Volume 13, Issue 2

Prior literature has documented improvements in cancer survival over time. However, ambiguity remains over the relative contributions of improved treatment and earlier detection to survival gains. Using registry data, we developed a novel framework to estimate the relative contributions of advances in treatment and detection. Our approach compares changes in the probability of early detection, which we interpret as the effects of advances in detection, to improvements in stage-conditional survival, which we interpret as the effects of treatment. We applied this methodology using SEER data to estimate probabilities of early detection and stage-conditional survival curves for several cancers, by race, between 1988 and 2000. Survival increased for all of the cancers we examined, with blacks experiencing larger survival gains than whites for all cancers combined. Our baseline analysis found that treatment advances account for the vast majority of survival gains for all the cancers examined: breast cancer (83%), lung cancer (85%), colorectal cancer (76%), pancreatic cancer (100%), and non-Hodgkin’s lymphoma (96%). Compared to whites, treatments appear to explain a lower percentage of survival gains for blacks for all cancers combined; breast cancer, NHL, and pancreatic cancer show a higher percentage of survival gains than lung cancer; and roughly the same percentage for the colorectal cancer. These results are robust to sensitivity analyses examining potential length and lead time bias. Overall, our results suggest that while improved treatment and early detection both contributed to the recent gains in survival, the majority of gains from 1988 to 2000 appear to have been driven by better treatment, manifested by improved stage-conditional survival. These results have important policy implications regarding investment in research and development and the evaluation of efforts to improve cancer screening.

While the effects of low birth weight have long been explored, the literature on the effects of high birth weight is sparse. However, with increasing obesity rates in the United States, high birth weight has become a potential concern, and has been associated in the medical literature with an increased likelihood of becoming an overweight child, adolescent, and subsequently an obese adult. Overweight and obesity, in turn, are associated with a host of negative effects, including lower test scores in school and lower labor market prospects when adults. If studies only focus on low birth weight, they may underestimate the effects of ensuring that mothers receive adequate support during pregnancy. This study finds that cognitive outcomes are adversely affected not only by low birth weight (<2500 grams) but also by high birth weight (>4500 grams). Our results have policy implications in terms of provision of support for pregnant women.

We propose a model of enrollee incentives in consumer directed health plans (CDHPs) and estimate the model with data from a large employer that offered a CDHP in addition to two traditional health insurance plans. In the CDHP a portion of the enrollee's pretax compensation is placed in an account that can be used to pay for out-of-pocket medical expenses or rolled over to the next year. In a multi-period model, healthy employees should save part of the account to pay for future medical contingencies. We measured health status by the employee's predicted medical spending in the year prior to the CDHP offering. We found that healthy CDHP enrollees tended to spend less in three post-enrollment years than a comparison group of healthy employees who elected to keep their traditional health insurance coverage. However, CDHP enrollees with high predicted spending—a measure of poorer health—spent more than their comparison group of traditional health insurance enrollees in the following three years.

Persistent lack of health insurance might arise from two distinct sources. First, individuals who lack insurance might possess certain traits, also exhibiting persistence, that associate with lower probabilities of having insurance. Second, persistence might arise if lack of insurance in the present period directly increases the probability of lacking insurance in future periods. This second channel, called "true state dependence", implies a causal mechanism from past uninsurance. State dependence can also arise if insurance status "feeds back" to future factors that affect insurance status in subsequent periods. This paper extends standard dynamic models to incorporate feedback from uninsurance to future health and employment. Results indicate that, after incorporating feedback effects, lacking insurance six months ago increases the probability of current uninsurance by 57-59 percentage points. Similarly, lacking insurance two years ago increases the probability of current uninsurance by 18-22 percentage points. The large estimates of state dependence suggest that future uninsurance can be effectively reduced by enacting blanket policies that increase insurance rates now. On the other hand, estimates also reveal that unmeasured heterogeneity contributes more to persistence than observed heterogeneity, especially in the long run. This finding draws into question the effectiveness of implementing new, or expanding upon existing, targeted reforms.

In this paper, we use publicly available data from the Medical Expenditure Panel Survey - Insurance Component (MEPS-IC) to investigate the effect of Massachusetts' health reform plan on employer-sponsored insurance premiums. We tabulate premium growth for private-sector employers in Massachusetts and the United States as a whole for 2004 - 2008. We estimate the effect of the plan as the difference in premium growth between Massachusetts and the United States between 2006 and 2008—that is, before versus after the plan—over and above the difference in premium growth for 2004 to 2006. We find that health reform in Massachusetts increased single-coverage employer-sponsored insurance premiums by about 6 percent, or $262. Although our research design has important limitations, it does suggest that policy makers should be concerned about the consequences of health reform for the cost of private insurance.

This study identifies factors that predict internal medicine resident satisfaction with the quality of teaching by attendings. A key issue facing educators is whether high-quality instruction can be maintained in an environment in which attending physicians have many competing demands placed on their time. A national survey of clinical third-year internal medicine residents in 125 academically affiliated generally medical training programs was conducted. Univariate analyses describe the characteristics of the sample, and multivariate analyses evaluate the factors associated with resident satisfaction with teaching. The response rate was 64.1% (n=1354). Positive factors relating to satisfaction with teaching on inpatient ward rotations included: number of patients seen during rounds, attendings were fulltime, attending did clinical teaching during bedside work rounds, attending gave spontaneous and prepared presentations, and attendings were reached soon when needed. Negative factors included: number of residents in a ward team, number of patients admitted on overnight call, attendings seemed rushed and eager to finish rounds, and attendings were temporarily called away during rounds. Positive factors relating to satisfaction with teaching in continuity clinics included: residents being female and amount of time spent on talking to or examining patients. Negative factors included: amount of time spent on paperwork or routine work, attending changed resident’s decisions, attendings were difficult to reach, and attendings were temporarily called away during teaching. Different clinic settings also affected satisfaction. This study identifies several factors associated with internal medicine residents’ satisfaction with teaching and highlights mutable factors that faculty may consider changing to improve education and satisfaction.

Government-sponsored reinsurance for individuals with high health costs is a commonly proposed strategy to improve access and affordability in the individual and small-group health insurance markets. While reinsurance may have some benefits, other schemes may be more effective at accomplishing the same goals at lower cost. Reinsurance can be seen as a crude special case of risk-adjusted insurance subsidies. This paper estimates the effect of different reinsurance schemes on insurance premiums and insurers’ disincentives to enroll potentially high-cost individuals. We find that reinsurance is relatively ineffective at reducing cream-skimming incentives and argue that more sophisticated risk-adjustment schemes are more effective, particularly under community rating with guaranteed issue. Although in the past risk adjustment had been considered too complex to implement in practice, recent experience suggests that it is now feasible, and we argue that incorporation of risk adjustment would strengthen current health insurance reform efforts.

This study develops a macroeconometric model of the Nigerian economy to examine the potential impact of human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS) on key macroeconomic outcomes in Nigeria. The baseline model of the Nigerian economy is estimated using data from 1980 to 2000. The simulated values of key endogenous macroeconomic outcomes are shown to closely follow actual historical data and also future macroeconomic outcomes from 2001 to 2006. Simulations are conducted to examine (1) the potential effects of an increase in HIV/AIDS prevalence and (2) the potential effects of increased government expenditure for treatment and prevention of HIV. The simulations show increased HIV/AIDS prevalence will reduce output in the agriculture and manufacturing sectors and will have little or even a positive effect on output in the oil and gas sector. The simulations also show that increased government spending on HIV treatment and prevention will increase output across all industries; however, it will reduce gross fixed capital formation and capital expenditures.

In this paper, we employ a rich data set at the individual level in order to examine which factors are most highly correlated with obesity. Our main result is that, even after controlling for income levels and other factors, high “price-sensitivity” for food products is associated with high obesity rates. We find that a woman of average height who stated that prices were “not important at all” when purchasing food products had a weight circumference 4.5 centimeters (roughly 1.8 inches) smaller than those who stated that price was “very important.” We also show that this price effect is not limited to those with low income levels.

This paper investigates the link between various risk factors, including socioeconomic status (SES), and the spread of Severe Acute Respiratory Syndrome (SARS) in Hong Kong in 2003. A comprehensive data set compiled by the author shows a negative and significant correlation between SARS incidence and various measures of income, but not years of education, unlike previous studies on other health conditions. The income-SARS gradient can be accounted for by controlling for pre-SARS housing values but not an array of measurable living conditions. Areas with more white-collar workers experienced a higher incidence rate, largely driven by the share of service and sales workers, after controlling for SES. These results have implications for the understanding of the SES-health link in the context of a contagious disease, the potential causality of the SES-SARS relationship and for future SARS containment strategies.

Previous investigators argued that increasing 5-year survival for cancer patients should not be taken as evidence of improved prevention, screening, or therapy, because they found little correlation between the change in 5-year survival for a specific tumor and the change in tumor-related mortality. However, they did not control for the change in incidence, which influences mortality and is correlated with 5-year survival. The purpose of this study was to reexamine the question of whether increasing 5-year survival rates constitute evidence of success against cancer. We estimate the relationship across cancer sites between long-run changes in population-based mortality rates and both (1) changes in 5-year relative survival rates, and (2) changes in incidence rates, using data from both the U.S. and Australia. We analyze two outcome measures, and the relationship between them: the unconditional mortality rate (number of deaths per 100,000 population), and the 5-year relative survival rate. When incidence growth is controlled for, there is a highly significant correlation, in both the U.S. and Australia, between the change in 5-year survival for a specific tumor and the change in tumor-related mortality. The increase in the relative survival rate is estimated to have reduced the unconditional mortality rate by about 15% in the U.S. between 1976 and 2002, and by about 15% in Australia between 1984 and 2001. While the change in the 5-year survival rate is not a perfect measure of progress against cancer, in part because it is potentially subject to lead-time bias, it does contain useful information; its critics may have been unduly harsh. Part of the long-run increase in 5-year cancer survival rates is due to improved prevention, screening, or therapy.

Recent U.S. studies report much smaller youth smoking participation elasticities compared to research based on 1980s and 1990s data. We exploit the considerable time-series variation available within and across Canadian provinces. In particular, we study the dramatic (50%) reduction in cigarette excise taxes that occurred in February 1994 in most eastern provinces in Canada as well as significant increases within most provinces between 1994 and 2006. OLS and logit estimates from a variety of surveys suggest participation elasticities from –0.1 to –0.3 for teens aged 15 to 19 years, which are lower than traditional estimates. However, children aged 10 to 14 are significantly more tax elastic than older peers, with participation elasticities between -1.5 and -2. Finally, employing different sub-samples, we find that sharp hikes and reductions generate similar cigarette tax elasticities.

While many believe that an individual’s health plays an important role in both their willingness and ability to obtain health insurance in the employment-based setting, relatively little agreement exists on the extent to which health status affects coverage rates, particularly for those with lower incomes. In this paper, we examine the relationship between health risk and the purchase of group health insurance and whether that relationship differs by a person’s income and whether they obtain coverage in the small, medium, or large group market. Using the panel component of the 1996-2002 Medical Expenditure Panel Survey (MEPS), we find that health risk is positively associated with private health insurance across the different markets, and that this positive relationship is stronger for low and middle income people, particularly in the large group market. Our results are consistent with the existence of adverse selection in the group market in the form of low rates of coverage among low risks due to an absence of risk rating of premiums. We conclude that pooled premiums for low risks, particularly those with low incomes, may represent a more important financial barrier to coverage in voluntary group insurance than high premiums for high risks.