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The importance of determining the capacity of the health care labor force to meet the needs of older Americans continues to increase in the face of a rapidly aging population. This dissertation consists of three essays that examine two important public policy issues related to the population health of older Americans: rural-urban differences in health care provider supply and the relationship between labor market conditions and health outcomes.
The three chapters of this dissertation explore different aspects of labor and health economics. My first chapter explores moral hazard in the context of a popular recent medical innovation called PrEP. PrEP is a drug introduced in 2012 that essentially eliminates the risk of contracting HIV. Since its introduction, it has become popular among gay men, who are responsible for the majority of HIV infections. Given the reduced risk of contracting HIV, users might be more likely to engage in risky sexual behaviors that might lead to increases in other STIs. In this paper, we examine this empirically. In our main specification, we proxy for PrEP use in a given state using the predetermined share of the population that is gay in that state, a measure that is highly predictive of PrEP use. We then exploit this pre-treatment cross-state variation in the concentration of gay men to estimate difference-in-difference and triple-difference event studies. We estimate that one additional male PrEP user increases male chlamydia, gonorrhea and syphilis cases by 0.66, 0.51, and 0.04, respectively. Counterfactual distributions suggest that male STI rates would have been between 17.9% and 25.6% lower in the absence of PrEP. This paper adds to the literature on moral hazard by examining the behavioral response to a medical innovation that is cheap, accessible, and confers substantial reduction in risk that is highly salient to users. In addition, it informs an open question regarding the increases in STIs in recent years. In my second chapter I explore the effect of extreme weather on migration in the United States. Extreme weather has become more frequent and intense over the past few decades. Its effect on migration in developed countries has been understudied. Given that the United States population has been historically highly mobile, direct and indirect effects of extreme weather could catalyze people to migrate. I test this empirically by exploiting spatial and temporal variation in extreme weather (temperature, precipitation and natural disasters) at the county level over 6 decades (1950-2010). A non-parametric estimation yields an inverted U-shape relationship between temperature and net-migration, where decades in which the temperature was further away from the 50-60 temperature bin exhibit lower net-migration; the effect is strongest at the extreme temperature bins. Specifically, one additional day in a year (averaged over a decade) with temperature above 90 decreases net migration by approximately 1.33 migrants per 100 population. Incidences of natural disasters and increased precipitation are also associated with decreased net-migration. I find that the effect is strongest for younger people, and I find no effect for old people. I also find that the magnitude of the relationship is not stronger for agriculture-dependent counties. This result is important as migration could mitigate the detrimental effects of climate change in the developed world. In addition, it suggests that future increase in extreme weather could entail a migration response that will affect different markets, which should be taken into account when considering the general equilibrium effects of climate change. In my third chapter I explore the labor market effects of a generous child allowance policy in Israel. Child allowances are generous in both eligibility and value and are one of the largest social welfare programs in Israel. Although prevalent in developed countries, research on the effect of universal child allowances on labor outcomes has been scarce. I aim to fill this gap by examining the effect on labor outcomes of a policy that drastically reduced child allowances in Israel during the years 2002-2005 in varying degrees of intensity, depending on parity. Employing several difference-in-differences analyses, I find that the policy increased the labor force participation of young women by 6.6% from baseline; I find no effect on working hours. I also find that younger and more educated women were more responsive. This paper informs policy makers in designing cash transfer programs in general and child benefits programs in particular
The third part is the combination of labor and health economics, which is concerned with the question how economic recessions affect the aggregate health outcomes of a population living in the same community. This chapter uses all inpatient data in Pennsylvania for the 2000-2011 period, during which people experienced two recessions, uses county unemployment rates as the primary indicator of recessions, and analyzes the effects of recessions on the percentage of total population in a community that are hospitalized for certain stress-related diseases, while controlling for the community's socio-demographic characteristics. This chapter finds that recessions significantly increase the risk of hospitalization due to alcohol-related conditions among all communities, but decrease the hospitalization rates for AMI and stroke among the high-population-density and high-poverty communities, respectively. Finally, there is no evidence showing any persistent effects of recessions on health.
Chapter I: The Impact of Occupation on Health Participation in meaningful occupations contributes to good health and well-being. Workers are more likely to derive satisfaction from participating in occupations well-suited to their skills and training. This project provides causal evidence of the impact of occupation on health among college graduates. In particular, I estimate the health effect of participation in occupations well-suited to their education level, that is, occupations that value college education. Valuation of college education in an occupation is measured by occupation-specific college earning premium: the adjusted percentage difference in earnings between workers with and without college degrees in this given occupation. The causal inference relies on estimation with instrumental variables, which are constructed in the spirit of Hausman's price instrumental variables. The result suggests that college educated individuals participating in occupations with higher college earning premiums have better self-reported health, even after accounting for income, occupational prestige, and within-occupation hierarchy. This is the first paper to establish the causal impact of occupation on health. I also show that this causal impact remains significant across various specifications. Chapter II: The Power of Propaganda Since the 1950s, China's central government's gender equality propaganda is widely accepted as the explanation for China's high female labor force participation rate. In an effort to provide empirical evidence for this viewpoint, this project shows that early exposure to propaganda promoting gender equality affects individuals' attitudes towards women in the workforce. We gauge variation in the political climate between 1952 and 2008 by using the official newspaper of the central government, People's Daily, which has been under the direct control of the Chinese Communist Party's top leadership. For causal inference, we exploit provincial variation in propaganda intensities, proxied by provincial level radio and television signal coverage. In addition, we use the timing of exogenous events to generate an instrumental variable for intensity peaks of the gender-equality propaganda. First, we exploit the exogenous timing of a series of national and international Women's Conference as one set of instrumental variables. Second, we utilize the timing of Jiang Qing's (Mao's wife) coming into prominence and her sudden removal by a political coup towards the end of the Cultural Revolution. We find that women with more intense exposure to propaganda promoting gender equality before age 26, and men with more intense exposure before age 18 tend to endorse women's participation in the workforce. The effect of propaganda is more pronounced on women than men. It is worth noting that while propaganda encourages women's participation in the workforce, it does not emphasize men's responsibility in the household. We indeed find evidence of the "superwoman complex": women are expected to strive for a career and do the bulk of the housework. This further evidence suggests that propaganda is able to transmit a more nuanced message, rather than a singularly progressive one. This is the first paper to empirically establish the long-term effect of early exposure to propaganda on individual's preference formation. Chapter III: Do Food Stamps Need More Restrictions? Given the high prevalence of obesity in low income population, several times in the history of Supplemental Nutrition Assistance Program (SNAP), Congress has considered placing limits on the types of food that could be purchased with program benefits. This study provides empirical evidence on the effectiveness of such potential restriction by examining the impact of income on calorie consumption patterns. The intuition is that if limited budget is the main reason why low-income households choose calorie dense food items, then subsidy without any restriction, acting as an upward shift in income, would reduce the likelihood of obesity. Using the National Health and Nutrition Examination Survey data from 2007-2014, I compare individuals from households who were recently dropped from SNAP, most likely due to a positive income shock, to individuals who are still participating in the program. I find little income effect on calorie consumption patterns. Whereas reduced grocery store accessibility is significantly correlated with an increase in total calorie intake, and calorie intake from sugar and fat. The result of this study suggests that placing limits on the types of food that could be purchased would be effective in curbing the obesity pandemic in low income population, and it also confirms the importance of eliminating food deserts.
In the United States, health insurance is often necessary for access to regular, affordable health care. With only eight of every hundred Americans buying private insurance plans on the individual market, the main sources for health insurance traditionally have been employers and the government. As new laws are being debated and introduced to reform an expensive health care industry in which nearly one-sixth of the population is uninsured, research is needed in order to evaluate the costs and benefits of these policy changes and to predict their success. To this end, in addition to understanding how likely individuals are to adopt new health insurance policies, we also should be interested in knowing how the demand for health insurance and changes in its accessibility will affect non-medical decisions. Specifically, labor market choices have been theorized to be directly related to decisions involving insurance coverage. If the availability of health insurance distorts a workers' job-related decisions, then the changing the landscape for how to access insurance may reverberate in employment outcomes. My dissertation focuses on understanding the factors that influence the demand for health insurance and the role that health insurance plays in an individual's decision to work, where to work, and how much to work. Specifically, I focus on the following three related questions: how does the demand for insurance affect labor market decisions such as when to exit unemployment? what drives insurance demand, and in particular, what motivators work best to increase demand for health coverage among the uninsured? and lastly, what are the supply-side employment responses to the provision of free or reduced-cost public health insurance? My first chapter explores how the demand for health insurance can change re-employment decisions among the unemployed, as well as the speed at which individuals return to work. Past research on this issue focuses on job-to-job switches and "job lock" but has yet to focus on individuals looking for work. This chapter uses data on laid-off individuals from the Medical Expenditure Panel Survey to compare the job search behavior and outcomes of individuals who differ in their demand for health insurance. I use three proxies for demand, based on spousal health and past insurance offer take-up decisions. Although each is potentially confounded by unobserved determinants of job search, I use a difference-in-differences and propensity score designs to isolate plausibly causal effects. I find consistent patterns across all three proxies (despite different potential omitted variables biases). Overall unemployment durations do not vary with demand for insurance, but this masks variation in the types of jobs taken. Individuals with higher demand for insurance have higher hazards for exiting unemployment into a job with insurance, but lower hazards for exiting to a job without insurance. This points to effects of insurance demand on both search effort and reservation wages, and to potentially important distorting effects of employer-linked health insurance. Whereas the first chapter takes variation in demand for insurance as a given, my second chapter digs deeper into the basis for this variation and whether it can be affected. In this chapter, I investigate the reasons the uninsured choose to forego insurance coverage and the impact of different messages on their insurance demand. Working with Enroll America, a large non-profit dedicated to decreasing the number of uninsured Americans, I conducted a stratified experiment to determine the best communication strategies to encourage participation in the healthcare exchanges. We test a combination of the following behavioral and information treatments: a risk treatment that emphasizes the average financial risk for someone without health insurance; a norms treatment that alerts our participants that staying uninsured will be against the law; a savings treatment that highlights the average savings available at the exchanges; a wording treatment where we refer to the Affordable Care Act (ACA) as "Obamacare"; and lastly, a cost-calculator treatment that allows individuals to explore the likely cost of insurance based on their own characteristics. Among the uninsured, we find that the cost-calculator treatment, the risk treatment, and the mandate are most effective in increasing intention to purchase insurance. The cost-calculator and the risk treatment increase informedness among this population, but the cost-calculator (when paired with the savings treatment) is the only treatment that increases willingness to pay for insurance. We use the information on willingness to pay to construct sub-group price elasticities of demand to compare to previous work interested in the demand for health insurance. Overall, the results of this chapter highlight the importance of informational campaigns to increase awareness of the costs and benefits of health coverage, particularly after large changes such as those implemented by the ACA. My third chapter continues by looking at the changes that have been introduced as a result of the ACA. Specifically, it explores whether expanding access to government-provided insurance affects individuals' decisions regarding employment and overall hours of work. Recent findings have suggested that increasing access to health insurance outside of employment has a sizable, negative impact on labor force participation. Along these lines, the Congressional Budget Office predicted that the expansion of Medicaid and private health insurance will cause a 1.5 to 2% reduction in hours worked in the first ten years. Comparing states by whether they chose to expand Medicaid under reforms introduced by the ACA, I look at changes in the probability a childless adult receives Medicaid, as well as changes in this group's employment likelihood and hours of work. Using household survey data from the CPS monthly survey and ASEC Supplement, I confirm a marked increase in the percent of childless adults insured by Medicaid but find no statistically significant changes in employment outcomes. I compare these results to other estimates of "employment lock" in recent literature. These results, though imprecise, align with the findings in Chapter 1 which suggest that overall employment is not drastically affected by insurance demand.
Collection of essays on the economics of health and health services in the USA - covers supply and demand, budgetary resources, cost and objectives with regard to medical care, and considers wages and income distribution among medical personnel, effects of health care on labour productivity, etc. References and statistical tables.