This paper examines the relationship between union membership and deaths of despair. Using state-level variation in the timing of the adoption of right-to-work laws as a natural experiment, I show that right-to-work laws are associated with a decline in union membership and an increase in deaths of despair. Two-way fixed-effects (TWFE) difference-in-differences (DiD) estimates suggest that the adoption of a right-to-work law is associated with a 2.6 percentage point reduction in union membership and an increase in deaths of despair mortality of 13 additional persons per 100,000, implying there are approximately 7.5 additional deaths of despair for every 1,000 workers who lose union membership. An analysis of mechanisms suggests the increase in mortality is largely driven by increased opioid usage and a concomitant increase in overdose deaths. I support the TWFE results with estimates from two alternative estimators robust to concerns about treatment effect heterogeneity and variation in treatment timing. Estimates from the Callaway and Sant'Anna (2021) estimator and the Borusyak et al. (2024) estimator support the TWFE findings: right-to-work laws reduce union membership and increase deaths of despair.
This paper studies the health consequences of administrative centralization in healthcare, focusing on the consolidation of Local Health Authorities (LHAs) within the Italian National Health Service. This type of reform fits within a broader set of cost-containment efforts aimed at reducing administrative expenditures and exploiting economies of scale. In the Italian case, the reform centralized governance and expanded the scale of health administration, creating authorities with substantially larger catchment areas and shifting decision-making to more heterogeneous jurisdictions. Such changes may affect the responsiveness of healthcare provision to local needs, the coordination of service delivery, and access to care. Using an event-study Difference-in-Differences design, we estimate the policy's impact on municipal mortality rates, accounting for heterogeneous treatment effects and co-occurring fiscal adjustment policies. We find a significant increase in mortality starting four years after implementation, with an average treatment effect on the treated of 2.1%. The effects are concentrated in municipalities belonging to absorbed LHAs and in those exposed to mergers involving relatively large pre-reform LHAs and substantial post-merger expansions in catchment areas; they are also unevenly distributed, creating new vulnerable areas. Welfare estimates based on life-years lost indicate that the monetary costs of increased mortality exceed plausible administrative savings by roughly an order of magnitude.
Social health insurance expansions can affect not only new beneficiaries but also those who remain outside the program. This paper studies these spillovers in the context of Medicare Part D. Increases in insured demand can raise or lower price depending on market conditions: they may increase price when pharmaceutical firms face less elastic demand, but reduce price when demand concentration strengthens bargaining and pass-through in competitive markets. I find that Part D lowered the out-of-pocket unit price paid by Americans under age 65 without prescription drug insurance. Price declines are larger in therapeutic classes more exposed to Part D and in classes with stronger within-class competition, consistent with a demand-concentration channel. Demand increases mainly for generic drugs and among existing users. The implied consumer-surplus gain is roughly $76 per person per year, comprising about $65 from lower price on inframarginal consumption and $11 from additional consumption. Demand responses appear strongest among lower-income, younger, and healthier uninsured individuals, consistent with greater pre-existing non-adherence. Although price fall across several drug classes, demand does not increase significantly for medications associated with greater overuse in the United States, suggesting potentially positive net health spillovers.
Despite substantial disability-related costs, participation in public disability benefit programs remains incomplete in many countries. This is particularly the case in low- and middle-income countries where disability programs are relatively new and awareness of eligibility rules may be limited. This paper evaluates whether reducing information frictions can increase enrolment in Vietnam's national disability benefits program. In a randomised controlled trial across 70 rural communes, standardised information about disability benefits was embedded within routine government loudspeaker broadcasts over a five-week period. Using commune-level administrative data observed approximately two years after the intervention, the results show that program enrolment was 9 percent higher in treated communes. The effects are larger among individuals classified with severe disabilities, for whom enrolment increased by 12 percent. Smaller effects are observed among persons with the most severe disabilities, who were likely already well covered by the program. Larger effects are also observed among children who are eligible for higher monthly disability pension amounts. These findings demonstrate that a low-cost and scalable information campaign delivered through existing government communication infrastructure can substantially increase participation in disability benefit programs.
We study the effects of retirement on cognitive functioning among women aged 63 to 67 by exploiting a German retirement reform that raised the early retirement age for women born after 1951 by three years, from 60 to 63. Our indicators of cognitive functioning are objective cognitive test scores (word recall, semantic fluency, and the Stroop test) from a large biomedical dataset, as well as the diagnosis of cognitive disorders from administrative health insurance claims. We find reductions of around 13% of a standard deviation per year in retirement for measures of fluid intelligence, whereas crystallized intelligence remains unaffected. These estimates reflect the reform-induced shift in retirement duration for compliers around the eligibility cutoff. In contrast, additional years in retirement do not affect diagnosis of cognitive disorder and decrease diagnoses of dementia-related risk factors such as hypertension, depression, and sleep problems. The improvement in health outcomes suggests that cognitive decline is not driven by health deterioration but might possibly be due to reduced cognitive engagement after leaving work.
Determining the value of different post-acute care settings for clinically similar patients is important for providers and payers. This study examines the causal effect of post-acute care (PAC) setting on Medicare spending and short-term patient outcomes among beneficiaries discharged from hospitals following treatment for stroke or congestive heart failure (CHF). Using 2013-2017 Medicare claims data, we implement an instrumental variable strategy that exploits daily variation in skilled nursing facility (SNF) bed occupancy at the hospital service area level to estimate the local average treatment effect of SNF versus home health agency (HHA) care. Our findings reveal no significant differences, on average, in 30-day mortality or rehospitalization rates between SNF and HHA care among stroke and CHF patients. However, the 95% confidence intervals do not exclude clinically meaningful reductions in 30-day mortality. Meanwhile, SNF care is associated with approximately $4700 more in Medicare spending per PAC episode. The spending gap is larger in markets with more constrained SNF capacity, particularly in states with Certificate of Need regulations, rural areas, and low-income neighborhoods. However, we do not detect statistically significant differences in short-term health outcomes across these markets on average, suggesting that supply constraints may amplify the spending implications of SNF use while the relationship between PAC setting and short-term clinical outcomes remains uncertain. These findings highlight the importance of aligning PAC discharge decisions with both clinical needs and local capacity considerations, particularly under value-based payment models.
We examine the financial consequences of the 2007 California Fair Pricing Law, which places a price ceiling on hospital bills for financially vulnerable individuals. Using cross-sectional variation in exposure to the law, proxied by county-level uninsured rates, we estimate its impact on individual financial outcomes. We find that the law reduces the likelihood of incurring non-medical debt in collections and the number of non-medical accounts in collections. In addition, we find evidence that credit scores increased and suggestive evidence that the number of delinquent accounts decreased for individuals in more exposed counties. Our results suggest hospital billing regulations can improve targeted individuals' financial outcomes.
We estimate the short-term cognitive effects of fine particulate matter (PM2.5) exposure using novel exposure data collected during cognitive testing in Kenya. Unlike most existing studies that rely on satellite-based or fixed monitoring station data, we measure highly localized ambient pollution using portable monitors deployed at cognitive testing sites and link these readings directly to Harmonized Cognitive Assessment Protocol (HCAP) scores. Higher PM2.5 exposure during testing is associated with lower cognitive performance, particularly in executive function, memory, and visuospatial tasks. Binned exposure models suggest a monotonic pattern, with more negative estimates at higher exposure levels. Notably, effects are significantly larger among more educated individuals, possibly due to greater task demands or lower chronic exposure that limits physiological adaptation. Given that cognitive impairment is evident even at PM2.5 levels below Kenya’s mean annual regulatory threshold of 35μg/m3, the findings suggest that short-term exposure may impose underappreciated human capital costs that current regulatory standards fail to mitigate. The results highlight the potential cognitive and economic returns to interventions that reduce air pollution exposures in low-resource settings.
This paper estimates the causal effect of online food delivery platforms on body weight in China. Exploiting the staggered rollout of Eleme across Chinese cities between 2010 and 2020, we find that platform entry shifts the BMI distribution rightward among urban young adults: it increases body mass index, lowers underweight prevalence, and raises the likelihood of being overweight. Effects are negligible among urban older adults, consistent with lower platform adoption in this group. Mechanism analysis points to shifts in dietary preferences toward energy-dense foods, reduced meal preparation time, and increased restaurant entry. Our findings highlight the health trade-offs associated with digital food platforms in rapidly urbanizing developing countries, where improved caloric access may coexist with greater exposure to lower-quality, energy-dense foods.
We analyse the impact of a change in the administration of social security payments, occurring in utero and early infancy, on health in early childhood. We identify this impact through the gradual rollout of the so-called 'income management' policy in Aboriginal communities in Australia's Northern Territory in 2007. This policy changed the delivery method of social security payments but not their value - however, implementation challenges meant that many families did not receive their payments on time. Using linked administrative data, we find that children who were exposed to the policy rollout in utero or in their first three months of life (the 'fourth trimester') were at higher risk of severe infection requiring hospitalisation. These children spent, on average, 4.7 more days in hospital between birth and their 8th birthday. Most of this impact is concentrated in hospitalisations for infection, which increased by 23 percent. These admissions are driven by a range of infection types: bacterial, viral and respiratory. We link our findings to the 'immune programming hypothesis', i.e. maternal stress and poor nutrition during key stages in immune system development can permanently weaken the child's immune system. Our findings highlight the importance of attention to key phases in child development when designing policies that affect households' financial resources, even temporarily.
We study the long-run consequences of fertility policy for aging and survival, exploiting the staggered provincial rollout of China's 1970s Later, Longer, Fewer campaign. Linking variation in exposure to the Chinese Longitudinal Healthy Longevity Survey (1998-2021), we find that cohorts subject to fertility restrictions experienced significantly higher late-life mortality, over 10% on average, and worse cognitive and psychological outcomes. These effects arise because smaller sibships, delayed childbearing, and wider spacing reduced both the supply and timing of intergenerational care. While the subsequent introduction of LTCI mitigated some adverse impacts, the effects were driven by in-kind benefits, whereas cash-based LTCI provided little offset, underscoring the limits of formal substitution for kin-based support. Our findings reveal a fundamental intergenerational trade-off in fertility control and highlight the enduring demographic costs of policies that reshape family structure.
We introduce a novel approach to identify state-dependent reporting bias in subjective health measures. The central idea is that health operates as a stock, making abrupt shifts in self-reported health (SRH) following retirement more likely to reflect reporting bias than actual changes. To capture such shifts, our analysis integrates three key elements: (1) differentiating stock and flow outcomes based on classical health theory; (2) leveraging an identification strategy inspired by regression discontinuity design; and (3) exploiting a unique high-frequency dataset on monthly health and retirement. Traditional estimates find a decline in SRH after retirement over longer periods; however, this decline steadily diminishes as the observation window narrows, showing no evidence of state-dependent reporting bias. Our analysis of short-term health dynamics also emphasizes distinguishing stock and flow health outcomes in policy evaluations.
Many volunteer markets, and most prominently markets for substances of human origin, feature dynamic coordination problems where volunteering today can temporarily restrict volunteering later. We show that, unsurprisingly, these restrictions reduce market surplus compared to no restrictions. We examine whether providing volunteers with demand or supply information improves market surplus without and with intertemporal restrictions. We show theoretically that, without restrictions, providing demand or supply information increases market surplus, while with restrictions, providing supply rather than demand information causes higher market surplus. Experimental results support most predictions and further show that supply information especially improves market surplus when intertemporal restrictions exist. Overall, comparative static inferences in an environment without intertemporal restrictions do not carry over to an environment with restrictions. Thus, policies based on analyses of static conditions will not necessarily be effective in situations featuring dynamic spillovers.
This paper examines how expanding the legal definition of sexual assault affects fertility and sexual behavior, using a panel of European countries. I find that switching to tacit consent-based legislation reduces fertility by about 4% relative to the mean. This effect is driven by a decrease in couple formation and an increase in abortion rates. Supporting evidence is consistent with a behavioral channel in which more risk-averse individuals withdraw from dating and partner markets following the reform, altering the composition of those who remain active toward a pool that is less precautionary. Consistent with this compositional shift, contraceptive use rises among younger women but declines among older age groups, while condom use falls among young men. Finally, an analysis of appeals court verdicts in Sweden following the adoption of consent-based legislation shows a decline in unanimous guilty verdicts, indicating challenges in assessing tacit consent. These results are consistent with a simple framework in which heterogeneity in risk perceptions and precautionary behavior in dating and partner markets, including reduced participation by some individuals, helps explain the observed decline in fertility following the reform.
Patients experiencing acute health symptoms often face uncertainty about how and where to receive care. We study patients who call a nurse advice line and receive one of four recommendations: emergency department (ED), urgent care (UC), primary care (PC), or self-care (Home). Leveraging an extension of examiner designs that recovers margin-specific effects for each pair of adjacent recommendations (ED-UC, UC-PC, PC-Home), we estimate the impact of nurse recommendations on both patient decisions and their subsequent health outcomes. We find that recommendations have large impacts on patient decisions at each margin. We then show that UC recommendations reduce 28-day healthcare costs by $404 relative to ED recommendations and by $247 relative to PC recommendations, suggesting substantial potential for cost savings through improved triage.
Poor health and unstable housing are closely linked. Most research has focused on how housing shapes health, with little empirical study of whether and how health events can lead to future residential mobility or housing instability. This paper uses high-frequency administrative data on residential location and health among Medicaid enrollees in New York City to test whether adverse health events trigger housing mobility or insecurity, independent of the financial toll of medical bills. Using an event study design, I find that health shocks-or, sudden hospitalizations after two hospital-free years-immediately increase residential mobility (21-35 % relative increase) and the probability of living in shelters or on the street (6-10 % relative increase). These increased rates of mobility and instability persist above expected levels for at least two years. For unplanned or urgent hospital admissions, the impact of health events is even greater. These estimates imply that, in their immediate aftermath, adverse health events could be a tipping point for approximately 80,000 additional moves and 20,000 additional cases of homelessness among the U.S. Medicaid-insured population annually. The effects of health events on residential mobility are smaller for those with subsidized housing, a usual source of outpatient care, higher-quality inpatient care, and social support, suggesting potential areas for policy interventions to break the relationship between health problems and housing outcomes, from both inside and outside of health systems. This work also contributes to our understanding of the long tail of social consequences of adverse health events.
Equitable healthcare access for mobile, informally employed populations remains elusive in many developing contexts. We examine the impact of the first phase of China’s cross-regional instant reimbursement (CRIR) reform— a province-level reform —on enrollment in health insurance and healthcare utilization. Informed by a theoretical model, we implement a triple-differences design leveraging CRIR’s staggered rollout to identify causal effects. Results show that CRIR substantially increased local UEBMI enrollment (by 8%) and healthcare visits (by 14%), while reducing out-of-pocket spending (by 22%). These gains stem from lower administrative frictions and strengthened financial protection. Low-income, less-educated, and more informally employed migrants benefit the most, underscoring the reform’s role in promoting inclusive development. Our findings highlight the importance of portable social insurance in improving healthcare access for mobile populations and offer insights for similar reforms in other developing settings.
This paper develops a unified framework for evaluating health outcomes that jointly incorporates equity and productivity. Extending beyond traditional QALYs, PALYs, and the more recent PQALYs, we introduce a broader class of evaluation functions that integrate equity- and productivity-sensitive conditions. By imposing several normative criteria, including independence from measurement scales and Pigou-Dalton transfer principles, we obtain tractable power-form representations. In balancing equity and efficiency, the framework provides a coherent foundation for assessing interventions in contexts where both health and productive capacity are at stake.
Billions of people worldwide still lack access to healthy diets, with a high concentration in rural areas of developing countries. This paper examines how major transportation investments can improve dietary quality among rural households, leveraging the staggered rollout of the “Five Vertical and Seven Horizontal” National Trunk Highway System (5V7H), the country’s largest expressway network completed by 2007. Using a staggered difference-in-differences design, we find that the 5V7H access increases the Dietary Diversity Score (DDS) and Chinese Healthy Eating Index (CHEI) of rural residents by 0.326 and 2.197 points, respectively. These benefits are more prominent among households with more children, access to refrigerators, or meal preparers with better nutrition knowledge, and less so among households with more diversified agricultural production. We further show that the 5V7H connection improves rural residents’ dietary quality primarily through demand-side channels, including promoting off-farm employment, raising household income, and enhancing dietary literacy. In contrast, the contributions of supply-side channels, such as improved market access or lower food prices, are modest. Overall, our findings highlight the benefits of large-scale transportation infrastructure in facilitating the transition to healthier diets in rural areas of developing countries.
Heavy workloads facing health care providers may lead to changes in care processes that, in turn, affect quality of care and patient outcomes. Using direct observations of vaginal deliveries in three high-volume Kenyan hospitals, we study how workload affects care in maternity wards - a high-stress environment where hard-to-schedule patient admissions and uncertainty around labor progression can result in unexpected fluctuations in workload throughout the day. We first document that these facilities are persistently understaffed relative to international staffing benchmarks, implying high baseline workloads. Exploiting short-run variations in provider workload in this environment, we find that workload has little to no effect on quality, as measured by provider adherence to clinical guidelines and disrespectful care. We show that coping strategies employed by providers, such as using clinical interventions to speed up labor and delegating tasks to less qualified team members, may have weakened the relationship between workload and the quality measures we examine. However, these coping mechanisms could have negative implications for other (unmeasured) aspects of quality. Drawing on anecdotal and other evidence, we propose additional hypotheses for why quality may not be sensitive to workload in this setting.
