The seminar series of the academic year 2021/2022 has been successfully completed, see the program for spring 2022 below. EuHEA would like to thank all speakers, discussants, and chairs for their valuable contributions to the series and the many interesting presentations and discussions. EuHEA would also like to thank the chairs of the Scientific Committee, Rossella Verzulli (University of Bologna) and Pedro Pita Barros (Universidade Nova de Lisboa), as well as all other members of the SC for the coordination of the series.
23 February 2022, 14:30-15:30 (CET)
This paper explores the evolution of inequality of opportunity in the incidence of chronic diseases along the life-cycle and across different birth cohorts for individuals aged 50 or older and living in 14 European countries. We adopt an ex-ante parametric approach and rely on the dissimilarity index as our reference inequality metric. In addition to commonly used set of circumstances, we pay particular attention to the role of adverse early life conditions, such as the experienced harm episodes and the quality of the relationship with parents. In order to quantify the relative importance of each circumstance we apply the Shapley inequality decomposition method. Our results suggest that inequality of opportunity in health is not stable over the life-cycle - it is generally higher at younger ages. Moreover, it varies between different birth cohorts - it results generally higher for younger individuals than for older age groups. Finally, the contribution of adverse early life conditions ranges between 25% and 35%, which is significantly higher than the relative contribution of other demographic and socio-economic circumstances.
2 March 2022, 14:30-15:30 (CET)
Objective: Severe health shocks may affect one’s objective health and subjective health perceptions, but potentially in different ways. Specifically, self-perceived health might revert back to pre-shock levels as individuals adapt to their new health state over time, even when the effects on objective health remain persistent. This difference is important given that individuals make decisions based on these biased subjective health perceptions. We explore how health perceptions, lifestyle behavior, and medication use change after experiencing a negative health shock that persistently affects objective health: an ischemic stroke or an acute myocardial infarction. We shed new light on post-health shock recovery and on the role of health perceptions and choices using a novel combination of detailed administrative and survey data.
Methods: We combined two large Dutch health surveys from 2012 and 2016 with administrative data on hospital admissions, healthcare demand and death records from 1995 to 2018. We identified a sample of 13,000 heart attack and 9,000 stroke patients providing survey responses on subjective outcome measures at different relative time points to their respective health shocks. The resulting repeated cross-section of heart attack/stroke patients is interviewed between 6 years prior and 7 years after their event. We use a doubly robust event-study approach that exploits the exogenous timing of the occurrence of these shocks to explore the causal effects of heart attacks and strokes on subjective outcome measures, risky health behaviors, and medication use over time.
Results: A heart attack or stroke has large immediate negative effects on subjective health perceptions as self-assessed health decreases substantially by one-third of a standard deviation in the year after a heart attack or stroke occurs. Despite these substantial initial differences, the effects attenuate quickly. While individuals experience an increased objective burden of disease over time, reflected in an increasing prevalence of long-term physical disability, their self-assessed health reverses towards pre-shock levels. Further we observe heterogenous impacts on a range of (risky) health behaviors with both health shocks leading to long-term decreased smoking prevalence of around 10-15 percentage points but only temporary decreases in alcohol consumption and no change in overweight rates or physical activity.
Discussion: Our findings suggest that even after a severe health shock like a heart attack or a stroke, individuals health perceptions return to pre-shock levels within a short period of time, despite an increasing burden of disease observed. Our results on health behaviors confirm previous studies that find smoking behavior to be consistently affected by a health shock. In line with the temporary effect on subjective health, we find that most effects on lifestyle behaviors are short-lasting. Only for smoking we observe a permanent decrease. In ongoing work, we aim to extend our analyses to the health perceptions and behaviors of cohabiting family members and to explore whether the observed pattern of adapted health perceptions also influence economic behaviors such as the decision to retire or rejoin the labor force, individuals’ choice of health insurance deductibles or adherence to prescription medicine.
9 March 2022, 14:30-15:30 (CET)
In 2016 the UK government imposed a new national contract on NHS Junior Doc- tors, involving an increase in the basic salary but also more weekend working paid at the standard weekday rate. This paper studies how the introduction of the 2016 Junior Doctor Contract (JDC) affected the retention of Junior Doctors within the English NHS, by implementing a Difference-in-Difference (DiD) analysis with heterogeneous treatment intensity. We construct a predetermined and continuous measure of individual exposure to treatment, based on the remuneration for unsocial work earned by Trust-level Foundation Doctors. This approach identifies Junior Doctors that rotated across Trusts where unsocial work was more common and that reasonably felt more penalized by the new contractual terms. We find that a one-standard-deviation increase in the ratio between unsocial supplement pay and basic salary was associated with a 0.11% increase in the monthly probability of leaving the NHS, equivalently to about 8.8% of all Junior Doctors leaving the NHS over a year. Furthermore, we show that specialties in which weekend working is more frequent (e.g. A&E, Surgery) experienced a greater loss of trainees compared to those in which much of the work takes place over a 5-day week (e.g. Pathology, Psychiatry). These findings highlight the importance of working conditions and contractual agreements for the progression in the medical career and the retention of healthcare workers.
16 March 2022, 14:30-15:30 (CET)
For years, diagnosis and treatment for gestational diabetes mellitus (GDM) has been an unresolved question. Current guidelines have established diagnosis and treatment standards, but the question remains on the potential impacts on child development via in-utero exposure to diabetes medications. We use uniquely rich data from the Born-in-Bradford cohort study, in which all pregnant women underwent universal screening for GDM based on clear thresholds over oral glucose tolerance tests (OGTT), rather than using pre-existing conditions as a screening criterion (as it is the standard practice in England and elsewhere). To evaluate the effects of GDM treatment, we use the OGTT cutoff within a sharp regression discontinuity design, so we compare children from pregnancies with a positive and negative GDM diagnosis near the cutoff. We find that diagnosis and subsequent treatment of GDM resulted in improved outcomes at birth, in particular a significant reduction in the odds of being a macrosomic newborn. We also detect child BMI differences postnatally, but these fade out after 3 years of age; additionally, at five years of age, children of mothers diagnosed with GDM in pregnancy have reduced blood pressure. At age five, however, children of non-diagnosed mothers outperform those of GDM mothers in the Early Years Foundation Stage Profiles standardised test, a nationally-administered measure of school readiness. Hence, we confirm that treatment for GDM, as shown in the medical literature, improves outcomes of children at birth. However, we present for the first time evidence of potential adverse outcomes of treating GDM on children academic achievement five years later. Therefore, studies on long-run consequences of these GDM treatments on child development are urgently required.
23 March 2022, 14:30-15:30 (CET)
We evaluate the short- and long-term effects for women of access to legal, subsidized abortion. We find evidence that the legalization of abortion in Spain in 1985 led to an immediate decrease in births, more pronounced for younger women in provinces with a higher supply of abortion services. Affected women were more likely to graduate from high school, less likely to marry young, less likely to divorce in the long-term, and reported higher life satisfaction as adults. We do not find negative effects on completed fertility, nor do we find significant effects on labor market outcomes in the long run.
30 March 2022, 14:30-15:30 (CET)
Our theoretical growth model studies the complex patterns of income and obesity, accounting for changes in behavior related to exercise. By combining Becker’s (1965) theory of time allocation with Veblen’s (1899) theory of conspicuous leisure, our model determines conditions for a static and a dynamic Kuznets curve for obesity. Both curves result from the interaction between the rising opportunity cost of exercise and peer effects. Both effects rise with income, whether we consider income cross-sections, or economic development over time. Focusing on calorie expenditure, we shed light on mechanisms explaining the rise and slowdown in obesity prevalence in the USA, and the correlation between obesity and income per worker (positive in developing countries and negative in industrialized countries). Our numerical simulations indicate that exercise choices have slowed down the rise in obesity prevalence, but do not generate a dynamic Kuznets curve in the USA. Peer effects would need to be larger than empirically observed for a dynamic Kuznets curve to occur. By contrast, we find a static Kuznets curve, which peak corresponds to a per worker capital stock 25% higher than its current average level, and an average weight of 187 pounds. We discuss policy implications of our findings.
6 April 2022, 14:30-15:30 (CET)
We study physicians’ migration intentions and relative preferences for various job characteristics by undertaking a Discrete Choice Experiment with medical students at Italian Universities. Using a mixed logit model, we estimate students’ willingness to pay for various job characteristics and find that not only are they willing to sacrifice a significant portion of their yearly salaries for desirable job features but also that they are willing to pay significantly more for them in order to stay in Italy. This emphasizes the importance of better job designing by policy makers in order to retain doctors in Italy in the presence of a huge brain drain of doctors over the past years. We also find significant heterogeneities in the likelihood of emigrating on the basis of observable non-cognitive characteristics. Specifically, we find that students with higher willingness to take risks and higher levels of altruism are more predisposed to leaving their home countries. This result has implications for the quality of the pool of doctors leaving Italy and those left behind.
13 April 2022, 14:30-15:30 (CET)
The diffusion of generic drugs is of great importance in reducing healthcare costs. Using the universe of statins prescriptions data in Finland, this paper constructs physician networks connected through patients and examines the effect of patient- sharing network on the prescription of generic versus branded drugs. When a patient moves from one physician to another, two physicians are connected as peers and pa- tients transmit information between physicians. The results show that a physician’s likelihood of prescribing generic drugs is not influenced by the behaviours of peers when the information channel of new patients is considered. The empirical evidence suggests that patients can be a valuable channel for knowledge transfer between physicians. Physicians are more likely to prescribe generic drugs when they treat more new patients, conditional on patient, physician, and drug characteristics. The effects are stronger if the new patients come from peers comparing to those new to the patient population.
20 April 2022, 14:30-15:30 (CET)
This paper is the first empirical analysis to assess the effect of health insurance premium changes on labour markets in the context of a developing country. In 2011, the government of Rwanda implemented a health insurance premium policy change that increased insurance premiums for non-poor individuals by 200 % while proving poor households with waivers. We apply difference-in-differences with matching on national representative cross-sectional data to estimate the effect of increased premiums on labour supply in the short and medium term. We find that premium increases reduced time allocation to non-agricultural activities while increasing time allocation to subsistence agricultural activities with limited effect on total time worked. We provide a conceptual framework which allows for endogenous household responses due to changes in the health insurance premium via income thresholds. Households reduce labour supply possibly due to the negative incentives to gain premium waivers, i.e. to be classified as poor. Our results suggest that revisiting the community-based targeting might be worthwhile in addressing the unintended effects of a possibly flawed targeting method.
27 April 2022, 14:30-15:30 (CET)
This paper uses a sufficient statistic approach to estimate risk aversion in the context of health insurance. First, I develop a model of health insurance demand, with (possibly) distorted individual risk perceptions. Second, I show that risk preferences establish a strict relationship between three elasticities of health insurance demand: the compensated price, income, and public insurance coverage elasticities. Lastly, I use estimates of these elasticities from the US health insurance market to measure both the underlying relative and absolute risk aversion. The estimation method does not require measurement of individual risk perceptions, or to make structural assumptions about utility. An extension to ex-post moral hazard does not affect the results significantly.
4 May 2022, 14:30-15:30 (CET)
We quantify the effects of novax propaganda on vaccines takeup and vaccine- preventable health complications among individuals untargeted by the immunization. We collect the universe of Italian vaccine-related tweets for the period 2013-2018, label the novax stances through Natural Language Processing, and match them with vaccination coverage and vaccine-preventable hospitalizations data at the most gran- ular level available (municipality and year). We then exploit the Twitter network structure as well as the exogeneity of news-related flows of information regarding vaccines to implement a mixed two-stage least squares estimation. We find that a 10 pp increase in the municipality novax stance causes a 0.17 pp decrease in coverage in Measles-Mumps-Rubella vaccine, a 0.8 additional hospitalization every 100k res- idents among individuals untargeted by the immunization (newborns, the immuno- suppressed, pregnant women) and an excess expenditure of 2325 euro, representing a 4% increase in health expenses. Finally, we provide a rationale for the interplay between topic controversialness and polarization in online social networks, showing that if controversy is a byproduct of policy interventions, policymakers should ad- dress these unintended consequences which have the potential to backfire in terms of further polarization and the associated social costs.
11 May 2022, 14:30-15:30 (CET)
In February 2017, Portugal implemented a tax on sugar-sweetened beverages (SSBs), under which producers were to be taxed according to the amount of sugar contained in the drinks they manufactured. We exploit administrative accounting data covering the universe of Portuguese firms between 2012 and 2019 to assess the causal impact of this tax on the behavior and performance of producers of SSBs. Our identification strategy relies on event study specifications, using producers of bottled water as counterfactual. Our findings indicate that SSBs producers became significantly less profitable in the post-tax period, vis-à-vis water bottlers, which was driven by a significant decrease in domestic sales. The soda tax hindered firms’ capacity to convert receivables into cash and financial health deteriorated as liabilities grew. SSBs producers did not respond to this negative shock by cutting jobs or modifying their labor force towards relatively more skilled labor or higher R&D capacity.
Speaker: João Pereira dos Santos, RWI - Leibniz Institute for Economic Research and Nova School of Business and Economics
Discussant: Eleonora Fichera, University of Bath
Chair: Pierre Dubois, Toulouse School of Economics
18 May 2022, 14:30-15:30 (CET)
Accurate and precise measurements of the short-term effects of air pollution on health play a key role in setting air quality standards. Yet, statistical power calculations are rarely—if ever—carried out. We first collect estimates and standard errors of all available articles found in the epidemiology and economics literatures. We find that nearly half of them may suffer from a low statistical power and could thereby produce statistically significant estimates that are actually inflated. We then run simulations based on real data to identify which parameters of research designs affect statistical power. Despite their large sample sizes, we show that studies exploiting rare exogenous shocks such as transport strikes or thermal inversions could have a very low statistical power, even if effect sizes are large. Our simulation results indicate that the observed discrepancy in the literature between instrumental variable estimates and non-causal ones could be partly explained by the inherent imprecision of the two-stage least-squares estimator. We also provide evidence that subgroup analysis on the elderly or children should be implemented with caution since the average number of events for an health outcome is a major driver of power. Based on these findings, we build a series of recommendations for researchers to evaluate the design of their study with respect to statistical power issues.
25 May 2022, 14:30-15:30 (CET)
This paper aims at finding whether vaccination in childhood is an important source of improved health over the life cycle and across generations. We leverage high-quality individual-level data from Sweden covering the full life spans of three generations between 1790 and 2016 and a historical quasi-experiment – a smallpox vaccination campaign. To derive the causal impact of this campaign, we employ the instrumental-variables approach and the siblings/cousins fixed effects. Our results show that the vaccine injection by age 2 improved longevity of the first generation by 14 years and made them much wealthier in adult ages. These effects, with the magnitude reduced by two thirds, persisted to the second and the third generation. Such magnitudes make vaccination a powerful health input in the very long term and suggest the transmission of environmental beyond genetic factors.
1 June 2022, 14:30-15:30 (CET)
We introduce a novel experiment that disentangles health inequality aversion from equity weights for non-health characteristics. This allows us to capture aversion to health differences that are correlated with, and possibly caused by, these characteristics. In our experiment, participants allocate resources that differentially impact recipients' health. In separate within-subject treatments, recipients are labelled 1) anonymously, 2) by income, and 3) by income that causes health. Our rich experimental dataset (26,286 obvs.) allows us to estimate preference parameters, across a number of social welfare functions, for health inequality aversion and income-dependent weights; these capture aversion to a) income-related health inequality, and b) income-caused health inequality. In a representative sample of the UK adult population (n=337), we find substantial aversion to health inequality and higher weights for the income poor. There is extensive heterogeneity across participants, both for inequality aversion and income weights, but, we find lower inequality aversion than most previous estimates. We find that those who believe in a stronger causal relationship between income and health are more pro-poor, but participants' responsiveness to experimental manipulations of this causal relationship is mixed. Allocations are more consistent with invariance to relative inequality than with invariance to absolute inequality and with consequentialism than with preferences that ignore the health consequences of resource allocations.
8 June 2022, 14:30-15:30 (CET)
The economic incentives of physicians when recommending medical treatments constitutes an important agency problem in health care. In this paper, a patient experiences symptoms of an illness and visits a physician, who recommends the treatment or not based on the results of a personalized (combination of) test(s), which can deliver a signal of health or of illness that changes the beliefs of the patient. The test is chosen by thephysician, whose payoff depends on the payment for each treatment performed, on the treatment cost and on the testing cost. We show that at equilibrium there are three categories of patients. Patients with extreme preferences towards the treatment do not receive a test. Among them, those who are reluctant against a treatment refraining from treatment, whereas those inclined take the treatment. Differently, patients with intermediate preferences receive a test and take unnecessary treatment with positive probability. We discuss some policy interventions aiming at improving the health loss and the welfare loss compared to first best of no uncertainty.
15 June 2022, 13:00-14:00 (CET)
This paper analyzes patterns in M&A in the pharmaceutical industry involving drugs under development. Drawing on a detailed dataset of all corporate R&D activities related to antidiabetics over the period 1997-2017, we study the identity of targets and acquirers (who), timing of acquisitions (when) and which type of R&D projects change hands in terms of their technological nature and novelty (what). Conversely to the recent narrative of M&A in pharmaceutical markets that portrays large incumbent firms as typical acquirers and small firms as targets, we find that the majority of M&A activity takes place between small and research-focused firms. Further, it is also small and research-focused firms that engage in transactions involving novel or “high risk/high gain” projects. These potentially disruptive, but highly uncertain, projects are most likely to be acquired soon after their initiation, pointing towards an important yet so far unexplored pattern in M&A activity. By contrast, the largest incumbents in antidiabetics are less active acquirers, opting instead to conduct R&D in-house. Our findings have implications for where the scope of antitrust inquiry should be broadened when assessing the effects of M&As on innovation and competition in the pharmaceutical industry - a topic which has recently caught the attention of policymakers and academics.
The EuHEA Seminar Series in the academic year 2021/2022 was coordinated by:
- Rossella Verzulli, University of Bologna (Chair)
- Pedro Pita Barros, Universidade Nova de Lisboa (Co-Chair)
- Francesca Barigozzi, University of Bologna
- Stefan Boes, University of Lucerne
- Davide Dragone, University of Bologna
- Geir Godager, University of Oslo
- Dorte Gyrd-Hansen, University of Southern Denmark
- Daniela Iorio, University of Bologna
- Tor Iversen, University of Oslo
- Oddvar Kaarboe, University of Bergen
- Sverre Kittelsen, Frisch Centre
- Matteo Lippi Bruni, University of Bologna
- Paolo Pertile, University of Verona
- Liza Sopina, University of Southern Denmark