Abstracts of Selected Recent NBER Working Papers

WP 15841
Jessica Wolpaw Reyes
The Effect of Malpractice Liability on the Specialty of Obstetrics and Gynecology

Using data from a 2003 survey of 1,476 obstetrician-gynecologists, the effects of malpractice pressure on the specialty are investigated. Physicians report having made substantial changes to their practice in response to the general environment and to liability pressures. Regression analysis finds that liability pressure increases reports of income and practice reductions, but direct effects on actual income and productivity are less clear. Liability pressures may lead to a specialization effect, with some physicians concentrating more in obstetrics and others in gynecological surgery. Overall, the evidence suggests that liability pressure has moderate but significant effects on the specialty.

WP 15858
Richard Frank, Thomas G. McGuire
Mental Health Treatment and Criminal Justice Outcomes

Are many prisoners in jail or prison because of their mental illness? And if so, is mental health treatment a cost-effective way to reduce crime and lower criminal justice costs? This paper reviews and evaluates the evidence assessing the potential of expansion of mental health services for reducing crime. Mental illness and symptoms of mental illness are highly prevalent among adult and child criminal justice populations. The association between serious mental illness and violence and arrest is particularly strong among individuals who are psychotic and do not adhere to medication. Two empirical studies augment the empirical research base relating mental illness to crime. In a recent community sample of adults, we find higher rates of arrest for those with serious mental illness and with substance abuse. Among youth, even with family fixed effects, antisocial personality scores predict future school problems and arrests. A large body of research tracks mental health and criminal justice outcomes associated with treatments and social policies. Reviews of the cost-effectiveness of treatments for children with behavioral problems, mental health courts, and mandatory outpatient treatment are inconclusive.

WP 15969
Dhaval Dave, Henry Saffer
The Impact of Direct-to-Consumer Advertising on Pharmaceutical Prices and Demand

Expenditures on prescription drugs are one of the fastest growing components of national health care spending, rising by almost three-fold between 1995 and 2007. Coinciding with this growth in prescription drug expenditures has been a rapid rise in direct-t o-consumer advertising (DTCA), made feasible by the Food and Drug Administration's (FDA) clarification and relaxation of the rules governing broadcast advertising in 1997 and 1999. This study investigates the separate effects of broadcast and non-broadcast DTCA on price and demand, utilizing an extended time series of monthly records for all advertised and non-advertised drugs in four major therapeutic classes spanning 1994-2005, a period which enveloped the shifts in FDA guidelines and the large expansions in DTCA. Controlling for promotion aimed at physicians, results from fixed effects models suggest that broadcast DTCA positively impacts own-sales and price, with an estimated elasticity of 0.10 and 0.04 respectively. Relative to broadcast DTCA, non-broadcast DTCA has a smaller impact on sales (elasticity of 0.05) and price (elasticity of 0.02). Simulations suggest that the expansion in broadcast DTCA may be responsible for about 19 percent of the overall growth in prescription drug expenditures over the sample period, with over two-thirds of this impact being driven by an increase in demand as a result of the DTCA expansion and the remainder due to higher prices.

WP 16012
Jonathan Kolstad, Amanda Kowalski
The Impact of an Individual Health Insurance Mandate on Hospital and Preventative Care: Evidence from Massachusetts

In April 2006, the state of Massachusetts passed legislation aimed at achieving near universal health insurance coverage. A key provision of this legislation, and of the national legislation passed in March 2010, is an individual mandate to obtain health insurance. In this paper, we use hospital data to examine the impact of this legislation on insurance coverage, utilization patterns, and patient outcomes in Massachusetts. We use a difference-in-difference strategy that compares outcomes in Massachusetts after the reform to outcomes in Massachusetts before the reform and to outcomes in other states. We embed this strategy in an instrumental variable framework to examine the effect of insurance coverage on outcomes. Among the population discharged from the hospital in Massachusetts, the reform decreased uninsurance by 28% relative to its initial level. Increased coverage affected utilization patterns by decreasing length of stay and the number of inpatient admissions originating from the emergency room. We also find evidence that outpatient care reduced hospitalizations for preventable conditions. At the same time we find no evidence that the cost of hospital care increased. The reform affected nearly all age, gender, income, and race categories. We identify some populations for which insurance had the greatest direct impact on outcomes and others for which the impact on outcomes appears to have occurred through spillovers.

WP 16013
Damon Clark, Heather Royer
The Effect of Education on Adult Health and Mortality: Evidence from Britain

There is a strong, positive and well-documented correlation between education and health outcomes. There is much less evidence on the extent to which this correlation reflects the causal effect of education on health - the parameter of interest for policy. In this paper we attempt to overcome the difficulties associated with estimating the causal effect of education on health. Our approach exploits two changes to British compulsory schooling laws that generated sharp differences in educational attainment among individuals born just months apart. Using regression discontinuity methods, we confirm that the cohorts just affected by these changes completed significantly more education than slightly older cohorts subject to the old laws. However, we find little evidence that this additional education improved health outcomes or changed health behaviors. We argue that it is hard to attribute these findings to the content of the additional education or the wider circumstances that the affected cohorts faced (e.g., universal health insurance). As such, our results suggest caution as to the likely health returns to educational interventions focused on increasing educational attainment among those at risk of dropping out of high school, a target of recent health policy efforts.

WP 16066
Courtney Coile, Phillip B. Levine
Recessions, Reeling M arkets, and Retiree Well-Being

This paper examines the impact of late-career investment returns and job loss on subsequent retiree well-being. Specifically, we explore whether there is a link between the income of retirees aged 70 to 79 and the stock market and labor market conditions that existed around the time of their retirement. We use data from the 2000 Census and the 2001 through 2007 American Community Surveys and consider both total personal income and income by type. We find that a long-term decline in the stock market in the years leading up to retirement leads to a modest reduction in investment income a decade or so later for those in the top third of the income distribution. The consequences of approaching retirement when the labor market is weak are more severe. A higher unemployment rate around the time of retirement reduces Social Security income for those in the bottom two-thirds of the income distribution; we estimate that an unemployed worker experiences a roughly 20 percent drop in Social Security income, consistent with claiming benefits several years early. Overall, our results indicate the importance of the challenges faced by lower-income workers who face a weak labor market as they approach retirement.

WP 16077
Andrew Cook, Martin Gaynor, Melvin Stephens, Jr., Lowell Taylor
The Effect of Hospital Nurse Staffing on Patient Health Outcomes: Evidence from California's Minimum Staffing Regulation

Hospitals are currently under pressure to control the cost of medical care, while at the same time improving patient health outcomes. These twin concerns are at play in an important and contentious decision facing hospitals - choosing appropriate nurse staffing levels. Intuitively, one would expect nurse staffing ratios to be positively associated with patient outcomes. If so, this should be a key consideration in determining nurse staffing levels. A number of recent studies have examined this issue, however, there is concern about whether a causal relationship has been established. In this paper we exploit an arguably exogenous shock to nurse staffing levels. We look at the impact of California Assembly Bill 394, which mandated minimum levels of patients per nurse in the hospital setting. When the law was passed, some hospitals already had acceptable staffing levels, while others had nurse staffing ratios that did not meet mandated standards. Thus changes in hospital-level staffing ratios from the pre- to post-mandate periods are driven in part by the legislation. We find persuasive evidence that AB394 did have the intended effect of decreasing patient/nurse ratios in hospitals that previously did not meet mandated standards. However, our analysis suggests that patient outcomes did not disproportionately improve in these same hospitals. That is, we find no evidence of a causal impact of the law on patient safety.

WP 16088
Ryan Edwards
Trends in World Inequality in Life Span Since 1970

Previous research has revealed much global convergence over the past several decades in life expectancy at birth and in infant mortality, which are closely linked. But trends in the variance of length of life, and in the variance of length of adult life in particular, are less well understood. I examine life-span inequality in a broad, balanced panel of 180 rich and poor countries observed in 1970 and 2000. Convergence in infant mortality has unambiguously reduced world inequality in total length of life starting from birth, but world inequality in length of adult life has remained stagnant. Underlying both of these trends is a growing share of total inequality that is attributable to between-country variation. Especially among developed countries, the absolute level of between-country inequality has risen over time. The sources of widening inequality in length of life between countries remain unclear, but signs point away from trends in income, leaving patterns of knowledge diffusion as a potential candidate.



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