We use restricted-access birth records from the National Vital Statistics System (NVSS) to document the full age and parity fertility effects of the Colorado Family Planning Initiative (CFPI). The CFPI provided access to every FDA approved method of contraception for free to anyone living below approximately 200% of the federal poverty line from 2009 to 2015. Previous research has demonstrated important effects on fertility at ages 15-29. We estimate the statewide fertility effect of the CFPI for all age groups (15-44) and for all births and for first and non-first births using the synthetic control method. We find large and statistically significant reductions in birth rates for 15-24-year-olds that largely line up with other recent studies, but we find important heterogeneity across parity. For teenagers, we find reductions in first birth rates of about 9%, but much larger reductions in non-first birth rates of 17%-25%. We also find reductions in overall fertility for 20-24 and 25-29-year-olds, but these are entirely driven by reductions of 5%-9% in non-first birth rates, with no significant changes in first births. For 30-39-year-olds, we find small but statistically significant reductions in fertility of 3%-7% across parity levels, and we find a 6% reduction in fertility for 40-44-year-olds. We also conduct inference using synthetic difference-in-differences (SDID) and placebo-based methods. When we do this, our coefficient estimates are similar, though confidence intervals are wider, with specifications on older age groups no longer statistically significant.
Waiting times for planned health care treatments have been increasing in England and other OECD countries. One policy to reduce the impact of waiting times on patients' health is for doctors to prioritise patients according to their health status. This study tests the extent to which publicly-funded patients in poorer health are prioritised on the list, and whether prioritisation differs between public and private providers. We use hospital administrative data in 2015-2021 on hip replacements in England. Our results provide evidence of inpatient waiting-time prioritisation (from specialist addition to list to admission for surgery) based on pre-operative health with a difference of at least 15 days between patients with lowest and highest pre-operative health. The gradient becomes steeper as waiting times increase, and much steeper during COVID-19. While outpatient waiting times (from referral to specialist visit) comprise a substantial proportion of total time waited (inpatient plus outpatient), we find limited evidence of outpatient waiting time prioritisation. Differences in inpatient waiting-time prioritisation between public and private providers are mostly due to different casemix and shorter average waiting times by private providers. We also simulate the effect of prioritisation policies that reduce inpatient waiting times for patients with low pre-operative health by 20% while simultaneously increasing it for those with high pre-operative health. We find that these policies could generate health gains of 183 QALYs in a given year. We conclude that there is scope for improving prioritisation of patients on the waiting list.
Diet-related morbidity and mortality now exceed those associated with hunger worldwide. Although risk and time preferences are correlated with dietary behavior, evidence from the Global South remains limited. In particular, the role of human-capital risk-distinct from health risk-in shaping dietary choices has not been systematically examined. This study addresses this gap using incentivized lab-in-the-field experiments and 2024 survey data from Mekelle city, northern Ethiopia. A control-function approach accounts for potential health-status endogeneity, Oster's coefficient stability test assesses sensitivity to unobserved heterogeneity, and double Lasso tests the exclusion of insignificant variables while controlling for structural errors. Results show that impatience, impulsivity, and risk aversion are generally negatively associated with demand for healthy dietary components, although associations vary by outcome. Risk-averse subjects report stronger healthy-eating intentions but exhibit comparatively lower observed investment in healthy foods, consistent with concerns about human-capital risk.
We expand the literature on marginal returns to birth interventions by studying a common intervention: early induction of labor for a growing share of pregnancies, high-Body Mass Index (BMI) women. We exploit Danish guidelines which recommend routine induction at 7 days after the expected due date instead of 10-13 days after for mothers with a pre-pregnancy BMI of at least 35. Our results show that early labor induction improves immediate maternal and neonatal health, reduces universal nurse visits during the child's first year of life, as well as maternal postpartum depression risks (suggestive).
Multidimensional patient-reported outcome measures (PROMs) are increasingly used to compare the performance of health care providers. Meaningful comparisons require the data to be adjusted for differences in case-mix. The common approach in the literature is to aggregate PROM data into univariate summary scores prior to case-mix adjustment. In this paper, we extend the work by McCarthy (2015, 2016) to develop a dimension-specific adjustment methodology for performance assessment. This method permits to model the influence of patient characteristics separately for each dimension while retaining the maximum amount of information to inform different stakeholders. We conduct a simulation study to compare the performance of both methods in terms of their ability to identify provider performance, and to identify context-specific factors that should guide the choice of methodology in applied research. We follow this up with a real-world case study of knee replacement surgery in the English NHS. We find that the domain-specific approach outperforms the summary score approach in most cases but the differences are small. We conclude that the choice of method ought to consider not just performance but also ease of implementation and retention of decision-relevant granular information.
This paper estimates the causal effect of Berkeley's sugar-sweetened beverage (SSB) tax on beer purchases and prices using retail scanner data from 2014 to 2015. Applying both synthetic control and difference-in-differences (DID) approaches, we find that the tax reduced beer purchases within Berkeley by 8.9%, while having a negligible effect on beer prices. Mechanism analysis indicates that the decline in beer sales is driven primarily by cross-border shopping rather than a reduction in overall beer consumption.
Agency theory suggests that variation in providers' quality of care may be explained by their heterogeneous motivations. We provide novel empirical evidence on the links between different sources of provider motivation and quality of care by combining a unique 4-year survey dataset on Danish general practitioners' motivations with quality indicators and control variables from rich register data. Using a within-between regression specification, we estimate the associations between two key sources of motivation (financial motivation and non-paternalistic altruism toward patients) and seven quality indicators related to accreditation standards in general practice. We find that providers' financial motivation is associated with high-quality care that relates to remunerated services. We further find that non-paternalistic altruism toward patients associates with lower-quality prescribing for drugs that may be highly demanded by patients and fewer annual control visits for chronic disease. These links are mostly found when we compare heterogeneously motivated practices (between estimates) rather than when we look at changes within the same practices over time (within estimates). The findings can help policymakers address agency problems that may arise from patient demands and design policies that motivate delivery of high-quality care.
Investigating the impact of healthcare expenditure on health is crucial for optimizing public resource allocation. This can inform the value of expanding healthcare budgets and provide a benchmark for allocations within healthcare systems. However, empirical evidence remains mixed. The potential causes of mixed results-reverse causality and unobservable confounders-need to be addressed through robust empirical methods. This study assesses the South Korean public healthcare cost of producing one quality-adjusted life year (QALY) by using conversion factors-elements in the pricing formula of healthcare services determined by negotiations-as the instrument, with two-way fixed effects. Moreover, since morbidity significantly affects health, it is crucial to estimate the impact of healthcare expenditure on morbidity using credible data. We use a unique dataset of directly measured regional EQ-5D indices from 240 municipalities for the period 2008-2019, which is unavailable in other countries. We estimate that $12,847 of public healthcare expenditure is required to gain one QALY. Sensitivity analyses using alternative calculation methods, data, and models produce estimates ranging from $8850 to $17,674 per QALY. Our findings suggest that the healthcare cost of producing one QALY is substantially lower than the GDP per capita and the willingness-to-pay for health in South Korea.
Choosing a hospital for elective inpatient care is a complex decision due to pervasive information asymmetries and multidimensional quality attributes. Online reviews provide an accessible and salient source of hospital quality information that could influence patient choices. Using the universe of hospital Yelp reviews and inpatient claims data for elective procedures in Florida (2012-2017), we exploit exogenous variation in online ratings to estimate the causal effect of online reviews on hospital selection. Depending on the underlying condition, we find that patients are willing to travel 7.9% farther for labor and delivery and 33.5% farther for orthopedic surgery for a one-standard-deviation increase in a hospital's rating percentile rank within its market, which is roughly a half-star increase. The larger response for orthopedic procedures is consistent with greater reliance on online information when provider relationships are weaker. Falsification tests on emergency admissions yield null results, confirming that online reviews influence elective rather than urgent decision-making. Our findings highlight the role of consumer-generated information in healthcare markets and suggest that online platforms can meaningfully shape provider competition.
Surgical treatments are offered more widely than ever before, increasingly to older and high-risk patients. However, it is unclear whether patients making surgical decisions are fully informed about the risks of surgery and the available non-surgical treatments. Especially for high-risk patients, unrecognized elevated post-surgery risks may make non-surgical treatments particularly relevant. In this paper, we study the role of information provision and the availability of non-surgical treatments for high-risk patients considering hip replacement surgery in the UK. We develop a discrete choice model of incorrect beliefs about post-surgery outcomes and limited availability of non-surgical treatments, which we estimate using an online choice experiment. In the experiment, participants take the perspective of a hypothetical high-risk patient; we elicit their beliefs about post-surgery outcomes and randomize additional information about these outcomes and the availability of physiotherapy. We find that beliefs differ systematically from predicted post-surgery outcomes and that the provision of additional information has heterogeneous effects on belief accuracy. We show that excluding physiotherapy from the available treatments accounts for four-fifths of the participants' total welfare loss, while incorrect beliefs about post-surgery outcomes account for the remainder. We find evidence that education is a strong predictor of welfare loss from incorrect beliefs.
Although flexible employment policies can help employed individuals balance caregiving and paid work, limited evidence has been devoted to examining the effect of working flexibly on the supply of care to older adults. In this paper, we study the impact of flexible working conditions on the supply of informal adult care and mental health. We exploit variation from the 2014 expansion of the Right to Request Flexible Work (RRFW) to employees in the UK. Our findings point to a gendered response to increased employment flexibility. We document a 1.3-percentage-point increase in the likelihood that men provide informal care within the household, alongside less regular daytime work, greater control over working hours, and higher engagement in home production. In contrast, among potential female caregivers, we find that the reform reduced the probability of high-intensity caregiving, which is typically incompatible with employment or related activities. We document that the increased workplace flexibility not only encourages caregiving but also helps reduce gender disparities in unpaid care. We additionally find suggestive evidence of improved mental health outcomes, particularly among men.
A near majority of states have now passed recreational marijuana laws (RMLs), but their impact on labor market behavior remains unclear. This study provides new causal evidence on the relationship between RMLs and workplace absence. Using a generalized difference-in-differences framework to exploit the staggered rollout of RMLs, I first document that the onset of legal recreational sales is accompanied by a 50% increase in the prevalence of prior-month adult marijuana use in treated states relative to control states. Next, I show that retail market access leads to a 14% increase in the incidence of prior-week workplace absence. Supplemental analyses of health outcomes suggest that part of the effect may be driven by increases in self-reported mental health problems following the opening of recreational dispensaries. These findings suggest that marijuana legalization may affect labor market outcomes along margins not typically captured by employment status alone.
Limited utilization of healthcare services remains a persistent challenge for poor populations in many countries. This study examines the impact of China's Poverty Alleviation Relocation Program (PARP) on healthcare utilization, utilizing panel data from rural households in 16 counties across eight provinces. Employing a difference-in-differences (DID) framework, we find that relocation leads to a 24.6% increase in clinic visits and a 36.9% increase in hospital visits per household, helping prevent minor illnesses from escalating. Despite higher utilization, relocation does not significantly raise total medical expenditure, out-of-pocket medical costs, or reimbursement levels, due to reduced per-visit costs. Mechanism analysis suggests that relocation improves access to healthcare facilities and boosts household income. Our findings highlight the critical role of combining housing mobility with healthcare system improvements to promote healthcare equity, offering important insights for the design of poverty alleviation strategies in other developing country contexts where access to healthcare remains a critical constraint.
Compulsory licensing is a legal mechanism that allows governments the use of patented medicines without the owner's consent, subject to conditions and compensation, to meet public-health needs. Despite its policy relevance and increasing use, empirical evidence on its market effects remains limited. This study examines the association between compulsory licensing and the commercial accessibility and affordability of HIV medications across 11 countries from 2002 to 2022. We combine quarterly data on drug sales and prices from IQVIA with implementation dates from the TRIPS Flexibilities Database, focusing on 21 HIV drugs subject to at least one compulsory license. Using a staggered difference-in-differences design, we estimate the average treatment effect on the treated (ATT) of compulsory licensing on drug consumption and prices, under a parallel trends assumption. We find an economically meaningful increase in retail and hospital sales following the implementation of compulsory licenses, amounting to approximately 21% of a standard deviation in the countries that implemented them. In addition, we estimate a reduction in prices of approximately 19% of a standard deviation. These associations are consistent with compulsory licenses having contributed to improved availability of HIV drugs through commercial channels, with meaningful effects on prices. Our estimates do not capture-and therefore cannot rule out-potential additional effects on access via public importation or production, donations, or NGO-led supply chains.
Tobacco 21 (T21) laws effectively reduce youth tobacco use by preventing initiation. This study examines their impact on body weight among young adults aged 18-20. Using 2009-2019 Behavioral Risk Factor Surveillance System data and a two-way fixed-effects difference-in-differences (DID) design, we find limited evidence of broad weight changes in either direction across the BMI distribution. Obesity declines due to modest weight reductions concentrated near the upper BMI threshold, with no significant changes in overweight status or average BMI. Event study shows that the obesity decline emerges in the first post-T21 year and attenuates afterward. Results are robust to alternative specifications, including an imputation DID approach addressing staggered adoption. Effects are driven by "never smokers", consistent with a prevention-based pathway, and are more pronounced among males and non-White individuals, with heterogeneity observed across education levels in the upper BMI tail. Supplemental analyses using Youth Risk Behavior Survey data show reduced adverse weight outcomes among high schoolers aged 18+. T21 laws increase exercise, improve diets, and reduce sedentary behavior, underage drinking, marijuana use, and mental distress. Overall, T21 laws avoid the typical cessation-related weight gain and modestly improve weight outcomes among at-risk young adults, suggesting broader public health benefits beyond tobacco prevention.
Even though data on hospital admissions are widely used in health research, hospitalization-related estimands measured using these data are not always clearly conceptualized. Consequently, estimators of these quantities can have unclear rationales and undesirable properties. We evaluate three "rate" estimators for measuring hospitalization-related estimands. Using the Grossman human capital model, we motivate the importance of measuring healthy time. We show that an upper bound on healthy time can be calculated using lengths of hospital stay without assumptions about health status outside the hospital. We illustrate the empirical value of these bounds. Next, we find that an admission rate conventionally used in clinical research is a patient follow-up time weighted average that lacks a clear basis for the weights. We propose an alternative estimator with more desirable properties and weaker assumptions. We assess its performance using a model of hospital admissions and death. Finally, we evaluate the Centers for Medicare and Medicaid Services (CMS) use of risk-standardized readmission rates to penalize hospitals by showing that risk-standardized rates can be sensitive to patient case mix, potentially leading to hospital rankings that do not reflect hospital quality. We propose treating hospital specific intercepts in the CMS risk-standardization model as a measure of quality.
Adolescent mental health has become a growing public health concern. This study examines the impact of teacher quality, proxied by teacher experience, on student mental health. To address potential endogeneity concerns and identify causal effects, we exploit data from a sample of schools where students and teachers are plausibly randomly assigned to classes. Our results indicate that students assigned to head teachers with greater experience exhibit significantly improved mental health. By contrast, we find no such effects for subject teachers who are solely responsible for academic instruction. The mechanism analysis suggests that more experienced head teachers strengthen teacher-student relationships, engage more with parents, report higher work satisfaction, and promote more supportive peer interactions. Our results highlight the important role of school environments in determining adolescents' mental health and offer actionable insights for interventions.
Economic policy can be a powerful instrument to influence food environments and support improved diets and health. Over the past 20 years, the use of fiscal policy to improve diets has increased dramatically. This paper reviews the trajectory of policy change, and explores the ways in which research has informed three different dimensions of economic policy change in relation to nutrition: policy paradigms, policy instruments and policy settings. The increasing use of fiscal policy contrasts to more limited use of other economic policy instruments, including trade policy, to shape food environments for improved nutrition. Insights from the case studies explored in this paper indicate the important role of research in supporting policy change, including through generating evidence that speaks to sectoral needs and priorities, which can enable policy makers to identify and support potential synergies, as well as providing evidence from real-world evaluations of policy measures. The case studies also highlight the importance of constructive engagement between nutrition and economic policy makers. Finally, the paper identifies three considerations for research moving forward related to policy innovation, knowledge equity, and gender.
Low-income elderly consumers, often overlooked in studies of public financial assistance programs, may face challenges in managing resources to maintain dietary health. This study examines how the payment frequency of an unconditional cash transfer program impacts dietary behaviors among low-income elderly populations in Colombia. Using nationally representative data from a federal financial assistance program, we implement a Multivalued Treatment Model with Propensity Score Matching and Augmented Inverse Probability Weighting to assess the effects of monthly versus bi-monthly payments on food expenditures, dietary diversity, and diet quality. Results show that monthly payments enhance dietary diversity and diet quality by supporting healthier food purchases compared to bi-monthly payments. Subgroup analyses revealed that older seniors and males benefit most from monthly payments. Mechanisms explored include consumption smoothing and subjective wealth perceptions, with findings suggesting that more frequent and predictable income flows may foster greater perceived financial stability. The study advances consumer behavior theory by linking payment frequency to dietary outcomes and offers practical implications for optimizing financial assistance programs. While bi-monthly payments reduce administrative costs, monthly payments are recommended to improve dietary health. These findings contribute to understanding income timing's role in fostering healthier consumer behavior.
While extensive literature is available on the impact of early childhood nutritional food program on human capital gains, little we know about the impact of targeted nutritious food provisioning at a later stage on human capital gains. This paper fills this gap in the literature. We examine the causal impact of the Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (SABLA), a nutrition-led multifaceted program for adolescent girls aged 11-18 years introduced by the central government in India in 2010, on girls' educational and learning outcomes. The implementation of this program provides us with enough variation in treatment. We glean data from multiple nationally representative datasets and employ difference-in-differences framework to estimate the causal impact of the SABLA program. Our results indicate that the program significantly improved enrollment and basic learning outcomes, including reading ability and math skills. We attribute the salutary effects of the program to significant improvement in health status (BMI and weight) of the adolescent girls exposed to the program and increased child-specific educational expenditure. Our findings are consistent across different datasets, and robust to potential confounding factors, and alternative empirical specifications.
