical insurance programmes and to elicit the willingness to pay for some LTC coverage prospects. Moreover, thanks to the application of a nested logit specification with ‘partial degeneracy’, we are able to model the determinants of the preference for status quo situations where no systematic cover for LTC exists. On the basis of this empirical model, we test for the effects of a series of socio-demographic variables as well as personal and household health-state indicators. Copyright © 2007 John Wiley & Sons, Ltd.

Social capital and its relationship with measures of health status: evidence from the Health Survey for England 2003.

Abstract: Social capital is a concept that attempts to describe the quantity and quality of social interactions in a community. This study explores the relationship between individual measures of social capital and alternative measures of health status within the context of a large national survey of population health. Using data for 13 753 adult participants in the 2003 Health Survey for England, linear regression with weighted least-squares estimation and Tobit regression with upper censoring were used to model the relationship between individual measures of social capital and EQ-5D utility scores. In addition, logistic regression was used to model the relationship between individual measures of social capital and a dichotomous self-reported health status variable. The study demonstrated that low stocks of social capital across the domains of trust and reciprocity, perceived social support and civic participation are significantly associated with poor measures of health status. The implications for health economists and, potentially, for policymakers are discussed. Copyright © 2007 John Wiley & Sons, Ltd.

A comparison of the performance of the EQ-5D and SF-6D for individuals aged >or= 45 years

Abstract: We sought to compare the performance of the EQ-5D and SF-6D with regard to the criteria of practicality, convergent validity, and construct validity, the level of agreement between the two measures was also assessed. Responses from 1865 individuals aged >or= 45 years in one general practice were analysed. Of these, 93.1% completed the EQ-5D, compared with 86.4% for the SF-6D, where individuals who were older, female, of a lower occupational skill level, from an area of lower deprivation, or used prescribed medication were significantly less likely to complete the SF-6D. The performance of both measures was comparable with regard to both convergent and construct validities, as both the EQ-5D and SF-6D scores were closely related to scores on the EuroQol visual analogue scale (VAS) (p<0.001) and able to discriminate between people who did and did not take: (i) analgesics and (ii) other prescribed medication. Despite EQ-5D and SF-6D scores being highly correlated (p<0.001), individuals who were healthier (according to the VAS) had higher mean scores on the EQ-5D (p<0.001), whereas less healthy individuals had higher mean scores on the SF-6D (individuals with knee pain, osteoarthritis, back pain, rheumatoid arthritis, and hip pain had significantly lower mean scores on the EQ-5D, p<0.001).

Variability in healthcare treatment costs amongst nine eu countries - results from the healthbasket project

Abstract: Patient mobility gives rise to some fundamental information requirements, such as the nature of the basket of services offered in the different Member States, how these are defined, how often they are used for particular patients, what their costs are, what prices are paid for them, the quality with which they are delivered, and their cost-effectiveness. This knowledge will enable both Member States and the European Commission to formulate coherent policies on patient mobility in a way that will preserve both the financial viability of existing health systems and the treasured principles of universality, equity and accessibility. Further, if patients are to benefit from the opportunity offered by the European Union’s emerging healthcare market, they too will need to know the nature, quality and costs of services available elsewhere. Finally, international comparison based on good quality data is an important tool for learning from best practice within and between countries. However, international comparisons of service, cost and quality data are currently not routinely available for individual treatments. Up to now, healthcare cost comparisons have been usually made at an aggregate level and variations have been identified at the macro-level, e.g. in purchasing power parities (PPPs) per capita, as a percentage of GDP, distribution of expenditure per sector. Most fundamentally, analysis of international variation in the costs of individual services at the micro-level is difficult because of manifest limitations in the comparability of data. As a result, where cost data for individual treatments have become available, it has usually been unclear whether differences are due to (1) differences in the actual type of service delivered, e.g. in the technologies chosen or the human resources skills mix employed, (2) the intensity with which technologies or personnel are used per treatment episode (e.g. treatment time and length of stay), and (3) differences in input costs (e.g. costs of implant and hourly costs of personnel). The delivery of a seemingly identical service might vary across countries due to variations in (1) the definition of the start and end of a service (e.g. whether rehabilitation following a hip replacement is part of the hospital treatment or seen as a separate service with its own tariff); (2) the technology used (especially regarding the use of innovative and/or expensive technologies, e.g. cemented hip replacement vs costlier uncemented hip replacement); and (3) the accounting treatment of associated services (e.g.

Projections of the costs associated with colorectal cancer care in the United States, 2000-2020.

Abstract: Because of aging trends in the US, the number of prevalent colorectal cancer patients is expected to increase. We projected economic burden to the Medicare program and its beneficiaries through the year 2020. Burden was estimated for the initial phase of care, the period following diagnosis, the last year of life, and the continuing phase. Projected burden was evaluated with varying assumptions about incidence, survival, and costs of care. Estimated costs of care in 2000 in the initial, continuing, and last year of life phases of care were approximately $3.18 billion, $1.68 billion, and $2.63 billion, respectively. By the year 2020 under the 'fixed' current incidence, survival, and cost scenario, projected costs for the initial, continuing, and last year of life phases were $4.75 billion, $2.63 billion, and $4.05 billion. Under the current trends scenario (decreasing incidence, improving survival, and increasing costs), costs were $5.19 billion, $3.57 billion, and $5.27 billion. By the year 2020, estimated costs of colorectal cancer care among individuals aged 65 and older increased by 53% in the fixed scenario and by 89% in the current trends scenario. The future economic burden of colorectal cancer to the Medicare program and its beneficiaries in the US will be substantial.

The adoption of hospital information systems.

Abstract: This paper empirically examines the diffusion of hospital information systems (ISs), specifically, pharmacy, laboratory, and radiology systems. Given the policy significance of health IS and the widespread perception that it's diffusion is slow, a better understanding of the mechanisms driving IS adoption is needed. A novel data set incorporating both IS adoption and hospital characteristics was constructed. These data follow the behavior of 1965 hospitals for the years 1990–2000. Hypotheses pertaining to hospital characteristics, hospital competition, and strategic behavior are tested utilizing proportional hazard models. I find that IS adoption is related to multi-hospital system membership, payer mix, and hospital scale. The role of scale, however, significantly diminishes throughout the time period, likely reflecting improved personal computer performance and improved IT scalability. Conversely, I find little that strategic behavior or hospital competition affects IS adoption. Likewise, hospital ownership does not affect the adoption of these systems. Overall, these results suggest that hospital IS diffusion has not been normatively slow. Copyright © 2007 John Wiley & Sons, Ltd.

Does age or life expectancy better predict health care expenditures

Abstract: It is an unresolved issue whether age or (expected) remaining life years better predicts health care expenditures. We first estimate a set of hazard models to predict life expectancy based on individual demographic characteristics and health conditions, and then use regression analyses to compare the predictive power of age and life expectancy in explaining health care expenditures. This paper differs from previous studies in that it uses predicted life expectancy to address the censoring of death; as a result, this paper goes beyond the large health care expenditures at the end of life and the results apply to both deceased and survivors. We find that age has little additional predictive power on health care expenditures after controlling for life expectancy, but the predictive power of life expectancy itself diminishes as health status measures are introduced into the model. These results are not of esoteric interest only for their statistical properties; we show that using life expectancy rather than age results in lower projections of future health care expenditures. This result suggests that increases in longevity might be less costly than models based on the current age profile of spending would predict. Copyright © 2007 John Wiley & Sons, Ltd.

Equity in health and health care in a decentralised context: evidence from Canada

Abstract: The impact of administrative decentralisation on equity in health and health care is an important unresolved issue in the health policy debate. Predictions from the limited theoretical literature and the relevant empirical research are both insufficient to draw any firm conclusions. Many countries are nevertheless experimenting with decentralisation policies in the absence of research evidence. This paper presents an exploratory empirical analysis of decentralisation by investigating the spatial dimensions of health-related equity in Canada, a highly decentralised setting. Using data from the 2001 Canadian Community Health Survey, we apply a decomposition method of the Concentration Index to explore whether income-related inequalities in health and inequities in the use of health care are more likely to be due to gaps between rich and poor Canadian provinces rather than to differences between rich and poor individuals within them. The results show that within area variation is the most important source of income-related health inequality, while income-related inequities in health care use are mostly driven by differences between provinces.

Health service costs in Europe: cost and reimbursement of primary hip replacement in nine countries

Abstract: This paper assesses variations in the cost of primary hip replacement between and within nine member states of the European Union (EU). It also compares the cost of service with public-payer reimbursements. To do so, data on cost and reimbursement were surveyed at the micro-level in 42 hospitals in Denmark, England, France, Germany, Hungary, Italy, The Netherlands, Poland, and Spain. The total cost of treatment ranged from 1290 euros (Hungary) to 8739 euros (The Netherlands), with a mean cost of 5043 euros (STD +/- 2071 euros). The main cost drivers were found to be implants (34% of total cost on average) and ward costs (20.9% of total cost on average). A one-way random effects analysis of variance model indicated that 74.0% of variation was between and only 26% of variation was within countries. In a two-level random-intercept regression model, purchasing-power parities explained 79.4% of the explainable between-country variation, while the percentage of uncemented implants used and the number of beds explained 12.1 and 1.6% of explainable within-country variation, respectively. The large differences in cost and reimbursement between Poland, Hungary, and the other EU member states shows that primary total hip replacement is a highly relevant case for cross-border care.

Maternal employment and overweight children: does timing matter?

Abstract: Recent literature has shown consistent evidence of a positive relationship between maternal employment and children’s excess body weight. These studies have largely focused on the effect of average weekly work hours over the child’s life on its overweight status. The aim of this paper is to explore the importance of the timing of employment. Timing of maternal absences has been shown to matter for child cognitive and behavioral outcomes. This paper explores whether this timing effect als o exists with respect to children’s excess body weigh t. Data on a nationally representative British birt h cohort are used to examine this, permitting a detai led exploration of the potential endogeneity of mother’s employment. The results show a significant positive correlation between full-time maternal employment during midchildhood and the probability of being overweight a t age 16. There is no evidence that part-time or fu lltime employment at earlier or later ages leads to a higher probability of being overweight at age 16. Subgroup analysis suggests this effect is driven by lower socio-economic groups. Various econometric techniques are used to explore whether employed mothers are systematically different from nonemployed mothers, but there is no evidence that thi s unobserved heterogeneity biases the estimates.

Effects of ownership, subsidization and teaching activities on hospital costs in Switzerland

Abstract: This paper explores the cost structure of Swiss hospitals, focusing on differences due to teaching activities and those across different ownership and subsidization types. A stochastic total cost frontier with a Cobb-Douglas functional form has been estimated for a panel of 150 general hospitals over the six-year period from 1998 and 2003. Inpatient cases adjusted by DRG cost weights and ambulatory revenues are considered as two separate outputs. The adopted econometric specification allows for unobserved heterogeneity across hospitals. The results indicate that the time-invariant unobserved factors could account for considerable cost differences that could be only partly due to inefficiency. The results suggest that teaching activities are an important cost driving factor and hospitals that have a broader range of specialization are relatively more costly. The excess costs of university hospitals can be explained by more extensive teaching activities as well as the relatively high quality of medical units. However, even after controlling for such differences university hospitals have shown a relatively low cost-efficiency especially in the first two or three years of the sample period. The analysis does not provide any evidence of significant efficiency differences across ownership and subsidization categories.

Does free complementary health insurance help the poor to access health care? Evidence from France.

Abstract: The French government introduced a ‘free complementary health insurance plan’ in 2000, which covers most of the out-of-pocket payments faced by the poorest 10% of French residents. This plan was designed to help the non-elderly poor to access health care. To assess the impact of the introduction of the plan on its beneficiaries, we use a longitudinal data set to compare, for the same individual, the evolution of his/her expenditures before-and-after enrolment in the plan. This before-and-after analysis allows us to remove most of the spuriousness due to individual heterogeneity. We also use information on past coverage in a difference-in-difference analysis to evaluate the impact of specific benefits associated with the plan. We attempt at controlling for changes other than enrolment through a difference-in-difference analysis within the eligible (rather than enrolled) population. Our main result is the plan's lack of an overall effect on utilization. This result is likely attributable to the fact that those who were enrolled automatically in the free plan (the majority of enrollees), already benefited from a relatively generous plan. The significant effect among those who enrolled voluntarily in the free plan was likely driven by those with no previous complementary coverage. Copyright © 2007 John Wiley & Sons, Ltd.

Infant mortality and child nutrition in Bangladesh.

Abstract: The excess female infant mortality observed in South Asia has typically been attributed to gender discrimination in the intra-household allocation of food and medical care. However, studies on child nutrition find no evidence of gender differences. A natural explanation could be that in environments of high infant mortality of females, the surviving children are healthier, so that child nutrition cannot be studied independently of mortality. In this paper, we use data from the 2004 Bangladesh Demographic Health Survey to investigate if there are any gender differences in survival probabilities and whether this leads to differences in child nutrition. We argue the importance of establishing whether or not there exists a dependence relationship between the two random variables--infant mortality and child nutrition--and in order to detect this we employ a copula approach to model specification. The results suggest, for example, that while male children have a significantly lower likelihood of surviving their first year relative to female children, should they survive they have significantly better height-for-age Z-scores. From a policy perspective, household wealth and public health interventions such as vaccinations are found to be important predictors of better nutritional outcomes.