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Health Policy
In conjunction with the Population Council, Assistant Professor Shelley Clark is studying HIV risks in Sub-Saharan Africa, with a focus on young married women. Her working paper, “Early Marriage and HIV Risks in Sub-Saharan Africa,” finds that young, married girls are at greater risk for contacting HIV than unmarried girls for a variety of reasons, including having more frequent and unprotected sex, and having partners who are older, more sexually experienced, and thus more likely to have HIV-AIDS. Working with the World Health Organization and the Population Council, Clark is exploring the policy implications of these findings. Current HIV-AIDS policy focuses on personal behavior modification (using condoms, being more cautious, etc.), which is likely to be ineffective with married women. A related project includes an HIV-AIDS study on social networks in Malawi. Using data collected through the University of Pennsylvania, the study explores married women’s knowledge of their husband’s infidelity (and its risk for HIV-AIDS exposure). Clark is also exploring the implications of gender preference in India
on child outcomes. This work continues her research published in Demography
on how gender preference in India alters family structures. She has also
published several papers on nonsurgical (medical) abortion in the International Journal
of Obstetrics and Gynecology and Obstetrics Assistant Professor Helen Levy, with Assistant Professor Thomas DeLeire, are using data from the 1997–2000 National Health Interview Surveys and the 1989–2000 Current Population Survey (CPS) annual March income supplements to examine the relationship between family size, health insurance coverage, and access to medical care for children. The project aims to determine how the number of children in a family affects rates of insurance coverage for both children and adults, and whether differences in insurance coverage owing to family size translate into differences in access to medical care for children. In a related vein, several of Levy’s recent working papers examine
health insurance and the consequences of being uninsured, including “Private
Employer- Sponsored Disability Insurance: Where are the Gaps in Coverage?” and “The
Economic Consequences of Being Uninsured.” In “What do People
Buy When They Don’t Buy Health Insurance” (with Thomas DeLeire),
she uses data from the 1994–1998 Consumer Expenditure Surveys to
compare the share of household Associate Professor David Meltzer and Professor Willard Manning are studying the benefits of a new type of doctor, called hospitalists, who focus on hospital patients and care. Published in the December 3, 2002, issue of the Annals of Internal Medicine, their article finds that hospitalists are more successful at preventing short-term mortality and reducing the length of hospital stays and costs. These results improved further in the second year as the doctors gained experience. The study tracked 6,511 patients admitted between July 1997 and June 1999 and treated by two hospitalists and 58 general internists. Meltzer is beginning a larger study involving several major medical centers across the country. In a related vein, Meltzer, with Paul Chung et al., published “Resident Satisfaction on an Academic Hospitalists Service: Time to Teach,” in the American Journal of Medicine (2002). Manning is also a member of a committee of the Institute of Medicine/National Academies examining “The Consequences of Uninsurance.” The three-year study is assessing evidence about the health, economic, and social consequences for persons without health insurance and their families, health care systems and institutions, and communities as a whole. The published reports are: Coverage Matters: Insurance and Health Care (October 2001); Care without Coverage: Too Little, Too Late (May 2002), which examines the real health consequences for people who lack health insurance; Health Insurance is a Family Matter (September 2002), which examines the consequences of being uninsured for family health, financial stability, and general well-being, as well as the health of children and pregnant women; and Communitywide Effects of an Uninsured Population (Winter 2003). Manning chaired the subcommittee responsible for the first report. David Meltzer was a member of the subcommittee that produced the second report. Manning, with Assistant Professor Thomas DeLeire, has also been studying the impact of injury and illness on the labor market. In “Labor Market Costs of Injury and Illness: Prevalence Matters,” forthcoming in Health Economics, they examine two common omissions when assessing the labor market effects of injury and illness: (1) the impact on employers; and (2) any shifts in labor market equilibrium if the condition is prevalent enough such that shifts in labor supplied are large. To illustrate the magnitude of the bias, they use estimates for the labor costs of alcohol, drug abuse, and mental illness. In several related papers, Manning has explored econometric problems arising from skewed data in health care studies. In these papers, he examines the effectiveness of common methods of dealing with skewed data, including OLS, alternative, generalized linear model (GLM) approaches, the decomposition of the response into a series of models that deal with specific parts of the distribution (e.g., multi-part models), or various combinations of these. One of these papers, “Estimating Log Models: To Transform or Not to Transform,” with John Mullahy, received the 2002 Arrow Award for best health economics article in 2001. A follow-up paper with Mullahy and Harris graduate student Anirban Basu was presented at the Demography Workshops Series, hosted by the Population Research Center at NORC during the fall term. With coauthors P. Veazie and R. L. Kane, Manning published “Improving Risk Adjustment for Medicare Capitated Reimbursement using Nonlinear Models,” forthcoming in the journal Medical Care. In this article, Manning proposes an alternative risk adjustment approach for paying for health care expenses of frail elderly enrolled in social HMOs. The model differs from earlier systems by using an alternative transformation of the dependent variable, rather than assuming the usual proportional effects. Alcoholism and alcohol abuse was the topic of Manning’s paper, “Effect of Alcohol Prices on Alcohol Dependence and Abuse” (published in the Journal of Health Economics, February 2003), and coauthored with S. Ferrill and M. Fitch. The article finds that raising alcohol prices lowers the rates of alcohol consumption and abuse. Assistant Professor Jeffrey Milyo and Jennifer Mellor (College of William and Mary), in their Harris School working paper, “On the Importance of Full versus Partial Age-Adjustment in Ecological Studies of Social Determinants of Mortality,” explore a potential weak link in studies that document a connection between mortality rates and socioeconomic factors, such as income inequality, minority racial concentration, and various social capital measures. Most prior studies age-adjust the dependent variable to account for higher mortality rates of older populations, but they do not similarly adjust all other explanatory variables. This, argues Milyo and Mellor, could be a significant oversight. Using a full age-adjustment eliminates the link between mortality and income inequality, and mortality and social capital. The association between mortality and minority racial concentration is attenuated and becomes only marginally significant. These findings suggest the need to revisit the link between state-level socioeconomic factors and state mortality rates. Milyo and Mellor are also the authors of “Individual Health Status and Minority Racial Concentration in U.S. States and Counties.” Health policy publications by Milyo and Mellor also include the forthcoming journal articles, “Is Exposure to Income Inequality a Public Health Concern? Lagged Effects of Income Inequality on Individual and Population Health,” in Health Services Research; and “Income Inequality and Health Status in the United States: Evidence from the Current Population Survey,” in the Journal of Human Resources (volume 37, 2002). Tomas Philipson and Darius Lakdawalla (RAND) examine obesity in America in their Harris School working paper, “The Growth of Obesity and Technological Change.” They find that technological advances in the workplace and in food production together are key to weigh gain in the United States. The paper is featured in a Harris School policy brief (see accompanying policy brief in this report). Controlling health care costs is the topic of a RAND Journal of Economics article (volume 33, 2002) by David Meltzer, Jeanette Chung (Princeton University), and Harris School graduate student Anirban Basu. In “Does Competition under Medicare Prospective Payment Selectively Reduce Expenditures on High-Cost Patients?” the authors examine whether competition and prospective payment systems (PPS) together provide incentives to selectively reduce expenditures on high-cost relative to low-cost users. Using patient discharge and hospital financial data from California, the authors find that competition increased costs before PPS, but that this effect decreased afterward, especially among patients with the highest costs. Meltzer is continuing his work analyzing medical cost-effectiveness. His focus in this area is how to perform such analyses when there is uncertainty about the benefits and costs of medical interventions, especially at the population level. One of the potential applications of this work is to help inform priorities for biomedical research. Professor Edward Lawlor’s book, Redesigning the Medicare Contract: Politics, Markets, and Agency, will be published in 2003 by the University of Chicago Press. The book offers an extensive look at the Medicare reimbursement policy and the ramifications of its redesign. |
