Income insecurity and mental health in pandemic times.

This paper contributes to the literature on the impact of the COVID-19 outbreak on mental health by providing novel evidence of its interaction with labor market conditions and the long-term persistence of these effects. We run four waves of a large-scale representative survey in Spain between April 2020 and April 2022, and benchmark our data against a decade of pre-pandemic information. We document an increase in the share of individuals reporting depressive feelings from 16% prior to the pandemic to 46% in April 2020. We show that this effect is more pronounced for women, younger individuals and those with unstable incomes. We apply machine learning techniques, mediation analysis and event studies to document the role of the labor market as an important driver of these effects. Our results are crucial for the design of targeted policies that proof useful in overcoming the long lasting consequences of the pandemic.

Reforming the provision of cross-border medical care: Evidence from Spain.

Cross-border medical care, defined as care facilitated by a local health provider under pre-established regional agreements, as in the case of European Union (EU) citizens accessing care within EU countries, has been on the rise. Unlike medical tourism, typically sought by patients through their own volition and paid for out-of-pocket, cross-border medical care is often reimbursable or paid for directly by the responsible government. Yet, because nations vary in the extent of health coverage offered to their residents, these expenditures are often only partially reimbursed. The resulting financial burden for some countries can be large and not reciprocal, straining regional and country-level finances. We analyze the effectiveness of a legislative measure adopted by a Spanish region in January 2012 with the purpose of curbing cross-border medical care. Using a comprehensive administrative dataset of all medical procedures performed in the country between 2008 and 2015, we find that the measure led to a drastic drop in the number of foreigners' hospitalizations and a reduction of 4.8 million euros/trimester in costs. Finally, the decrease in hospitalizations did not disproportionally affect patients based on their gender, age, or origin, although it fostered a reduction in readmissions.

Terrorist attacks, Islamophobia and newborns' health.

Islamophobia has increased in the last years, in part, due to terrorist attacks perpetrated by jihadist groups. This phenomenon might be a source of stress, being particularly problematic for pregnant (Muslim) women. We examine how stress generated by the 2017 Catalonia (Spain) attacks affected the health of newborns whose mothers are from a Muslim country (as the perpetrators). We use a difference-in-differences-in-differences model comparing newborns whose mothers come from a Muslim country and are residing in a municipality directly affected by the attacks, to other newborns, before-after the attacks. Results show that the share of low-birth-weight babies and deliveries with complications raise significantly by 23.77%, and 13.02%. We document a significant increase in Islamophobia and in emotional distress in our group of interest. We conclude that Islamophobia-related stress is possibly one of the channels affecting health at birth.

Business cycle and mortality in Spain.

In the last couple of decades, there has been a lot of interest on the impact of macroeconomic fluctuations on health and mortality rates. Many studies, for different countries, find that mortality is procyclical. However, studies examining the effects of more recent recessions are less conclusive, finding mortality to be less procyclical, or even countercyclical. In this paper, using data of Spanish provinces from 1999 to 2016, we investigate how this relationship works in the context of a country that is subject to extreme business cycle fluctuations. Furthermore, we analyze the impact of unemployment for different mortality causes and we explore differences by sex, age group and level of education. In general terms, we find mortality to be procyclical so that when the economy is in a recession, mortality falls. When exploring mortality causes, we show that deaths from cardiovascular disease, cancer, senility, transport accidents and homicides are procyclical. By sex, we find procyclicality for both men and women. By age, mortality is procyclical for all age groups; however, the causes of death that result in this procyclical behavior are specific to each age group. By educational level, suicide appears as a countercyclical cause for individuals with intermediate levels of education.

The impact of temporary contracts on suicide rates.

The number of suicides has increased in the last decades in several developed countries. For instance, Spain has experienced a gradual but steady increase in suicides since the 80's and it is currently the leading external cause of death in the country. At the same time, the dualisation of the labor market, with a strong and persistent incidence of temporary contracts, has increased the instability of employment conditions. Both developments have a stronger incidence for individuals with lower levels of education. Therefore, in this paper we use rich administrative data in order to estimate the impact of the wide spread use of temporary contracts on suicides. In order to do that we exploit a reform that liberalised the use of fix-term contracts in Spain in 1984. Our results show strong long-term effects of the reform, which increased the suicide mortality rate of affected cohorts (those entering the labor market just after the liberalisation) by at least 25.3%. We believe that this result has important policy implications and should be taken into account in the design of the national suicide prevention plans.

The effect of lockdowns and infection rates on supermarket sales.

In this paper we document the evolution of the supermarket sales in one of the European countries, Spain, that has been most hardly hit by the COVID-19 pandemic. Using a very detailed dataset at the weekly and municipality level on the sales of a supermarket chain, we are able to separately identify the effects on sales for 12 different food products and for three population age groups. Furthermore, we distinguish between the impact of the lockdown, which affected the entire territory by mid-March, from the effect of the number of new confirmed positive COVID-19 cases at the municipal level. Our results show strong stockpiling effects for most of the products in the first week of adoption of the lockdown measures. On the other hand, the number of new cases at the municipal level is associated with reductions in sales, pointing towards increased fears of being infected as the main driver of the slowdown in sales. Finally, when we do a separate analysis for different age groups, we find no effects for individuals aged 66 and over.

The effect of budget cuts on C-section rates and birth outcomes: Evidence from Spain.

Using data from Spain, we show the impact of significant health-sector budget cuts introduced in 2012 on the rates of cesarean sections and on infant health outcomes at birth, which we use as a proxy for the quality of birth centers. Exploiting a difference-in-differences fixed-effects approach at the hospital level, we estimate a 3% increase in C-sections as a result of the budget restrictions, with no significant consequences on health outcomes at birth. Given the additional evidence in the literature on the negative short- and long-term effects of non-medically indicated C-sections, our paper provides important policy implications for population health.

Linking Mediterranean Diet and Lifestyle with Cardio Metabolic Disease and Depressive Symptoms: A Study on the Elderly in Europe.

Against a backdrop of an aging population in Europe, promoting health in older adults becomes a pressing issue. This study aimed to explore if correlations exist between the adherence to the Mediterranean diet and specific health outcomes such as the incidence of chronic cardio metabolic illnesses and experiencing depressive symptoms for elderly individuals. We also looked into probable links between regularly engaging in vigorous physical activities and these health outcomes. Our goal was to clearly demonstrate these relationships while controlling for several individual characteristics and socio-demographic factors on a cross-national scale within Europe. Using the Survey of Health, Aging and Retirement in Europe (SHARE) data for adults aged 50 years and above, we found that following the Mediterranean diet was negatively correlated with the incidence of chronic illnesses, as well as with levels of depressive symptoms. These results were robust to the inclusion of a number of individual and socio-demographic controls. We also showed that regular participation in sports and other strenuous physical activities were associated with lesser chronic disorders and lower levels of depressive symptoms. These findings may have important implications in formulating preventive interventions on ensuring the quality of life of the older population.

Limiting health-care access to undocumented immigrants: A wise option?

The number of undocumented migrants in high-income countries has increased in recent decades, imposing considerable political, fiscal, and social pressures on governments. This has fostered discussions on whether and to what extent undocumented migrants should get access to public programs and public benefits. Looking at the 2012 Spanish health reform, this is the first paper to document the impacts of a restriction on access to the health-care system for undocumented migrants on health-care utilization, health-care system perceptions, and self-reported health in a high-income country. We show that such restrictions may significantly reduce planned care for undocumented migrants and result in sharp fall in positive opinions about the health-care services still left available to them. We also exploit the heterogeneity in implementing the policy across regions and report stronger effects in regions that enforced the national ban more fully. Furthermore, in the first 3 years since the implementation of the reform, we find suggestive evidence of a worsening in self-assessed health. This study is relevant for policymakers in the developed world, especially in countries that have recently implemented initiatives aimed at reducing the health-care coverage for targeted groups, such as the United Kingdom and the United States.

Effects of macroeconomic fluctuations on mental health and psychotropic medicine consumption.

Our aim in this paper is to understand the impact of macroeconomic fluctuations on mental health and psychotropic medicine consumption. In order to do that we exploit differences in the fluctuations of business cycle conditions across regional units in Catalonia. Our findings suggest that, in general, economic fluctuations at the local level had no significant effect on the consumption of psychotropic medicines. However, we show that a deterioration in local labour market conditions is associated with a reduction in the consumption of anxiolytics medicines. We also report an increase in the consumption of anxiolytics in regions with a softer deterioration in the economic situation. Although we report mild improvements in both mental and physical health for some sub-groups of the population, we also find significant reductions on the probability of sleeping 6 h or more. Thus, these elements point towards potential negative effects of local labour market conditions on health in the medium/long term.

Newborn health and the business cycle: The role of birth order.

We use 35 years of administrative data to document how newborn health varies with the business cycle in Spain. In panel regressions that include province and year fixed effects as well as province trends, we show that children have significantly better health outcomes at birth in times of high unemployment: a 10 percentage-point increase in the unemployment rate is significantly associated with about 2 log-points higher birth-weight, almost 2 percentage points fewer babies with low birth weight, 0.6 points fewer babies with very low birth-weight, and a 0.4-point drop in mortality rates in the first 24 h We explore several potential mechanisms. First, we show that the documented association is not driven by in-utero selection: we do not find that high unemployment is associated with more miscarriages, abortions, or stillbirths. Second, we explore the role of composition in terms of parental characteristics. We find evidence that unmarried and younger parents, who typically have unhealthier babies, are relatively less likely to have children when unemployment is high. Finally, we show that there are fewer first births during recessions, and birth order is strongly positively correlated with health at birth. Birth order can account for up to one fifth of the countercyclicality of birth weight.

Long run educational and spillover effects of unconditional cash transfers: Evidence from South Africa.

Cash transfer (CT) policy is promoted as an important financial vehicle to address household poverty and bring positive societal development. This study investigates the impact of an unconditional CT policy on children's education outcomes focusing on both the primary and secondary phases of education. We also examine the spillover effect of CT policy on parents' employment. To identify these effects we focus on South Africa and exploit the changes in age eligibility requirements of the CT policy to build credible control and treatment groups based on birth cohort. Our results show that CT policy improves reading and writing abilities at both the primary (by 3.7% and 3.3% respectively) and secondary education levels (by 10.2% and 10.1%, respectively) but it fosters school attendance only in secondary education. We also provide evidence that, for primary education students, the effects are only significant for boys. Notably, the positive effects of CT programs are also confirmed by the presence of spillover effects to other members of the family in our observance of increases in both mothers' and fathers' employment outcomes (by 35% and 34%, respectively). Therefore, in this paper we provide robust evidence that unconditional CT policy supports resilient development of the country's population in several dimensions that go beyond the educational achievement of targeted children.

Impact of SSB taxes on sales.

In this paper, we analyze a tax on sugar-sweetened beverages (SSB) that was introduced in Catalonia on May 1, 2017. The Bill established the requirement of a 100% pass-through of the tax to the final consumer and two levels of the tax: 0.08 euro/liter for products with 5-less than 8 g of sugar and 0.12 euro/liter for products with 8 g of sugar or more. Previous literature focusing on the impact of SSB taxes finds that pass-though is only complete in the long-term. Our paper provides new evidence that, when the tax increases prices substantially and immediately, the sales response is also significant. In particular, we estimate that the new SSB tax in Catalonia reduced SSB purchases by 7.7%. We document that part of this reduction is substituted by an increase in sales of zero/light drinks (substitution effect). Importantly, the reduction in purchases is stronger in areas with a higher incidence of obesity, in areas with higher household incomes and for products with higher sugar content.

Is changing the minimum legal drinking age an effective policy tool?

In year 1991, regional governments in Spain started a period of implementation of a law that rose the minimum legal drinking age from 16 to 18 years old. To evaluate the effects of this change on the consumption of legal drugs and its related morbidity outcomes, we construct a regional panel dataset on alcohol consumption and hospital entry registers and compare variation in several measures of prevalence between the treatment group (16-18 years old) and the control group (20-22 years old). Our findings show important differences by gender. Our main result regarding overall drinking prevalence shows a reduction of -21.37% for the subsample that includes males and females altogether. This effect on drinking is mainly driven by a reduction of -44.43% in mixed drinks and/or liquors drinking prevalence corresponding to the subsample of males. No causal effects regarding overall smoking prevalence and hospitalizations due to alcohol overdose or motor vehicle traffic accidents were found. To our knowledge, this is the first paper providing evidence on gender-based differences to policies aimed at reducing alcohol consumption. Our results have important policy implications for countries currently considering changes in the minimum legal drinking age.

Act now: The effects of the 2008 Spanish disability reform.

The 2008 reform of the Spanish disability system reduced the benefits for individuals who have a short contributory history relative to their age. It also unintentionally introduced an incentive for individuals to apply for disability in the present. We use a lifecycle model and an empirical analysis to understand the overall impact of the reform. Our baseline estimates suggest that men and women who were affected by the reform were 46% and 22% more likely to be on permanent partial disability following the reform, respectively, and 55% and 46% more likely to be on total disability, respectively.

Hiring subsidies for people with a disability: do they work?

This article evaluates the effectiveness of hiring subsidies targeted to people with disabilities. By exploiting the timing of implementation among different Spanish regions of a subsidy scheme implemented in Spain during the period 1990-2014, we employed a difference-in-differences approach to estimate the impact of the scheme on the probability of disability insurance (DI) beneficiaries of transiting to employment and on the propensity of individuals of entering the DI program. Our results show that the introduction of the subsidy scheme is in general ineffective at incentivizing transitions to employment, and in some cases it is associated with an increased propensity of transiting to DI. Furthermore, we show that an employment protection component incorporated into the subsidy scheme, consisting in the obligation for the employer to maintain the subsidized worker in employment, is associated with less transitions to permanent employment, more transitions to temporary employment and more transitions to DI, suggesting that these type of employment protection measures can have undesired effects for people with disabilities.

The earnings and employment losses before entering the disability system.

Although a number of papers in the literature have shown the employment and wage differences between individuals receiving disability benefits and non-disabled individuals, not much is known about the potential employment and wage losses that disabled individuals suffer before being officially accepted into the disability insurance system (DI). Therefore, in this paper we compare individuals that enter into the DI system due to a progressive deterioration in the health status (ordinary illness) to similar non-disabled individuals. Our aim is to identify the differences in employment and wages between these two groups before disabled individuals are officially accepted into the DI system. We combine matching models and difference-in-difference and we find that the wage (employment) growth patterns of both groups of workers become significantly different three (five) years before entering the DI system. More specifically, our estimates suggest that 1 year before entering the system, there is a difference of 79 Euros/month in the wages of the two groups (8.3% of average wage) as well as a 7.8% point difference in employment probabilities.

What happens to the employment of disabled individuals when all financial disincentives to work are abolished?

Policymakers and organizations representing people with disabilities have highlighted the importance of promoting the employment prospects of disabled individuals as a determinant to ensure their broader integration into the society. Policy reforms that attempt to incentivise disabled individuals to work typically involve reduced financial punishments for earning above a predetermined threshold (substantial gainful activity). This paper exploits a Spanish reform that entirely eliminated any disincentives for disabled individuals to work. Partially disabled individuals in Spain are subject to income taxation in all regions except in the province of Bizkaia. Before 2007, partially disabled individuals in Bizkaia were exempt from income taxation if they did not work. In December 2006, a new law was passed in Bizkaia that distinguished between individuals aged 55 or younger, who were no longer tax-exempt, and those who were older than 55 years, who continued to be tax-exempt if they did not work. I exploit this change in the legislation and employ both a difference-in-difference strategy comparing the employment outcomes of disabled young men across provinces and time as well as a triple difference model with disabled men older than 55 years, who are unaffected by the policy. My results show that the reform increased the probability of working by 6.5 percentage points for disabled men aged 55 or younger.

Business cycle impacts on substance use of adolescents: A multi-country analysis.

Populations respond to changes in the economic climate in a variety of ways. The recent 'Great Recession' has brought attention to the vulnerability of many economies around the world to changes in non-domestic macroeconomic fluctuations. However, empirical evidence on the responses of adolescents' substance consumption behaviour when the economy deteriorates is very scarce. Thus, the focus of this paper is to analyse the substance consumption patterns displayed by adolescents in response to changes in macroeconomic conditions in a large number of countries. Our results show that beer and wine consumption vary counter-cyclically (a 1pp increase in the unemployment rate increases the probability of drinking beer (wine) by 3% (5.5%)) while adolescent smoking prevalence varies pro-cyclically (a 1pp increase in the unemployment rate decreases the probability of being a current smoker by 3.8%). More importantly, we find that the probability of ever being drunk increases by 1.3% for a 1pp increase in the unemployment rate. Further to this, substantial heterogeneous effects from the aggregate-level results were found when analysing a variety of demographic and geographic dimensions. In light of the existing empirical evidence which outlines that early substance initiators demonstrate worse neurological deficits and suffer stronger labour market penalties (compared to later initiators or abstainers) these findings can aid policy makers in reducing these lasting adverse outcomes.

BAD TIMES, SLIMMER CHILDREN?

Although the majority of the literature has confirmed that recessions are beneficial for adults' health and babies' outcomes at delivery, this effect should not necessarily be the same for children. In this paper, we study the effect of business cycle conditions on infant underweight, overweight, and obesity. We exploit eight waves of repeated cross-sectional data (1987-2012) of the Spanish National Health Survey for children aged 2-15 and use the regional unemployment rate of the trimester of the interview as a proxy for the business cycle phase at the local level. We find that an increase in the unemployment rate is associated with lower obesity incidence, especially for children under 6 years old and over 12 years old. However, economic shocks also proof to have potentially negative consequences as they increase the prevalence of infant underweight for the same age groups. Moreover, we show that the possible mechanisms through which the cycle is impacting infant obesity is the nutritional composition of the children's diet, as well as, increases in the frequency of exercise. We provide some evidence that suggests that the impact of business cycle conditions on infant weight disorders have little objective health consequences in the short run. However, the potential long-term effects may become important as underweight during childhood is associated with worse outcomes later in life. Copyright © 2016 John Wiley & Sons, Ltd.