Effect of age-related premium readjustment on health insurance cancellation in Brazil: Regression discontinuity approach.

Age is one of the most relevant observable risk attributes in determining the value of health insurance premiums. Empirical evidence indicates that the cost of health insurance is the leading cause of contract switching, which can compromise access to healthcare services and potentially result in treatment discontinuities. Using data from a Health Maintenance Organization in the Southern region of Brazil, we examined the effect of health plan price readjustment resulting from changes in the beneficiary's age group on disenrollment or switches to a more limited coverage plan. The estimates were obtained using the method of regression discontinuity. The main findings indicate that for age group transitions at 59 years old, the price readjustment effect led to an increase in contract cancellations and switching to cheaper plans. These findings highlight that an important consequence of the difference in premium sensitivity among age groups is that the exit of individuals from the health insurance sector is selective in age. The results of this paper can support policymaking to improve access to health insurance.

Evaluating the association between receipt of a winter fuel cash transfer and older people's care needs, quality of life, and housing quality: Evidence from England.

BACKGROUND: Exposure to cold temperatures is known to be associated with deterioration of physical and mental health as well as poorer well-being in many countries. The Winter Fuel Payment, an unconditional direct cash transfer of value between £250-£300, was designed to help older people in England cover heating costs during the winter months, to counteract the particular vulnerability of older people to the effects of cold weather. AIMS: We evaluated the impact of the Winter Fuel Payment scheme on subsequent prevalence of care needs such as being unable to eat or shower independently, quality of life and the likelihood of having cold-related housing conditions. We also explored the potential effects of the Winter Fuel Payment across different sub-samples (poorer/richer individuals, those living in newer/older properties, and in the North/South of England) to explore whether its benefits (if any) are spread equally across the eligible population. DATA AND METHODS: We used a regression discontinuity design approach with age as running variable to analyse seven waves of a nationally representative sample, the English Longitudinal Study of Ageing, covering the period 2002/2003 to 2016/2017, and consisting of 24,651 observations. RESULTS: The Winter Fuel Payment had no overall effect on the outcomes of interest (care needs, quality of life, and cold-related housing problems). However, the Payment increased quality of life for poorer individuals, for those living in Northern regions of England, and for those living in newer dwellings. The likelihood of living in a property with at least one cold-related housing problem also decreased for those living in newer properties. CONCLUSIONS: Findings from this research provide important insights into the effectiveness of a winter cash transfer among the older population in England, and they are potentially relevant for other nations looking for strategies to deal with cold seasons and poorly insulated homes. In particular, this evaluation contributes to the 'universality versus targeting' policy debate and has implications for the development of energy-efficient policies.

How culture shapes choices related to fertility and mortality: Causal evidence at the Swiss language border.

Results from cultural evolutionary theory often suggest that social learning can lead cultural groups to differ markedly in the same environment. Put differently, cultural evolutionary processes can in principle stabilise behavioural differences between groups, which in turn could lead selection pressures to vary across cultural groups. Separating the effects of culture from other confounds, however, is often a daunting and sometimes intractable challenge for the working empiricist. To meet this challenge, we exploit a cultural border dividing Switzerland in ways that are independent of institutional, environmental and genetic variation. Using a regression discontinuity design, we estimate discontinuities at the border in terms of preferences related to fertility and mortality, the two basic components of genetic fitness. We specifically select six referenda related to health and fertility and analyse differences in the proportion of yes votes across municipalities on the two sides of the border. Our results show multiple discontinuities and thus indicate a potential role of culture in shaping stable differences between groups in preferences and choices related to individual health and fertility. These findings further suggest that at least one of the two groups, in order to uphold its cultural values, has supported policies that could impose fitness costs on individuals relative to the alternative policy under consideration.

The impact of retirement on blood pressure: evidence from a nationwide survey in China.

INTRODUCTION: The health impact of retirement is controversial. Most previous studies have been based on self-reported health indicators or the endpoints of some chronic diseases (e.g., morbidity or mortality), but objective physiological indicators (e.g., blood pressure) have rarely been used. The objective of this study is to elucidate the health effects of retirement on blood pressure, thereby offering empirical evidence to facilitate the health of retirees and to optimize retirement policies. METHODS: From 2012 to 2015, 84,696 participants of the Chinese Hypertension Survey (CHS) were included in this study. We applied the fuzzy regression discontinuity design (FRDD) to identify retirement's causal effect on systolic blood pressure (SBP), diastolic blood pressure (DBP) and pulse pressure. We also explored the heterogeneity in the effects of retirement across different sex and education level groups. RESULTS: Based on the fully adjusted model, we estimated that retirement increased SBP by 5.047 mm Hg (95% CI: -2.628-12.723, P value: 0.197), DBP by 0.614 mm Hg (95% CI: -3.879-5.108, P value: 0.789) and pulse pressure by 4.433 mm Hg (95% CI: -0.985-9.851, P value: 0.109). We found that retirement led to a significant increase in male participants' SBP and pulse pressure as well as a possible decrease in female participants' blood pressure. Additionally, the blood pressure levels of low-educated participants were more vulnerable to the shock of retirement. CONCLUSION: Retirement is associated with an increase in blood pressure level. There is a causal relationship between the increase in blood pressure levels of men and retirement. Policy-makers should pay extra attention to the health status of men and less educated people when adjusting retirement policies in the future.

Regression discontinuity design for the study of health effects of exposures acting early in life.

Regression discontinuity design (RDD) is a quasi-experimental approach to study the causal effect of an exposure on later outcomes by exploiting the discontinuity in the exposure probability at an assignment variable cut-off. With the intent of facilitating the use of RDD in the Developmental Origins of Health and Disease (DOHaD) research, we describe the main aspects of the study design and review the studies, assignment variables and exposures that have been investigated to identify short- and long-term health effects of early life exposures. We also provide a brief overview of some of the methodological considerations for the RDD identification using an example of a DOHaD study. An increasing number of studies investigating the effects of early life environmental stressors on health outcomes use RDD, mostly in the context of education, social and welfare policies, healthcare organization and insurance, and clinical management. Age and calendar time are the mostly used assignment variables to study the effects of various early life policies and programs, shock events and guidelines. Maternal and newborn characteristics, such as age, birth weight and gestational age are frequently used assignment variables to study the effects of the type of neonatal care, health insurance, and newborn benefits, while socioeconomic measures have been used to study the effects of social and welfare programs. RDD has advantages, including intuitive interpretation, and transparent and simple graphical representation. It provides valid causal estimates if the assumptions, relatively weak compared to other non-experimental study designs, are met. Its use to study health effects of exposures acting early in life has been limited to studies based on registries and administrative databases, while birth cohort data has not been exploited so far using this design. Local causal effect around the cut-off, difficulty in reaching high statistical power compared to other study designs, and the rarity of settings outside of policy and program evaluations hamper the widespread use of RDD in the DOHaD research. Still, the assignment variables' cut-offs for exposures applied in previous studies can be used, if appropriate, in other settings and with additional outcomes to address different research questions.

Japan's intensive health guidance program has limited effects on cardiovascular risk factors: a regression discontinuity analysis.

OBJECTIVES: It is uncertain whether the effects of health counselling programs differ depending on their intensity. This study compared the effectiveness of intensive health guidance (IHG) and less intensive motivation-enhancing guidance (MEG) on cardiovascular risk factors. STUDY DESIGN: A regression discontinuity design (RDD) was applied. METHODS: In Japan's specific health checkup (SHC) and guidance program, those with a high risk of metabolic syndrome are assigned to IHG or MEG. An RDD was applied using an SHC results database. Four groups were created in which IHG or MEG assignment was solely determined by single cut-off values of the running variables of triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), or haemoglobin A1c (HbA1c) measured during SHC. Outcomes were one year's changes in body mass index (BMI), waist circumference (WCF), systolic and diastolic blood pressure, HDL-C, low-density lipoprotein cholesterol, FBG, and HbA1c. RESULTS: A total of 541,809 observations among 225,115 people from 2008 to 2017 were analysed. Men assigned to IHG had a significantly but slightly lower BMI and WCF than those assigned to MEG the next year, only when TG or FBG was a running variable. There were no significant differences between IHG and MEG for women's BMI and WCF and other cardiovascular risk factors for both sexes. CONCLUSION: Since IHG has limited additional effects on cardiovascular risk factors compared with MEG, abolishing IHG may have little negative impact on the general public's health.

The effect of retirement on physical and mental health in China: a nonparametric fuzzy regression discontinuity study.

BACKGROUND: With the rapid aging of the domestic population, China has a strong incentive to increase the statutory retirement age. How retirement affects the health of the elderly is crucial to this policymaking. The health consequences of retirement have been debated greatly. This study aims to investigate the effects of retirement on physical and mental health among Chinese elderly people. METHODS: The data we use in this study comes from four waves (2011, 2013, 2015, and 2018) of the Harmonized China Health and Retirement Longitudinal Study (Harmonized CHARLS), a prospective cohort. We use the nonparametric fuzzy regression discontinuity design to estimate the effects of retirement on physical and mental health. We test the robustness of our results with respect to different bandwidths, kernel functions, and polynomial orders. We also explore the heterogeneity across gender and education. RESULTS: Results show that retirement has an insignificant effect on a series of physical and mental health outcomes, with and without adjusting several sociodemographic variables. Heterogeneity exists regarding gender and education. Although stratified analyses indicate that the transition from working to retirement leaves minimal effects on males and females, the effects go in the opposite direction. This finding holds for low-educated and high-educated groups for health outcomes including depression and cognitive function. Most of the results are stable with respect to different bandwidths, kernel functions, and polynomial orders. CONCLUSIONS: Our results suggest that it is possible to delay the statutory retirement age in China as retirement has insignificant effects on physical and mental health. However, further research is needed to assess the long-term effect of retirement on health.

Evaluating the impact of the Community Helpers Program on adolescents 12-18 years old in Edmonton, Canada.

INTERVENTION: Alberta Health Services (AHS) Community Helpers Program (CHP) to enhance mental health among youth. RESEARCH QUESTION: Identifying the impact of CHP on mental illness-related acute care use among adolescents aged 12-18 years in Edmonton and determining cost avoidance. METHODS: Using administrative data from AHS, public school catchment area data from the Edmonton Public School Board, and area-level socioeconomic deprivation status indicators from the Pampalon deprivation index, we applied geographical regression discontinuity design to estimate the effect of CHP implementation on depression-, anxiety-, and suicide-related acute care use (emergency department visits and inpatient admissions). Cost data were derived from Interactive Health Data Application of Alberta Health. The study period (2002-2022) included pre (2002-2011) and post (2012-2020) CHP implementation periods. RESULTS: CHP had statistically significant impact when distance from the boundary (catchment area identifier to divide the sample into treated and control groups) was between 600 and 800 m. About 90 and 80 fewer anxiety- and depression-related visits (per 1000 visits) were observed among individuals aged 12-15 and 16-18 years, respectively, in catchment areas of the public schools where CHP was implemented. Impact of CHP on suicide-related visits was only statistically significant among individuals aged 12-15 years. Annual cost reduction ranged from $161,117 to $269,255 for anxiety- and depression-related visits. CONCLUSION: Findings show contextual effect of CHP; i.e., being potentially exposed to the program reduced the likelihood of anxiety- and depression-related visits. Costs of CHP implementation could be compared with the avoided costs to assess economic benefits of implementing CHP.

RéSUMé: INTERVENTION: Le Programme d'aidants communautaires (CHP, Community Helpers Program) des Alberta Health Services (AHS) sert à améliorer la santé mentale des jeunes de l'Alberta. SUJET DE LA RECHERCHE: Déterminer l'incidence du CHP sur l'utilisation des soins de courte durée liés à la maladie mentale chez les adolescents d'Edmonton âgés de 12 à 18 ans et l'évitement des coûts. MéTHODES: Utilisant les données administratives des AHS, les données sur les zones d'implantation du conseil des écoles publiques d'Edmonton et les indicateurs de pauvreté socioéconomique au niveau régional de l'indice de défavorisation de Pampalon, nous avons appliqué un plan de discontinuité de la régression géographique pour estimer l'effet de la mise en œuvre du CHP sur l'utilisation des soins de courte durée liés à la dépression, à l'anxiété et au suicide (visites aux services d'urgence et admissions de patients hospitalisés). Les données relatives au coût ont été calculées à partir de l'application interactive des données sur la santé du ministère de la Santé de l'Alberta. La période de l'étude (2002-2022) inclut les périodes précédant (2002-2011) et suivant (2012-2020) la mise en œuvre du CHP. RéSULTATS: Le CHP a eu une incidence statistiquement significative lorsque la distance de la limite (identificateur de la zone d'implantation pour diviser l'échantillon en groupes traités et témoins) était entre 600 et 800 mètres. Environ 90 et 80 visites de moins, liées à l'anxiété et à la dépression (pour 1 000 visites), ont été observées chez les personnes de 12 à 15 ans et de 16 à 18 ans, respectivement dans les zones d'implantation des écoles publiques où le CHP a été mis en œuvre. L'incidence du CHP sur les visites liées au suicide n'était statistiquement significative que chez les personnes de 12 à 15 ans. La réduction annuelle des coûts variait de 161 117 $ à 269 255 $ pour les visites liées à l'anxiété et à la dépression. CONCLUSION: Les résultats montrent qu'un effet contextuel du CHP, c.-à-d. le fait d'être potentiellement exposé au programme, réduit la probabilité de visites liées à l'anxiété et à la dépression. Le coût de la mise en œuvre du CHP comparé aux coûts évités permet d'évaluer les avantages économiques de la mise en œuvre du CHP.

Study abroad programmes and student outcomes: Evidence from Erasmus.

Exploiting admission thresholds for participating in Erasmus, the most popular higher education study abroad programme in Europe, we implement a regression discontinuity design and show that student mobility does not delay graduation and, in addition, has a positive and significant impact on the final graduation marks of undergraduate students. We find that Erasmus mobility improves graduation results for undergraduate students enrolled in scientific and technical fields and for those who apply in the first year of their studies, especially when enrolled in more demanding degree courses. Investigating plausible mechanisms, we find that the positive impact on performance at graduation is stronger for students who visit foreign universities of relatively lower quality compared to their home university. Finally, we do not find statistically significant effects of Erasmus mobility on postgraduate educational choices and labour market outcomes one year after graduation.

Multi-institutional study of osimertinib dose-optimization in non-small cell lung cancer patients with EGFR activating mutation aged 70 years or older ('MONEY' trial).

Osimertinib is the standard of care for patients with epidermal growth factor receptor-activating mutation-positive non-small cell lung cancer. Dose-toxicity has been previously reported, but no dose-response data within the range of 20-240 mg daily (mg/d). Thus, the current 80 mg/d dosing might be too high for elderly Japanese patients with an average body weight of only 50 kg, resulting in excessive toxicity and cost. We therefore initiated a study to investigate whether osimertinib at 40 mg/d is non-inferior to 80 mg/d in patients with advanced or recurrent epidermal growth factor receptor-activating mutation-positive non-small cell lung cancer aged ≥70 years, using a regression discontinuity design. Osimertinib is administered at 40 mg/d for body weight ≤50 kg, and 80 mg/d for body weight >50 kg. The primary endpoint is progression-free survival. Sample size is 550 patients, based on a non-inferiority margin of the progression-free survival hazard ratio 1.333, 0.10 one-sided type I error and 80% power.

The impact of pension on the health behavior of elderly rural residents: evidence from China.

BACKGROUND: Unhealthy behavior is an important factor threatening the health of older rural residents in China. We examine the effects of receiving pension on elderly rural residents' health behavior (namely conscious control of sugar, salt, and edible oil intake, as well as learning health or wellness knowledge), also including effect heterogeneity by income level and gender. METHODS: Using China Rural Revitalization Survey (CRRS) in 2020, we used the policy rule of the China's New Rural Pension Scheme that only those people who are over 60 years old can have access to pension as the natural experiment, and explore the causal effect of receiving pensions on the health behaviors by using regression discontinuity design method. RESULTS: Having access to pension can improve the health behavior of rural elderly residents, including increasing the probability of rural residents' conscious control of sugar (p < 0.1) and conscious control of salt intake (p < 0.1), which is still valid after a series of robustness tests. Heterogeneity analysis finds that access to pensions is more likely to improve the health behavior of low-income families and male rural elderly residents. CONCLUSIONS: The research has expanded the discussion on the correlation between the pension and the health of rural elderly residents, and the conclusion provides important policy implications for optimizing the rural elderly insurance system and leveraging pension to improve the health behavior of rural elderly residents.

Examining the impact of a change in maternity leave policy in Canada on maternal mental health care visits to the physician.

PURPOSE: Maternity leave is a critical employee benefit that allows mothers to recover from the stress of pregnancy and childbirth and bond with their new baby. We aimed to examine the association between the extension of a maternity leave policy and maternal use of mental health services and prescription drugs in a universal public healthcare system. METHODS: This study uses administrative medical records from 18,000 randomly selected women who gave birth three months before and after an extension of the maternity leave policy. More specifically, mothers who gave birth after January 1st 2001, were entitled to 50 weeks of paid maternity leave, while mothers who gave birth before that date were entitled to only 26 weeks of paid maternity leave. Medical records were analyzed over a seven-year period (i.e., from October 1998 to March 2006). We examined the number and costs of mothers' medical visits for mental health care in the five years following delivery, as well as maternal use of prescribed medication for mental health problems. RESULTS: We found that mothers with extended maternity leave had - 0.12 (95%CI=-0.21; -0.02) fewer medical visits than mothers without a more generous maternity leave and that the cost of mental health services was Can$5 less expensive per women. These differences were found specifically during the extended maternity leave period. CONCLUSIONS: The extra time away from work may help mothers to balance new family dynamics which may result in less demand on the healthcare system.

Financial incentives and private health insurance demand on the extensive and intensive margins.

In countries with dual public and private healthcare systems, individuals are often incentivized to purchase private health insurance through subsidies and penalty. We use administrative data from Australia to study how high-income earners respond on both the intensive and extensive margins to the simultaneous withdrawal of a premium subsidy, and the increase of a tax penalty. We estimate regression discontinuity models by exploiting discontinuous changes in the penalty and subsidy rates. Our setting is particularly interesting because means testing creates different incentives at the extensive and intensive margins. Specifically, we could expect to see higher take-up of insurance coupled with downgrading to less expensive plans. We find evidence that the penalty - despite being large in value - only has a modest effect on take-up. Our results show little evidence of downgrading, which is consistent with a low price elasticity for the high-income earners we study.

The sword of damocles: Understanding the carbon abatement effects of top-down environmental management practices -- insights from China's campaign-style governance.

Inspection, standing for top-down environmental management practices, also known as campaign-style governance, is used by central governments to lessen local environmental pollution. However, there is no causal evidence for carbon abatement. Employing staggered difference-in-differences (DiD), I find that inspected cities mitigate carbon intensity and carbon emissions by 3.72% and 2.34%, respectively, with economic significance. Conducting a triple difference strategy, I suggest the channels are the local people's congresses and political consultative conferences' proposals, government attention, environmental regulation, industrial structure, and green innovation. Also, the heterogeneous effects suggest that municipal party secretaries assigned to their birthplace, the older the party standing and age, and those with natural sciences majors, are more conducive to the inspection achieving carbon mitigation. An alternative DiD specification shows that the "look-back" inspection achieves sustained carbon reduction. I support the argument that top-down inspection helps achieve resilience to climate change and reduce greenhouse gas emissions.

Massachusetts companion program bolsters COVID-19 vaccine rates among seniors.

In parts of the United States, COVID-19 vaccination rates remained low until late in Fall 2021 owing to both limited vaccine access and hesitancy. With colliding epidemics of RSV, flu, and COVID-19 in the winter, the retrospective evaluation of vaccine incentive policies is needed to inform future routine immunization campaigns. The Massachusetts companion program is one example of a policy that could boost vaccine uptake among older populations. Our regression discontinuity analysis suggests that the program was associated with an increase of up to 22 percentage points in the proportion of individuals aged 75 and older who have been fully vaccinated. Going forward, similar intervention strategies could be invaluable in scenarios where household contacts pose the greatest risk of transmission or where social ties can strongly influence individual decision-making.

Antenatal corticosteroids and newborn respiratory outcomes in twins: A regression discontinuity study.

OBJECTIVE: To estimate the effect of antenatal corticosteroids on newborn respiratory morbidity in twins. DESIGN: Regression discontinuity applied to population-based birth registry data. SETTING: British Columbia, Canada, 2008-2018. POPULATION: Twin pregnancies admitted for birth between 31+0 and 36+6 weeks of gestation. METHODS: During our study period, Canadian clinical practice guidelines recommended antenatal corticosteroid administration for imminent preterm birth up to 33+6 weeks. We used a logistic model to compare the predicted risks of our outcomes among pregnancies admitted for birth immediately before this clinical cut-point (higher probability of exposure to antenatal corticosteroids) versus immediately after it (lower probability). MAIN OUTCOME MEASURES: Our primary outcome was a composite of newborn respiratory distress or in-hospital death. Our secondary outcome was a composite of newborn respiratory intervention or in-hospital death. RESULTS: Among 2524 pregnancies (5035 liveborn twins), 47% of admissions before 34+0 weeks of gestation were exposed to antenatal corticosteroids but only 4.2% of admissions after this cut-point were exposed. The risk of newborn respiratory distress or in-hospital mortality increased abruptly at 34+0 weeks, corresponding to a protective effect of treatment (risk ratio [RR] 0.69, 95% CI 0.53-0.90; risk difference [RD] -12 cases per 100 births, 95% CI -20 to -4.1). There was no clear evidence for or against an effect on newborn respiratory intervention or in-hospital death (RR 0.89, 95% CI 0.70-1.13; RD -4.2 per 100, 95% CI -13 to +4.2). CONCLUSIONS: Our findings provide evidence for the effectiveness of antenatal corticosteroids in preventing adverse newborn respiratory outcomes in twins.

The effects of parental retirement on adult children's health: Evidence from China.

Using representative data from China, we examine the causal effects of parental retirement on the health of adult children. To do so, we adopt a fuzzy regression discontinuity design and exploit the mandatory retirement ages in China as cut-off points. We find no evidence that parental retirement has significant effects on the mental health, healthcare utilization, or risky health behaviors of adult children. However, paternal retirement and maternal retirement have different effects on adult children's Self-reported health (SRH). Paternal retirement has a significantly negative effect only on the SRH of sons, while maternal retirement does not induce such effects. Potential mechanisms of intergenerational transfer through which parental retirement might affect adult children's health are also explored.

Age penalties and take-up of private health insurance.

Financial penalties for delayed enrollment could be useful tools to encourage people to enroll earlier in health insurance markets, but little is known about how effective they are. We use a large administrative dataset for a 10% random sample of all Australian tax-filers to study how people respond to a step-wise age-based penalty, and whether the effect has changed over time. Individuals must pay a 2% premium surcharge for each year they delay enrollment beyond age 31. The penalty stops after 10 years of continuous hospital cover. The age-based penalty creates discontinuities in the incentive to insure by age, which we exploit to estimate causal effects. We find that people respond as expected to the initial age-penalty, but not to subsequent penalties. The 2% premium loading results in a 0.78-3.69 percentage points (or 2.1%-9.0%) increase in the take-up rate at age 31. We simulate the penalty impact and implications of potential reforms, and conclude that modest changes around the policy make little difference in the age distribution of insured, premiums or take-up rates. Our study provides important evidence on an understudied area in the literature and offers insights for countries considering financial penalties.

Changing the mindsets? Education and the intergenerational spread of tolerance for physical violence against women in Zimbabwe.

We investigate the relationship between childhood exposure to interparental violence and adult tolerance for violent beliefs against women. For individuals who have witnessed parental violence in childhood, our analysis suggests a 14.3-15.2 percentage point (pp) increase in tolerance, highlighting the transmission of violent beliefs across generations. Leveraging Zimbabwe's 1980 education reform as a natural experiment through a regression discontinuity design, we explore the potential of increased education to disrupt this intergenerational transmission. The reform led to an approximately two-year increase in female education, with a more pronounced impact in rural areas. This educational boost is associated with an estimated 4.1-7.9 pp reduction in tolerance for violence, especially among those who witnessed parental violence in childhood. We identify four primary mechanisms contributing to this reduction in tolerance: enhanced access to information, increased help-seeking behaviours, improved labour market outcomes, and higher educational levels among partners. Our findings underscore the effectiveness of educational policies in reducing tolerance for violence against women within low-income contexts such as Zimbabwe, thereby disrupting its intergenerational transmission. Moreover, these results emphasise the potential of education-based interventions in addressing the broader issue of violence against women in low-income countries.