The effects of Uber diffusion on the mental health of drivers.

While the spread of digital technologies and the growth of associated atypical forms of work are attracting increasing attention, little is known about the impact of these new forms of work on psychological well-being. This paper examines the effect of Uber diffusion on the mental health of drivers, taking advantage of the rollout of Uber across UK regions. We match individual-level information on health and sociodemographic characteristics from the UK Household Longitudinal Study (Understanding Society) between 2009 and 2019 with data on the diffusion of Uber across the country. We first show that Uber diffusion is positively associated with mental health, as measured by the General Health Questionnaire, in the population group of self-employed drivers. We argue that this positive correlation captures a selection effect (of comparatively healthier individuals into the category of self-employed drivers after Uber entry) and the omission of unobserved factors, rather than a causal effect. Indeed, we do not observe any improvement in mental health for workers who were already self-employed drivers before Uber entry. In parallel with this, among individuals who remained salaried drivers over time, our results suggest there may be a decline in mental health after Uber's introduction, probably because they feel the competition from Uber drivers.

Gig Workers during the COVID-19 Crisis in France: Financial Precarity and Mental Well-Being.

We set out to explore how precarious workers, particularly those employed in the gig economy, balance financial uncertainty, health risks, and mental well-being. We surveyed and interviewed precarious workers in France during the COVID-19 crisis, in March and April 2020. We oversampled gig economy workers, in particular in driving and food delivery occupations (hereafter drivers and bikers), residing in metropolitan areas. These workers cannot rely on stable incomes and are excluded from the labor protections offered to employees, features which have been exacerbated by the crisis. We analyzed outcomes for precarious workers during the mandatory lockdown in France as an extreme case to better understand how financial precarity relates to health risks and mental well-being. Our analysis revealed that 3 weeks into the lockdown, 56% of our overall sample had stopped working and respondents had experienced a 28% income drop on average. Gig economy drivers reported a significant 20 percentage point larger income decrease than other workers in our sample. Bikers were significantly more likely to have continued working outside the home during the lockdown. Yet our quantitative analysis also revealed that stress and anxiety levels were not higher for these groups and that bikers in fact reported significantly lower stress levels during the lockdown. While this positive association between being a biker and mental health may be interpreted in different ways, our qualitative data led to a nuanced understanding of the effect of gig work on mental well-being in this population group.

Military training exercises, pollution, and their consequences for health.

Militaries around the world perform training exercises in preparation for war. We study the relationship between in utero exposure to military exercises (bombing) and early-life health outcomes, combining data on naval bombing exercises in Vieques, Puerto Rico, and the universe of births from 1990 to 2003. Using a differences-in-differences design, we find that the sudden end of bombing practices is associated with a 56-79% decrease in the incidence of congenital anomalies. The evidence is generally consistent with the channel of environmental pollution through increases in contaminant levels in waters surrounding the live impact area.

Local inequality and departures from publicly provided health care in Canada.

This paper examines the relationship between changes in income inequality and the provision of resources in a health care system (the public-private mix). Specifically, we investigate whether increases in income inequality, as separate from overall income levels and growth, have changed the availability of both private clinics and privately financed physicians in a context where the dominant market player is the public system. Our findings provide reasonable evidence that increases in income inequality have led to substantial increases in both. We find that moving from median level of inequality across neighborhoods to the top 1% level of inequality increases the probably of a private clinic by 40% and the probability of having physicians who have opted out of the public system by 170%.

Rising inequality and the implications for the future of private insurance in Canada.

Income and wealth inequality have risen in Canada since its low point in the 1980s. Over that same period we have also seen an increase in the amount that Canadians spend on privately financed health care, both directly and through private health insurance. This paper will explore the relationship between these two trends using both comparative data across jurisdictions and household-level data within Canada. The starting hypothesis is that the greater the level of inequality the more difficult it becomes for publicly provided insurance to satisfy the median voter. Thus, we should expect increased pressure to access privately financed alternatives as inequality increases. In the light of these implications, the paper considers the implications for the future of private insurance in Canada.

Do stimulant medications improve educational and behavioral outcomes for children with ADHD?

We examine the effects of a policy change in the province of Quebec, Canada which greatly expanded insurance coverage for prescription medications. We show that the change was associated with a sharp increase in the use of stimulant medications commonly prescribed for ADHD in Quebec relative to the rest of Canada. We ask whether this increase in medication use was associated with improvements in emotional functioning or academic outcomes among children with ADHD. We find little evidence of improvement in either the medium or the long run. Our results are silent on the effects on optimal use of medication for ADHD, but suggest that expanding medication in a community setting had little positive benefit and may have had harmful effects given the average way these drugs are used in the community.

Health care cost containment strategies used in four other high-income countries hold lessons for the United States.

Around the world, rising health care costs are claiming a larger share of national budgets. This article reviews strategies developed to contain costs in health systems in Canada, England, France, and Germany in 2000-10. We used a comprehensive analysis of health systems and reforms in each country, compiled by the European Observatory on Health Systems and Policies. These countries rely on a number of budget and price-setting mechanisms to contain health care costs. Our review revealed trends in all four countries toward more use of technology assessments and payment based on diagnosis-related groups and the value of products or services. These policies may result in a more efficient use of health care resources, but we argue that they need to be combined with volume and price controls--measures unlikely to be adopted in the United States--if they are also to meet cost containment goals.

The economic costs of childhood disability.

Childhood disabilities entail a range of immediate and long-term economic costs that have important implications for the well-being of the child, the family, and society but that are difficult to measure. In an extensive research review, Mark Stabile and Sara Allin examine evidence about three kinds of costs-direct, out-of-pocket costs incurred as a result of the child's disability; indirect costs incurred by the family as it decides how best to cope with the disability; and long-term costs associated with the child's future economic performance. Not surprisingly, the evidence points to high direct costs for families with children with disabilities, though estimates vary considerably within these families. Out-of-pocket expenditures, particularly those for medical costs, for example, are higher among families with children with a special health care need. An important indirect cost for these families involves decisions about employment. Stabile and Allin examine several studies that, taken together, show that having a child with disabilities increases the likelihood that the mother (and less often the father) will either curtail hours of work or stop working altogether. Researchers also find that having a child with disabilities can affect a mother's own health and put substantial strains on the parents' relationship. In the longer term, disabilities also compromise a child's schooling and capacity to get and keep gainful employment as an adult, according to the studies Stabile and Allin review. Negative effects on future well-being appear to be much greater, on average, for children with mental health problems than for those with physical disabilities. Stabile and Allin calculate that the direct costs to families, indirect costs through reduced family labor supply, direct costs to disabled children as they age into the labor force, and the costs of safety net programs for children with disabilities average $30,500 a year per family with a disabled child. They note that the cost estimates on which they base their calculation vary widely depending on the methodology, jurisdiction, and data used. Because their calculations do not include all costs, notably medical costs covered through health insurance, they represent a lower bound. On that basis, Stabile and Allin argue that many expensive interventions to prevent and reduce childhood disability might well be justified by a cost-benefit calculation.

Socioeconomic status and child health: what is the role of health care, health conditions, injuries and maternal health?

There is a persistent relationship between socioeconomic status and health that appears to have its roots in childhood. Not only do children in families with lower income and with mothers with lower levels of education have worse health on average than those with greater socioeconomic advantage, but also the gradient appears to steepen with age. This study contributes to the literature on the relationship between socioeconomic status and child health by testing the hypothesis that the increasing effect of family income on children's health with age relates to the children's use of health care services. It also investigates the role of specific health conditions, injuries or maternal health in explaining the steepening gradient. Drawing on a nationally representative survey from Canada, the National Longitudinal Survey of Children and Youth from the period 1994/95-2008/09, this study provides further evidence of a steepening socioeconomic gradient in child health with age. It finds that accounting for health care use does not explain the steepening gradient and that the protective effect of income appears to be greater for those who had contact with the health system, in particular with regard to physician care and prescription drug use.

Showing "what right looks like"--how to improve performance through a paradigm shift around implementation thinking.

During a three-year period, Christiana Care has observed significant and sustained improvements in technology-enabled project outcomes. Just in the patient throughput area, Christiana Care has seen an 11 percent reduction in length of stay in the emergency department (ED), a 23 percent reduction in patients leaving ED without treatment and a 28 percent reduction in bed-clean turnaround time, all while accommodating patient volume increases of 7 percent. This performance is directly related to a broader view of implementation embraced by the organization. By looking at more than just traditional project management, Christiana Care has shifted their implementation paradigm, focusing on benefits planning, user adoption, value realization and goal delivery within the portfolio. This has been a result of a journey that has included a subtle but deliberate introduction of the new implementation thinking, primarily marked by an experience-driven approach of demonstrating the benefits of good implementation practices. Christiana Care has created the environment and process to get the greatest value for its IT-related investments and to show "what right looks like."

Child mental health and human capital accumulation: the case of ADHD.

One in five U.S. youngsters has a mental disorder, but we know little about the effects of these disorders on child outcomes. We examine U.S. and Canadian children with symptoms of Attention Deficit Hyperactivity Disorder (ADHD), the most common child mental health problem. Our innovations include the use of nationally representative samples of children, the use of questions administered to all children rather than focusing only on diagnosed cases, and the use of sibling fixed effects to control for omitted variables. We find large negative effects on test scores and schooling attainment suggesting that mental health conditions are a more important determinant of average outcomes than physical health conditions.

Household responses to public home care programs.

A choice-theoretic model of household decision-making with respect to care-giving time allocations and the use of publicly and privately financed home care services are proposed. Predictions concerning the effect of increased availability of publicly financed home care services on home care utilization, informal care giving, and health status are derived. These predictions are assessed through use of Canadian inter-provincial survey data on home care use and care giving that are matched with data on home care funding for the period 1992-1998. Increased availability of publicly financed home care is associated with an increase in its utilization, a decline in informal care giving, and an improvement in self-reported health status.

How does private finance affect public health care systems? Marshaling the evidence from OECD nations.

The impact of private finance on publicly funded health care systems depends on how the relationship between public and private finance is structured. This essay first reviews the experience in five nations that exemplify different ways of drawing the public/private boundary to address the particular questions raised by each model. This review is then used to interpret aggregate empirical analyses of the dynamic effects between public and private finance in OECD nations over time. Our findings suggest that while increases in the private share of health spending substitute in part for public finance (and vice versa), this is the result of a complex mix of factors having as much to do with cross-sectoral shifts as with deliberate policy decisions within sectors and that these effects are mediated by the different dynamics of distinctive national models. On balance, we argue that a resort to private finance is more likely to harm than to help publicly financed systems, although the effects will vary depending on the form of private finance.

Estimating price elasticities when there is smuggling: the sensitivity of smoking to price in Canada.

A central parameter for evaluating tax policies is the price elasticity of demand for cigarettes. But in many countries this parameter is difficult to estimate reliably due to widespread smuggling, which significantly biases estimates using legal sales data. An excellent example is Canada, where widespread smuggling in the early 1990s, in response to large tax increases, biases upwards the response of legal cigarette sales to price. We surmount this problem through two approaches: excluding the provinces and years where smuggling was greatest; and using household level expenditure data on smoking. These two approaches yield a tightly estimated elasticity in the range of -0.45 to -0.47. We also show that the sensitivity of smoking to price is much larger among lower income Canadians. In the context of recent behavioral models of smoking, whereby higher taxes reduce unwanted smoking among price sensitive populations, this finding suggests that cigarette taxes may not be as regressive as previously suggested. Finally, we show that price increases on cigarettes do not increase, and may actually decrease, consumption of alcohol; as a result, smuggling of cigarettes may have raised consumption of alcohol as well.