Health Economics

Members of the NBER's Program on Health Economics met on May 4 in Cambridge. Program Director Michael Grossman of City University of New York and Research Associates Theodore J. Joyce of City University of New York and Christopher Carpenter of Vanderbilt University organized the meeting. These researchers' papers were presented and discussed:

Emilia Simeonova, Johns Hopkins University and NBER, and Andreas Madestam, Stockholm University

Children of the Pill: The Effect of Subsidizing Oral Contraceptives on Children's Health and Wellbeing

What is the lasting and intergenerational impact of providing women with cheaper contraception? Simeonova and Madestam use a series of municipal-level experiments in Sweden between 1989 and 1998 to study the role of oral contraception (the pill) subsidies on women’s and children’s health, education, and economic outcomes. To examine the effects of the policy they combine differences in subsidy exposure across municipality, time, and age eligibility. They first show that subsidized contraception for young women increased pill sales, leading to fewer abortions and lower fertility for the eligible age groups. The researchers find that women affected by the subsidies were more likely to get some college education. Their children are in better health and they have better schooling outcomes, as measured by high school achievement scores. These effects are stronger in the population of women with lower socio-economic backgrounds.

Scott Cunningham, Baylor University; Jason M. Lindo, Texas A&M University and NBER; Caitlin K. Myers, Middlebury College; and Andrea Schlosser, Baylor University

How Far Is Too Far? New Evidence on Abortion Clinic Closures (NBER Working Paper No. 23366)

Cunningham, Lindo, Myers, and Schlosser estimate the effects of abortion-clinic closures on clinic access and abortions using variation generated by Texas HB2, a "TRAP" law that shuttered nearly half of Texas' abortion clinics in late 2013. Their results suggest a substantial and non-linear effect of distance to clinics. Increases from less than 50 miles to 50-100, 100-150, and 150-200 miles reduce abortion rates by 15, 25, and 40 percent, respectively, while additional increases in distance appear to have no additional effect. The researchers also introduce a proxy for congestion that captures the potential for there to be effects of closures which have little impact on distance but which reduce per-capita capacity. They demonstrate that this is also an important mechanism through which closures affect abortion, moreover, ignoring this mechanism causes the effects of distance to be somewhat overstated. Several features of the data imply that magnitude of the effects on abortion are too big to be explained by interstate travel. That said, the results of a simulation exercise demonstrates that the effects are too small to plausibly be detected in analyses of birth rates.

Jessamyn Schaller, University of Arizona and NBER; Lisa Schulkind, University of North Carolina, Charlotte; and Teny Maghakian Shapiro, Santa Clara University

The Effects of Perceived Disease Risk and Access Costs on Infant Immunization (NBER Working Paper No. 23923)

Schaller, Schulkind, and Shapiro examine the determinants of parental decisions about infant immunization. Using the exact timing of vaccination relative to birth, they estimate the effects of local pertussis outbreaks occurring in-utero and during the first two months of life on the likelihood of on-time initial immunization for pertussis and other immunizations. The researchers find that parents respond to changes in perceived disease risk: pertussis outbreaks within a state increase the rate of on-time receipt of the pertussis vaccine at two months of age. This response is concentrated among low-socioeconomic status (SES) subgroups. In addition, the researchers find that pertussis outbreaks increase the likelihood of immunization against other vaccine-preventable diseases. These spillover effects are almost as large as the direct effects and are present only for vaccines that are typically given during the same visit as the pertussis vaccine, which suggests that healthcare access costs play an important role in parents' vaccination decisions.

Ofer Malamud, Northwestern University and NBER; Andreea Mitrut, University of Gothenburg; and Cristian Pop-Eleches, Columbia University and NBER

The Effect of Education on Mortality and Health: Evidence from a Schooling Expansion in Romania (NBER Working Paper No. 24341)

Malamud, Mitrut, and Pop-Eleches examines a schooling expansion in Romania which increased educational attainment for successive cohorts born between 1945 and 1950. They use a regression discontinuity design at the day level based on school entry cutoff dates to estimate impacts on mortality with 1994-2016 Vital Statistics data and self-reported health with 2011 Census data. The researchers find that the schooling reform led to significant increases in years of schooling and changes in labor market outcomes but did not affect mortality or self-reported health. These estimates provide new evidence for the causal relationship between education and mortality outside of high-income countries and at lower margins of educational attainment.

Martin Andersen, University of North Carolina, Greensboro

Effects of Medicare Coverage for the Chronically Ill on Health Insurance, Utilization, and Mortality: Evidence from Coverage Expansions Affecting People with End-Stage Renal Disease

Andersen studies the effect of the 1973 expansions of Medicare coverage among individuals with end-stage renal disease (ESRD) on insurance coverage, health care utilization, and mortality. He finds that the expansions increased insurance coverage by between 22 and 30 percentage points, in models that include trends in age, with the increase explained by Medicare coverage, and increased physician visits by 18 to 35 percent. These expansions also decreased mortality due to kidney disease in the under 65 population by between 0.5 and 1.0 deaths per 100,000. Lastly, Andersen provides evidence for two mechanisms that affected mortality: an increase in access to and use of treatment, which may be due to changes in insurance coverage, and an increase in entry of dialysis clinics. In a simulation, the program saved between 2000 and 14000 life years per year, which is insufficient to offset the cost of the program.

Christopher Carpenter, and Casey Warman, Dalhousie University and NBER

Do 'All-Age' Bicycle Helmet Laws Work? Evidence from Canada (NBER Working Paper No. 24644)

Twenty-two states and the District of Columbia require youths to wear helmets when riding a bicycle, and there has been a push to extend such laws to adults. Carpenter and Warman provide the first quasi-experimental evidence of the effects of ‘all-age’ bicycle helmet laws on cycling behaviors and helmet use by studying Canada where four provinces and a handful of cities have adopted such policies. Using restricted area-identified public health survey data from 1994-2014, the two-way fixed effects models show that all-age helmet laws significantly increased the probability that children and adults report always wearing helmets while bicycling by about 50 to 190 percent relative to pre-reform levels. These effects are larger for children (12-17) than for adults (18-64), however there are important differences within the adult age group. In particular, while university educated cyclists already had very high helmet use rates, the least educated group saw a very large increase in helmet usage with the implementation of an all age law. This effect is more pronounced with the presence of children. Finally, the researchers find no evidence that helmet laws in Canada led to population-wide reductions in cycling. Overall their findings confirm that youth helmet laws increase youth helmet use and further suggest that all-age helmet laws can be effective at increasing population helmet use without significant unintended adverse health consequences. Further, the laws are important in inducing less educated cyclists to use a helmet.

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