Equity is more important for the social cost of methane than climate uncertainty.

The social cost of methane (SC-CH4) measures the economic loss of welfare caused by emitting one tonne of methane into the atmosphere. This valuation may in turn be used in cost-benefit analyses or to inform climate policies1-3. However, current SC-CH4 estimates have not included key scientific findings and observational constraints. Here we estimate the SC-CH4 by incorporating the recent upward revision of 25 per cent to calculations of the radiative forcing of methane4, combined with calibrated reduced-form global climate models and an ensemble of integrated assessment models (IAMs). Our multi-model mean estimate for the SC-CH4 is US$933 per tonne of CH4 (5-95 per cent range, US$471-1,570 per tonne of CH4) under a high-emissions scenario (Representative Concentration Pathway (RCP) 8.5), a 22 per cent decrease compared to estimates based on the climate uncertainty framework used by the US federal government5. Our ninety-fifth percentile estimate is 51 per cent lower than the corresponding figure from the US framework. Under a low-emissions scenario (RCP 2.6), our multi-model mean decreases to US$710 per tonne of CH4. Tightened equilibrium climate sensitivity estimates paired with the effect of previously neglected relationships between uncertain parameters of the climate model lower these estimates. We also show that our SC-CH4 estimates are sensitive to model combinations; for example, within one IAM, different methane cycle sub-models can induce variations of approximately 20 per cent in the estimated SC-CH4. But switching IAMs can more than double the estimated SC-CH4. Extending our results to account for societal concerns about equity produces SC-CH4 estimates that differ by more than an order of magnitude between low- and high-income regions. Our central equity-weighted estimate for the USA increases to US$8,290 per tonne of CH4 whereas our estimate for sub-Saharan Africa decreases to US$134 per tonne of CH4.

Social Decision-Making Analysis: A General Approach to Inform Decisions on Resources in the Public Sector.

OBJECTIVES: Public expenditure aims to achieve social objectives by improving a range of socially valuable attributes of benefit (arguments in a social welfare function). Public expenditure is typically allocated to public sector budgets, where budget holders are tasked with meeting a subset of social objectives. METHODS: Decision makers require an evidence-based assessment of whether a proposed investment is likely to be worthwhile given existing levels of public expenditure. However, others also require some assessment of whether the overall level and allocation of public expenditure are appropriate. This article proposes a more general theoretical framework for economic evaluation that addresses both these questions. RESULTS: Using a stylized example of the economic evaluation of a new intervention in a simplified UK context, we show that this more general framework can support decisions beyond the approval or rejection of single projects. It shows that broader considerations about the level and allocation of public expenditure are possible and necessary when evaluating specific investments, which requires evidence of the range of benefits offered by marginal changes in different types of public expenditure and normative choices of how the attributes of benefit gained and forgone are valued. CONCLUSIONS: The proposed framework shows how to assess the value of a proposed investment and whether and how the overall level of public expenditure and its allocation across public sector budgets might be changed. It highlights that cost-benefit analysis and cost-effectiveness analysis can be viewed as special cases of this framework, identifying the weakness with each.

Values Beyond "Health" in Budget-Constrained Healthcare Systems.

OBJECTIVES: Most current methods to value healthcare treatments only incorporate measures such as quality-adjusted life-years, combining gains in health-related quality of life and life expectancy in specific ways. Failure of these methods to recognize other dimensions of value has led to calls for methods to include additional values that are associated with the healthcare treatments but not captured directly by quality-adjusted life-years. This article seeks to provide methodologically sound ways to incorporate additional health-related outcomes, focusing on budget-constrained healthcare systems, in which using standard welfare economics methods are often eschewed. METHODS: The analysis develops standard extra-welfarist approaches to maximizing aggregate health, subject to fixed-budget constraints, using Lagrange multiplier methods. Then, additional valuable health-related outcomes, eg, reduced caregiver burden, real option value, and market- and non-market productivity are introduced. The article also introduces a social welfare function approach to illuminate how disability, disease severity and other equity-related issues can be incorporated into complete welfare measures. RESULTS: Resulting analysis, fully developed in an Appendix in Supplemental Materials found at https://doi.org/10.1016/j.jval.2024.02.005 and summarized in the main text, show that understanding how average and marginal healthcare costs increase with output and how health augments "additional values" provides ways to assess willingness to pay for them in these fixed-budget situations. CONCLUSIONS: In budget-constrained healthcare systems, only from actual budget allocations can values both of health itself and "additional values" be inferred. These methods, combined with methodologically sound social welfare functions, demonstrate how to move from "health" to "welfare" in measuring the value of increased healthcare use.

A welfare analysis of Medicaid and recidivism.

We present conservative estimates for the marginal value of public funds (MVPF) associated with providing Medicaid to inmates exiting prison. The MVPF measures the ratio between a policy's social benefits and its governmental costs. Our MVPF estimates suggest that every additional $1 the government spends on providing inmates exiting prison with Medicaid coverage can result in social benefits ranging between $3.45 and $10.62. A large proportion of the benefits we consider stems from the reduced future criminal involvement among former inmates who receive Medicaid. Employing a difference-in-differences approach, we find that Medicaid expansions reduce the average number of times a released inmate is reimprisoned within 1 year by approximately 11.5%. By combining this estimate with key values reported elsewhere (e.g., victimization costs, data on victimization and incarceration), we quantify specific benefits arising from the policy. These encompass diminished criminal harm due to lower reoffense rates, direct benefits to former inmates through Medicaid coverage, increased employment opportunities, and reduced loss of liberty resulting from fewer future reimprisonments. Net-costs consist of the cost of providing Medicaid net of changes in the governmental cost of imprisonment, changes in the tax revenue due to increased employment, and changes in spending on other public assistance programs. We interpret our estimates as conservative since we deliberately err on the side of under-estimating benefits and over-estimating costs when data on specific items are imprecise or incomplete. Our findings align closely with others in the sparse literature investigating the crime-related welfare impacts of Medicaid access, underscoring the substantial indirect benefits public health insurance programs can offer through crime reduction, in addition to their direct health-related advantages.

A theory of fiscal policy response to an epidemic.

Governments worldwide have issued massive amounts of debt to inject fiscal stimulus during the COVID-19 pandemic. This paper analyzes fiscal responses to an epidemic, in which interactions at work increase the risk of disease and mortality. Fiscal policies, which are designed to borrow against the future and provide transfers to individuals suffering economic hardship, can facilitate consumption smoothing while reduce hours worked and hence mitigate infections. We examine the optimal fiscal policy and characterize the condition under which fiscal policy improves social welfare. We then extend the model analyzing the static and dynamic pecuniary externalities under scale economies-the decrease in labor supply during the epidemic lowers the contemporaneous average wage rate while enhances the post-epidemic workforce health and productivity. We suggest that fiscal policy may not work effectively unless the government coordinates working time, and the optimal size of public debt is affected by production technology and disease severity and transmissibility.

The influence of welfare spending on national immunization outcomes: A scoping review.

Background: National policies influence the environments in which people live, but the ways in which these national policies influence people's health are not well understood. Welfare spending is one national policy that may influence population health. While some research indicates higher levels of welfare investment may positively influence health, mixed findings contradict this conclusion. These mixed results examining the link between welfare policies and health may be better understood by investigating the relationship between welfare spending and preventative health interventions, such as immunization. Objective: This article's purpose is to summarize the literature studying the relationship between national welfare spending and immunization outcomes. Design: This scoping review used the Joanna Briggs scoping review method. Data sources: The scoping review utilized scholarly databases and a focused gray literature search to find research articles that explored relationships between welfare spending and immunization outcomes. Review methods: Data was extracted from articles, including themes, aims, populations, years of study, methods, and findings. The articles' themes were further analyzed with a word cloud and principal component analysis to determine which themes were more likely to coincide in the literature. Results: Seven articles were included in the review. Most of these articles did not address the relationship between welfare spending or policy and immunizations directly or with rigorous methods. Conclusions: Ultimately, the results of the scoping review suggest a lack of literature regarding the relationship between welfare spending and immunization outcomes. Further research is needed to understand the impacts of national welfare spending on immunization outcomes.

Estimated societal costs of stroke in the UK based on a discrete event simulation.

BACKGROUND: there are around 100,000 new stroke cases and over a million people living with its consequences annually in the UK. This has large impacts on health and social care, unpaid carers and lost productivity. We aimed to estimate associated costs. METHODS: we estimated 2014/2015 annual mean cost per person and aggregate UK cost of stroke for individuals aged ≥40 from a societal perspective. Health and social care costs in the first and subsequent years after stroke were estimated from discrete event simulation modelling, with probability of progression and length of receipt of different health and social care services obtained from routine registry and audit data. Unpaid care hours and lost productivity were obtained from trial data. UK unit costs were applied to estimate mean costs. Epidemiological estimates of stroke incidence and prevalence were then applied to estimate aggregate costs for the UK. RESULTS: mean cost of new-onset stroke is £45,409 (95% CI 42,054-48,763) in the first year after stroke and £24,778 (20,234-29,322) in subsequent years. Aggregate societal cost of stroke is £26 billion per year, including £8.6 billion for NHS and social care. The largest component of total cost was unpaid care (61%) and, given high survival, £20.6 billion related to ongoing care. CONCLUSION: the estimated aggregate cost of stroke substantially exceeds previous UK estimates. Since most of the cost is attributed to unpaid care, interventions aimed at rehabilitation and reducing new and recurrent stroke are likely to yield substantial benefits to carers and cost savings to society.

The future incidence, prevalence and costs of stroke in the UK.

BACKGROUND: we project incidence and prevalence of stroke in the UK and associated costs to society to 2035. We include future costs of health care, social care, unpaid care and lost productivity, drawing on recent estimates that there are almost 1 million people living with stroke and the current cost of their care is £26 billion. METHODS: we developed a model to produce projections, building on earlier work to estimate the costs of stroke care by age, gender and other characteristics. Our cell-based simulation model uses the 2014-based Office for National Statistics population projections; future trends in incidence and prevalence rates of stroke derived from an expert consultation exercise; and data from the Office for Budget Responsibility on expected future changes in productivity and average earnings. RESULTS: between 2015 and 2035, the number of strokes in the UK per year is projected to increase by 60% and the number of stroke survivors is projected to more than double. Under current patterns of care, the societal cost is projected to almost treble in constant prices over the period. The greatest increase is projected to be in social care costs-both public and private-which we anticipate will rise by as much as 250% between 2015 and 2035. CONCLUSION: the costs of stroke care in the UK are expected to rise rapidly over the next two decades unless measures to prevent strokes and to reduce the disabling effects of strokes can be successfully developed and implemented.

Impact of International Monetary Fund programs on child health.

Parental education is located at the center of global efforts to improve child health. In a developing-country context, the International Monetary Fund (IMF) plays a crucial role in determining how governments allocate scarce resources to education and public health interventions. Under reforms mandated by IMF structural adjustment programs, it may become harder for parents to reap the benefits of their education due to wage contraction, welfare retrenchment, and generalized social insecurity. This study assesses how the protective effect of education changes under IMF programs, and thus how parents' ability to guard their children's health is affected by structural adjustment. We combine cross-sectional stratified data (countries, 67; children, 1,941,734) from the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys. The sample represents ∼2.8 billion (about 50%) of the world's population in year 2000. Based on multilevel models, our findings reveal that programs reduce the protective effect of parental education on child health, especially in rural areas. For instance, in the absence of IMF programs, living in an household with educated parents reduces the odds of child malnourishment by 38% [odds ratio (OR), 0.62; 95% CI, 0.66-0.58]; in the presence of programs, this drops to 21% (OR, 0.79; 95% CI, 0.86-0.74). In other words, the presence of IMF conditionality decreases the protective effect of parents' education on child malnourishment by no less than 17%. We observe similar adverse effects in sanitation, shelter, and health care access (including immunization), but a beneficial effect in countering water deprivation.

Program Impact Pathways and Contexts: A Commentary on Theoretical Issues and Research Applications to Support the EsIAN Component of Mexico's Conditional Cash Transfer Program.

This commentary on the Integrated Strategy for Attention to Nutrition (EsIAN) journal supplement begins with a discussion about the challenges that implementation researchers confront with respect to analyzing complex impact pathways. We note that the research on the implementation of the EsIAN component of Mexico's conditional cash transfer program was based implicitly or explicitly on a program impact pathway approach, which used both quantitative and qualitative methods to examine bottlenecks in program implementation. We then identify 5 categories of contexts that affect the impact, implementation, and survival of intervention programs: 1) biological, 2) social-cultural, 3) delivery modalities and platforms, 4) bureaucratic, and 5) political. Each of these contexts presents theoretical and methodological challenges for investigators. In this commentary, we focus primarily on biological and social-cultural contexts, discussing the theoretical and methodological challenges the investigators faced and the research strategies they used to address them, which have produced a unique compilation of "learning by doing" studies. We also touch briefly on the political context in which the Prospera program research was conducted. We conclude with statements that highlight the exceptional value of the journal supplement, not only with respect to the analysis of the interventions the studies cover and the sustained examination of a long-term program but also as a major contribution to the literature in implementation science in nutrition.

Sociocultural Influences on Poor Nutrition and Program Utilization of Mexico's Conditional Cash Transfer Program.

BACKGROUND: The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze. OBJECTIVES: We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program. METHODS: We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions. RESULTS: Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions. CONCLUSIONS: Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.

Closing the Nutrition Impact Gap Using Program Impact Pathway Analyses to Inform the Need for Program Modifications in Mexico's Conditional Cash Transfer Program.

BACKGROUND: Mexico's Prospera-Oportunidades-Progresa Conditional Cash Transfer Program (CCT-POP) included the distribution of fortified food supplements (FFS) for pregnant and lactating women and young children. Rigorous evaluations showed significant impacts on nutrition outcomes but also substantial gaps in addressing nutrition problems. OBJECTIVES: To highlight the program design-related and implementation-related gaps and challenges that motivated further research and the eventual design and roll-out of a modified nutrition component for CCT-POP. METHODS: We used a program impact pathway approach to highlight the extent and quality of implementation of CCT-POP, and its impact on nutrition outcomes. We drew on previously published and new primary data, organized into 3 sources: impact evaluations, studies to inform reformulation of the FFS, and a longitudinal follow-up study using qualitative and quantitative methods to document FFS use and the dietary intake of women and children. RESULTS: Despite positive impacts, a high prevalence of malnutrition persisted in the population. Coverage and use of health services improved, but quality of care was lacking. Consumption of FFS among lactating women was irregular. Micronutrient intake improved among children who consumed FFS, but the pattern of use limited frequency and quantity consumed. Substantial diversity in the prevalence of undernutrition was documented, as was an increased risk of overweight and obesity among women. CONCLUSIONS: Three key design and implementation challenges were identified. FFS, although well accepted for children, had limited potential to substantially modify the quality of children's diets because of the pattern of use in the home. The communications strategy was ineffective and ill-suited to its objective of motivating FFS use. Finally, the program with its common design across all regions of Mexico was not well adapted to the special needs of some subgroups, particularly indigenous populations. The studies reviewed in this paper motivated additional research and the eventual redesign of the nutrition component.

Welfare consequences for people diagnosed with nonepileptic seizures: A matched nationwide study in Denmark.

OBJECTIVE: We aimed to evaluate the excess direct and indirect costs associated with nonepileptic seizures. METHODS: From the Danish National Patient Registry (2011-2016), we identified 1057 people of any age with a diagnosis of psychogenic nonepileptic seizures (PNESs) and matched them with 2113 control individuals. Additionally, 239 partners of patients with PNES aged ≥18 years were identified and compared with 471 control partners. Direct costs included frequencies and costs of hospitalizations and outpatient use weighted by diagnosis-related group, and specific outpatient costs based on data from the Danish Ministry of Health. The use and costs of drugs were based on data from the Danish Medicines Agency. The frequencies of visits and hospitalizations and costs of general practice were derived from National Health Security data. Indirect costs included labor supply-based income data, and all social transfer payments were obtained from Coherent Social Statistics. RESULTS: A higher percentage of people with PNES and their partners compared with respective control subjects received welfare benefits (sick pay, disability pension, home care). Those with PNES had a lower employment rate than did controls for equivalent periods up to three years before the diagnosis was made. The additional direct and indirect annual costs for those aged ≥18 years, including transfers to patients with PNES, compared with controls, were €33,697 for people with PNES and €15,121 for their partners. SIGNIFICANCE: Psychogenic nonepileptic seizures have substantial socioeconomic consequences for individual patients, their partners, and society.

Health and social care costs at the end of life: a matched analysis of linked patient records in East London.

BACKGROUND: care in the final year of life accounts for 10% of inpatient hospital costs in UK. However, there has been little analysis of costs in other care settings. We investigated the publicly funded costs associated with the end of life across different health and social care settings. METHOD: we performed cross-sectional analysis of linked electronic health records of residents aged over 50 in a locality in East London, UK, between 2011 and 2017. Those who died during the study period were matched to survivors on age group, sex, deprivation, number of long-term conditions and time period. Mean costs were calculated by care setting, age and months to death. RESULTS: across 8,720 matched patients, the final year of life was associated with £7,450 (95% confidence interval £7,086-£7,842, P < 0.001) of additional health and care costs, 57% of which related to unplanned hospital care. Whilst costs increased sharply over the final few months of life in emergency and inpatient hospital care, in non-acute settings costs were less concentrated in this period. Patients who died at older ages had higher social care costs and lower healthcare costs than younger patients in their final year of life. CONCLUSIONS: the large proportion of costs relating to unplanned hospital care suggests that end-of-life planning could direct care towards more appropriate settings and lead to system efficiencies. Death at older ages results in an increasing proportion of care costs relating to social care than to healthcare, which has implications for an ageing society.

Supplemental Security Income enrollment and health care and social assistance employment and wages.

We examine the relationship between disabled working-age Supplemental Security Income (SSI) enrollment and health care and social assistance employment and wages. County-level data are gathered from government and other publicly available sources for 3144 US counties (2012 to 2015). Population-weighted linear regression analyses examine associations between each health care and social assistance employment and wage measure and SSI enrollment, controlling for factors associated with health care and social assistance employment and wages. Results show positive associations between county-level percent of the population enrolled in the SSI program and health care and social assistance employment and wages with strong associations identified for social assistance employment. A one standard deviation increase in SSI enrollment is associated with a 5.6% increase in the health care and social assistance sector employment percent compared with the mean and 9.7% and 7.3% increases in health care and social assistance sector employment and wage shares, respectively, when compared with the means. We find working-age adult SSI enrollment is positively associated with employment outcomes, primarily in the social assistance organization subsector and in lower wage paying jobs. Evolving federal disability policy may influence existing and future SSI enrollment, which has implications for health care workforce employment and composition.

Hong Kong Chinese aging adults voice financial care expectations in changing family and sociocultural contexts: implications for policy and services.

Despite being one of the world's wealthiest cities, approximately one-third of Hong Kong older adults live below the poverty line. Innovatively using the Photovoice research method, this study invited 36 Hong Kong Chinese aging adults to photograph images and voice their concerns and expectations regarding financial care. Insufficient government support, diminishing family support, insecurity and fear regarding future finances, and strong desire for self-sufficiency through early preparation and bridge employment were recurring themes observed in the participants' photographs and narratives. The shifting of the participants' financial care expectations from informal to formal sources in changing family and sociocultural contexts indicated that older people are in urgent need of policy reform from a needs-based to rights-based approach to foster empowerment and fulfill older people's rights of financial security, dignity and participation. Improving the retirement protection system should go hand in hand with encouraging family support and caregiving and creating age-friendly working environment for older residents. The findings of this study may have crucial policy implications for Hong Kong and other aging societies, especially those that share similar filial piety values and have seemingly ungenerous welfare systems.

Is There a Woodwork Effect? Addressing a 200-Year Debate on the Impacts of Expanding Community-Based Services.

In U.S. social welfare history, many have suggested that if benefits were too attractive, consumers would come out of the woodwork to take advantage of the opportunity. Clinical trials have provided evidence of the woodwork effect's existence, suggesting caution when expanding home- and community-based services (HCBS). However, it is unclear whether these studies are best suited to assess whether a system-level effect occurs. Using state and federal data tracking Ohio's long-term services and support (LTSS) system from 1995 to 2015, this paper examines changes in the utilization rates and expenditures of Medicaid LTSS to explore whether a woodwork effect occurred as Ohio moved to improve its LTSS system balance (80% Nursing Home [NH], 20% HCBS) to (49% Nursing Home [NH], 51% HCBS). After accounting for population growth of individuals older than 60 and those with two or more impairments in activities of daily living, there was no change in utilization rates of older people with severe disability (1995: 491 per 1000 population, 2015: 495 per 1000 population) or overall LTSS expenditures (1997: $2.7 million [in 2013 dollars], 2013: $2.9 million). Our results suggest that states can make significant strides in HCBS expansion without increasing the overall long-term services utilization rate.

Fairness in cost-benefit analysis: A methodology for health technology assessment.

We evaluate the introduction of various forms of antihypertensive treatments in France with a distribution-sensitive cost-benefit analysis. Compared to traditional cost-benefit analysis, we implement distributional weighting based on equivalent incomes, a new concept of individual well-being that does respect individual preferences but is not subjectively welfarist. Individual preferences are estimated on the basis of a contingent valuation question, introduced into a representative survey of the French population. Compared to traditional cost-effectiveness analysis in health technology assessment, we show that it is feasible to go beyond a narrow evaluation of health outcomes while still fully exploiting the sophistication of medical information. Sensitivity analysis illustrates the relevancy of this richer welfare framework, the importance of the distinction between an ex ante and an ex post approach, and the need to consider distributional effects in a broader institutional setting.