Getting the right tail right: Modeling tails of health expenditure distributions.

Health expenditure data almost always include extreme values, implying that the underlying distribution has heavy tails. This may result in infinite variances as well as higher-order moments and bias the commonly used least squares methods. To accommodate extreme values, we propose an estimation method that recovers the right tail of health expenditure distributions. It extends the popular two-part model to develop a novel three-part model. We apply the proposed method to claims data from one of the biggest German private health insurers. Our findings show that the estimated age gradient in health care spending differs substantially from the standard least squares method.

How do low-income enrollees in the Affordable Care Act marketplaces respond to cost-sharing?

The Affordable Care Act requires insurers to offer cost sharing reductions (CSRs) to low-income consumers on the Marketplaces. We link 2013-2015 All-Payer Claims Data to 2004-2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the actuarial value of CSR plans that are solely determined by income. This allows us to examine the effect of cost sharing on medical spending among low-income individuals. We find that enrollees facing lower levels of cost sharing have higher levels of health care spending, controlling for past health care use. We estimate demand elasticities of total health care spending among this low-income population of approximately -0.12, suggesting that demand-side price mechanisms in health insurance design work similarly for low-income and higher-income individuals. We also find that cost sharing subsidies substantially lower out-of-pocket medical care spending, showing that the CSR program is a key mechanism for making health care affordable to low-income individuals.

"The better you feel, the harder you fall": Health perception biases and mental health among Chinese adults during the COVID-19 pandemic.

The health risks of the current COVID-19 pandemic, together with the drastic mitigation measures taken in many affected nations, pose an obvious threat to public mental health. To assess predictors of poor mental health in the context of the COVID-19 pandemic, this study first implements survey-based measures of health perception biases among Chinese adults during the pandemic. Then, it analyzes their relation to three mental health outcomes: life satisfaction, happiness, and depression (as measured by the CES-D). We show that the health overconfidence displayed by approximately 30% of the survey respondents is a clear risk factor for mental health problems; it is a statistically significant predictor of depression and low levels of happiness and life satisfaction. We also document that these effects are stronger in regions that experienced higher numbers of confirmed COVID-19 cases and deaths. Our results offer clear guidelines for the implementation of effective interventions to temper health overconfidence, particularly in uncontrollable situations like the COVID-19 pandemic.

The Experience of Implementing a Low-Threshold Buprenorphine Treatment Program in a Non-Urban Medical Practice.

BACKGROUND: To respond to the U.S. opioid crisis, new models of healthcare delivery for opioid use disorder treatment are essential. We used a qualitative approach to describe the implementation of a low-threshold buprenorphine treatment program in an independent, community-based medical practice in Ithaca, NY. METHODS: We conducted 17 semi-structured interviews with program staff, leadership, and external stakeholders. Then we analyzed these data using content analysis. We used purposeful sampling aiming for variation in job title for program staff, and in organizational affiliation for external stakeholders. RESULTS: We found that opening an independent medical practice allowed for low-threshold buprenorphine treatment with less regulatory oversight, but state-certification was ultimately required to ensure financial sustainability. Relying on health insurance reimbursement alone led to funding shortfalls and additional funding sources were also required. The practice's ability to build relationships with licensed substance use treatment programs, community organizations, the legal system, and government agencies in the region differed depending on how much these entities supported a harm reduction philosophy compared to abstinence-based treatment. Finally, expanding the practice to a second location in a different region, co-located with a syringe service program, required adapting to a new cultural and political environment. CONCLUSION: The results from this study provide insight about the challenges that independent medical practices might face in delivering low-threshold buprenorphine treatment. They support policy efforts to address the financial burdens associated with providing low-threshold buprenorphine therapy and inform the external relationships that other providers would need to consider when delivering novel treatment models.

Awareness and use of (emergency) sick leave: US employees' unaddressed sick leave needs in a global pandemic.

We study US sick leave use and unaddressed sick leave needs in the midst of the global severe acute respiratory syndrome coronavirus type 2 (SARS COV 2) pandemic based on a representative survey. More than half of all US employees are unaware of the new emergency sick leave options provided by the federal Families First Coronavirus Response Act (FFCRA). Awareness and take-up rates are significantly higher among Asian Americans and lower among the foreign-born. About 8 million employees used emergency sick leave in the first 6 to 8 mo. Nevertheless, the share of employees who needed but could not take paid sick leave tripled in the pandemic; unaddressed sick leave needs total 15 million employees per month and are 69% higher among women. Our findings show that access to paid sick leave significantly reduces unaddressed sick leave needs. We conclude that given the fragmented US sick leave landscape, to address the strong increase in unaddressed sick leave needs during the pandemic, federal FFCRA response was not adequate.

Biased health perceptions and risky health behaviors-Theory and evidence.

This paper investigates the role of biased health perceptions as a potential driving force of risky health behaviors. We define absolute and relative health perception biases, illustrate their measurement in surveys and provide evidence on their relevance. Next, we decompose the theoretical effect into its extensive and intensive margin: When the extensive margin dominates, people (wrongly) believe they are healthy enough to "afford" unhealthy behavior. Finally, using three population surveys, we provide robust empirical evidence that respondents who overestimate their health are less likely to exercise and sleep enough, but more likely to eat unhealthily and drink alcohol daily.

A Harm Reduction Approach to Treating Opioid Use Disorder in an Independent Primary Care Practice: a Qualitative Study.

BACKGROUND: Stigma is a barrier to the uptake of buprenorphine to treat opioid use disorder. Harm reduction treatment models intend to minimize this stigma by organizing care around non-judgmental interactions with people who use drugs. There are few examples of implementing buprenorphine treatment using a harm reduction approach in a primary care setting in the USA. METHODS: We conducted a qualitative study by interviewing leadership, staff, and external stakeholders at Respectful, Equitable Access to Compassionate Healthcare (REACH) Medical in Ithaca, NY. REACH is a freestanding medical practice that provides buprenorphine treatment for opioid use disorder since 2018. We conducted semi-structured interviews with 17 participants with the objective of describing REACH's model of care. We selected participants based on their position at REACH or in the community. Interviews were recorded, transcribed, and analyzed for themes using content analysis, guided by the CDC Evaluation Framework. RESULTS: REACH provided buprenorphine, primary care, and mental health services in a low-threshold model. We identified three themes related to delivery of buprenorphine treatment. First, an organizational mission to provide equitable and low-stigma healthcare, which was a key to organizational identity. Second, a low-threshold buprenorphine treatment approach that was critical, but caused concern about over-prescribing and presented logistical challenges. Third, creation and retention of a harm reduction-oriented workforce by offering value-based work and by removing administrative barriers providers may face elsewhere to providing buprenorphine treatment. CONCLUSIONS: A harm reduction primary care model can help reduce stigma for people who use drugs and engage in buprenorphine treatment. Further research is needed to evaluate whether this model leads to improved patient outcomes, can overcome community stakeholder concerns, and is sustainable.

COVID-19 Emergency Sick Leave Has Helped Flatten The Curve In The United States.

This analysis examines whether the coronavirus disease 2019 (COVID-19) emergency sick leave provision of the bipartisan Families First Coronavirus Response Act (FFCRA) reduced the spread of the virus. Using a difference-in-differences strategy, we compared changes in newly reported COVID-19 cases in states where workers gained the right to take paid sick leave (treatment group) versus in states where workers already had access to paid sick leave (control group) before the FFCRA. We adjusted for differences in testing, day-of-the-week reporting, structural state differences, general virus dynamics, and policies such as stay-at-home orders. Compared with the control group and relative to the pre-FFCRA period, states that gained access to paid sick leave through the FFCRA saw around 400 fewer confirmed cases per state per day. This estimate translates into roughly one prevented case per day per 1,300 workers who had newly gained the option to take up to two weeks of paid sick leave.

The health effects of smoking bans: Evidence from German hospitalization data.

This paper studies the short-term impact of public smoking bans on hospitalizations in Germany. It exploits the staggered implementation of smoking bans over time and across the 16 federal states along with the universe of hospitalizations from 2000 to 2008 and daily county-level weather and pollution data. Smoking bans in bars and restaurants have been effective in preventing 1.9 hospital admissions (-2.1%) due to cardiovascular diseases per day, per 1 million population. We also find a decrease by 0.5 admissions (-6.5%) due to asthma per day, per 1 million population. The health prevention effects are more pronounced on sunny days and days with higher ambient pollution levels.

Lung cancer risk perception biases.

This paper provides new evidence on biased perceptions about the risks of smoking. It studies predictors of lung cancer risk perceptions. Lung cancer is one of the deadliest and most aggressive cancer types with 5-year survival rates of only up to 15%. A cross-sectional online survey in Berlin assessed lung cancer risk perceptions among smokers (n = 664), never smokers (n = 703), and former smokers (n = 501) in 2013. In addition to lung cancer risk perceptions, the survey measured many respondent characteristics, such as intention to quit smoking and a self-assessment of the likelihood of success in quitting. The findings show that 80% of all respondents overestimated lung cancer survival rates and suggest significant room for public health campaigns to educate smokers and nonsmokers about the deadliness of lung cancer. Multivariate linear regressions show that smokers who do not plan to quit estimate the 5-Year Lung Cancer Survival Rate to be 11% (p = 0.044) higher than other smokers. A reduction in risk perception biases may induce some smokers to alter their quitting intentions and others to successfully quit.

Introducing risk adjustment and free health plan choice in employer-based health insurance: Evidence from Germany.

To equalize differences in health plan premiums due to differences in risk pools, the German legislature introduced a simple Risk Adjustment Scheme (RAS) based on age, gender and disability status in 1994. In addition, effective 1996, consumers gained the freedom to choose among hundreds of existing health plans, across employers and state-borders. This paper (a) estimates RAS pass-through rates on premiums, financial reserves, and expenditures and assesses the overall RAS impact on market price dispersion. Moreover, it (b) characterizes health plan switchers and investigates their annual and cumulative switching rates over time. Our main findings are based on representative enrollee panel data linked to administrative RAS and health plan data. We show that sickness funds with bad risk pools and high pre-RAS premiums lowered their total premiums by 42 cents per additional euro allocated by the RAS. Consequently, post-RAS, health plan prices converged but not fully. Because switchers are more likely to be white collar, young and healthy, the new consumer choice resulted in more risk segregation and the amount of money redistributed by the RAS increased over time.

End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported.

Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.

U.S. Child Safety Seat Laws: Are they Effective, and Who Complies?

This paper assesses the effectiveness of child safety seat laws in the United States. Over the past 35 years, these laws have steadily increased mandatory child safety seat restraint ages. We exploit state-year level variation in the age until which children are required to ride in child safety seats to estimate triple difference models using Fatality Analysis Reporting System (FARS) data from 1975 to 2011. Our findings show that increasing the age thresholds is effective in increasing the actual age of children in safety seats. Across the child-age distribution, restraint rates increase by between 10 and 30 percentage points or by between 50 and 170 percent, in the long run. We also estimate the impact of the child safety seat laws on the likelihood that a child dies in a fatal accident. We find that the laws saved up to 39 children per year. Finally, we find that the laws primarily induce compliant parents to switch from traditional seatbelt use to child safety seat use, with only small effects among parents who do not restrain their children.

Non-separable time preferences, novelty consumption and body weight: Theory and evidence from the East German transition to capitalism.

This paper develops a dynamic model to illustrate how diet and body weight change when novel food products become available to consumers. We propose a microfounded test to empirically discriminate between habit and taste formation in intertemporal preferences. Moreover, we show that 'novelty consumption' and endogenous preferences can explain the persistent correlation between economic development and obesity. By empirically studying the German reunification, we find that East Germans consumed more novel Western food and gained more weight than West Germans when a larger variety of food products became readily accessible after the fall of the Wall. The observed consumption patterns suggest that food consumption features habit formation.

Inevitable? Doping attitudes among Berliners in 2011: the role of socialist state socialisation and athlete experience.

To design effective and commonly accepted public health policies against performance-enhancing drugs (PED), it is important to understand general population attitudes. This article elicits PED attitudes in the Berlin population and compares response rates of former athletes (N = 496) with those of non-athletes (N = 1686). In addition, exploiting the natural experiment of the division of Germany, by comparing East (N = 687) to West Berliners (N = 1315), the article studies the long-term impact of state socialisation on PED attitudes. Former West German amateur athletes are a statistically significant 6ppt more likely to believe that athletes can be successful without doping. Former GDR amateur athletes are 8ppt more likely to believe that doping is inevitable in professional sports.

Profiling the U.S. Sick Leave Landscape: Presenteeism among Females.

OBJECTIVE: To profile the sick leave landscape in the United States. DATA SOURCES: The 2011 Leave Supplement of the American Time Use Survey. STUDY DESIGN: Bivariate and multivariate analyses to identify (i) employees without sick pay coverage and (ii) employees who attend work sick. PRINCIPAL FINDINGS: Sixty-five percent of full-time employees have sick pay coverage. Coverage rates are below 20 percent for employees with hourly wages below $10, part-time employees, and employees in the hospitality and leisure industry. CONCLUSION: Each week, up to 3 million U.S. employees go to work sick. Females, low-income earners, and those aged 25 to 34 years have a significantly elevated risk of presenteeism behavior.

Analyzing regional variation in health care utilization using (rich) household microdata.

This paper exploits rich SOEP microdata to analyze state-level variation in health care utilization in Germany. Unlike most studies in the field of the Small Area Variation (SAV) literature, our approach allows us to net out a large array of individual-level and state-level factors that may contribute to the geographic variation in health care utilization. The raw data suggest that state-level hospitalization rates vary from 65 to 165 percent of the national mean. Ambulatory doctor visits range from 90 to 120 percent of the national mean. Interestingly, in the former GDR states, doctor visit rates are significantly below the national mean, while hospitalization rates lie above the national mean. The significant state-level differences vanish once we control for individual-level socio-economic characteristics, the respondents' health status, their health behavior as well as supply-side state-level factors.

Assessing the effectiveness of health care cost containment measures: evidence from the market for rehabilitation care.

This study empirically evaluates the effectiveness of different health care cost containment measures. The measures investigated were introduced in Germany in 1997 to reduce moral hazard and public health expenditures in the market for rehabilitation care. Of the analyzed measures, doubling the daily copayments was clearly the most effective cost containment measure, resulting in a reduction in utilization of about [Formula: see text] . Indirect measures such as allowing employers to cut federally mandated sick pay or paid vacation during inpatient post-acute care stays did not significantly reduce utilization. There is evidence neither for adverse health effects nor for substitution effects in terms of more doctor visits.

Welfare-related health inequality: does the choice of measure matter?

Using representative microdata from the German Socio-Economic Panel Study (SOEP), we show that the welfare measure choice has a substantial impact on the degree of welfare-related health inequality. To assess the sensitivity of welfare-related health inequality measures, we combine a unique set of income and wealth measures with different subjective, cardinalized, and (quasi-)objective health measures. The influence of the welfare measure is more pronounced when using subjective health measures than when using (quasi-)objective health measures.