This paper studies the effect of easing physician supply constraints in a large developing country. In this unique policy experiment, conducted in coordination with the Nigerian government, physicians were randomly assigned to primary health service areas. The physicians were posted to government health centers serving these areas. Prior to the arrival of the physicians, health care in the facility was provided entirely by mid-level health care providers. To separate skill from volume effects, another group of service areas was provided with an additional mid-level health worker. Okeke and Abubakar find that the arrival of the physicians led to a significant reduction in mortality for newborns. Their results imply a 4-percentage-point reduction in mortality among infants whose care was provided, at least in part, by a physician. Using the estimated value of lifetime earnings, the researchers calculate that the physician program generated nearly $7 million dollars in value (or about $1.7 million dollars in net present terms). Comparing this to the cost of the intervention, Okeke and Abubakar estimate that each $1 spent on the program returned nearly $8 in benefits.
Understanding the mechanistic effects of breastfeeding on child development is key to designing cost-effective policies that support optimal infant feeding practices. Benefits from breastfeeding may arise due to the consumption of breast milk itself, the substitution away from alternate food sources, or the physical act of breastfeeding. However, the prior literature has not determined which of these mechanisms is most important. Brenøe and Stearns study the causal effects of an intervention to promote prolonged and exclusive breastfeeding on infant feeding patterns and child health through adolescence, using data from the largest randomized controlled trial on breastfeeding ever conducted. They present three key results. First, compared to the control group, infants exposed to the intervention were breastfed twice as much, received more calorie-dense feedings, and consumed more calories overall throughout infancy. Notably, their mothers substituted frequent use of water and juice for breast milk. Second, the intervention only significantly and persistently increased weight-for-age, in contrast to other health outcomes. Third, the researchers show the increase in calories can almost entirely explain the weight gain in early infancy. Thus, Brenøe and Stearns provide novel evidence indicating that the mediating mechanism of the effect of breastfeeding on weight gain is improved infant nutrition. They conclude that breastfeeding has beneficial effects on infant health in countries where breast milk is a replacement for low-quality and low-calorie liquids. In contrast, the researchers caution policy makers from drawing conclusions about the effects of breastfeeding in environments where the alternative to breastfeeding is high-quality infant formula without more causal evidence from these settings.
Using a strict, age-specific lockdown order for adults aged 65 and older in Turkey, Altindag, Erten, and Keskin examine the mental health consequences of an extended period of tight mobility restrictions on senior adults. Adopting a regression discontinuity design, they find that the curfew reduced mobility by decreasing the number of days spent outside by 43 percent. The curfew-induced decline in mobility substantially worsened mental health outcomes, including somatic and nonsomatic symptoms of mental distress (0.20, 0.22 standard deviations, respectively). Exploring potential channels, the researchers document a large increase in social and physical isolation, with no evidence of changes in labor market outcomes or intrahousehold conflict for this subpopulation.
This paper studies whether team members' past collaboration creates team-specific human capital and influences current team performance. Using administrative Medicare claims for two heart procedures, Chen finds that shared work experience between the doctor who performs the procedure ("proceduralist") and the doctors who provide care to the patient during the hospital stay for the procedure ("physicians") reduces patient mortality rates. A one standard deviation increase in proceduralist-physician shared work experience leads to a 10-13 percent reduction in patient 30-day mortality. Patient medical resource use also declines with shared work experience, even as survival improves.
Andersen, Maclean, Pesko, and Simon study the effects of the temporary federal paid sick leave mandate that became effective April 1st, 2020 on 'social distancing,' as proxied by individuals' physical mobility behavior gleaned from cellular devices. The national paid leave policy was implemented in response to the COVID-19 outbreak and provided many private and public workers with up to two weeks of paid leave for own or family illness or dependent care. They study the impact of this policy using difference-in-differences methods leveraging pre-FFCRA county-level differences in the share of workers likely eligible for FFCRA benefits. The researchers find that FFCRA increased the average number of hours at home, and reduced the share of the individuals likely at work. In particular, comparing the county with the lowest to highest FFCRA exposure, Andersen, Maclean, Pesko, and Simon find that the average daily hours at home per day increased 4.2% while the average hours not at home per day and working decreased by 7.7% and 6.1% post-policy.
As many as 20 percent of inmates in jails reportedly suffer from a serious mental illness. In an effort to divert the mentally ill out of jails and prisons, many counties have introduced "mental health courts" which transfer defendants with mental illness symptoms into a specialty court. These courts usually place defendants on remove defendants from criminal justice constraints while awaiting disposition. Using administrative data from a large urban county's correctional complex, Vigliotti, Seward, and Cunningham use a leniency design with randomized therapists to estimate the causal effect of mental health court on criminal and health outcomes. They find that mental health court increases repeat offending by as much as 40 percent. However, the researchers also find that mental health court improves mental health symptoms and reduces suicide attempts and suicide ideation. Using the leniency design's quasi-random assignment to a public defender versus a private attorney for all mental health court defendants, Vigliotti, Seward, and Cunningham show that public defenders are responsible for the increased mental health scores and reduction in suicidal ideation and suicide attempts.
The COVID-19 pandemic in the US has been particularly devastating for nursing home residents. A key question is how have some nursing homes been able to effectively protect their residents, while others have not? Using data on the universe of US nursing homes, we examine whether establishment quality is predictive of COVID-19 mortality. Higher-quality nursing homes, as measured by inspection ratings, have substantially lower COVID-19 mortality. Quality does not predict the ability to prevent any COVID-19 resident or staff cases, but higher-quality establishments prevent the spread of resident infections conditional on having one. Preventing
COVID-19 cases and deaths may come at some cost, as high-quality homes have substantially higher non-COVID deaths, a result consistent with high excess non-COVID mortality among the elderly since March. The positive correlation between establishment quality and non-COVID mortality is driven entirely by nursing homes located in counties with below-median COVID-19 case rates. As a result, high-quality homes in these counties have significantly more total deaths than their low-quality counterparts. The concentration of excess death in low-risk areas suggests that future suffering could be avoided with more nuanced guidelines, such as those recently suggested by CMS that outline a role for in-person visits in lower-risk areas.
The Clean Water Act (CWA) led to significant improvements in surface water quality, but at a cost exceeding the estimated benefits. This paper is the first to quantify the impact of the Clean Water Act on a direct measure of health and to consider whether
incorporating health benefits alters the conclusion of a cost-benefit analysis. Flynn and Marcus use a difference-in-differences framework to compare infant health outcomes upstream and downstream from wastewater treatment facilities before and after the facility receives a CWA grant. They show that improvements in surface water quality were larger for facilities that were newly required under the CWA to upgrade their treatment technology. The researchers leverage this information in a triple difference design, using counties up and downstream from facilities that were not bound by the CWA's treatment technology requirements as an additional control group. They find that reductions in surface water pollution from the CWA are associated with an 8 gram increase in average birth weight. These results are driven by counties whose public water supply systems draw from surface water rather than groundwater. A back-of-the-envelope calculation finds that the monetary benefits of the CWA's effects on infant health are below 29 billion dollars, or 19 percent of the amount necessary to consider the Clean Water Act grants program cost-effective.