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Most developed nations provide generous coverage of care services, using either a tax financed healthcare system or social health insurance. Such systems pursue efficiency and equity in care provision. Efficiency means that expenditures are minimized for a given level of care services. Equity means that individuals with equal needs have equal access to the benefit package. In order to limit expenditures, social health insurance systems explicitly limit their benefit package. Moreover, most such systems have introduced cost sharing so that beneficiaries bear some cost when using care services. These limits on coverage create room for private insurance that complements or supplements social health insurance. Everywhere, social health insurance coexists along with voluntarily purchased supplementary private insurance. While the latter generally covers a small portion of health expenditures, it can interfere with the functioning of social health insurance. Supplementary health insurance can be detrimental to efficiency through several mechanisms. It limits competition in managed competition settings. It favors excessive care consumption through coverage of cost sharing and of services that are complementary to those included in social insurance benefits. It can also hinder achievement of the equity goals inherent to social insurance. Supplementary insurance creates inequality in access to services included in the social benefits package. Individuals with high incomes are more likely to buy supplementary insurance, and the additional care consumption resulting from better coverage creates additional costs that are borne by social health insurance. In addition, there are other anti-redistributive mechanisms from high to low risks. Social health insurance should be designed, not as an isolated institution, but with an awareness of the existence—and the possible expansion—of supplementary health insurance.
Albert A. Okunade and Ahmad Reshad Osmani
Healthcare cost encompasses expenditures on the totality of scarce resources (implicit and explicit) given up (or allocated) to produce healthcare goods (e.g., drugs and medical devices) and services (e.g., hospital care and physician office services are major components). Healthcare cost accounting components (sources and uses of funds) tend to differ but can be similar enough across most of the world countries. The healthcare cost concept usually differs for consumers, politicians and health policy decision-makers, health insurers, employers, and the government. All else given, inefficient healthcare production implies higher economic cost and lower productivity of the resources deployed in the process. Healthcare productivity varies across health systems of the world countries, the production technologies used, regulatory instruments, and institutional settings. Healthcare production often involves some specific (e.g., drugs and medical devices, information and communication technologies) or general technology for diagnosing, treating, or curing diseases in order to improve or restore human health conditions.
In the last half century, the different healthcare systems of the world countries have undergone fundamental transformations in the structural designs, institutional regulations, and socio-economic and demographic dimensions. The nations have allocated a rising share of total economic resources or incomes (i.e., Gross National Product, or GDP) to the healthcare sector and are consequently enjoying substantial increases in population health status and life expectancies. There are complex and interacting linkages among escalating healthcare costs, longer life expectancies, technological progress (or “the march of science”), and sectoral productivities in the health services sectors of the advanced economies. Healthcare policy debates often concentrate on cost-containment strategies and search for improved efficient resource allocation and equitable distribution of the sector’s outputs. Consequently, this contribution is a broad review of the body of literature on technological progress, productivity, and cost: three important dimensions of the evolving modern healthcare systems. It provides a logical integration of three strands of work linking healthcare cost to technology and research evidence on sectoral productivity measurements. Finally, some important aspects of the existing study limitations are noted to motivate new research directions for future investigations to explore in the growing health sector economies.
The rise in obesity and other food-related chronic diseases has prompted public-health officials of local communities, national governments, and international institutions to pay attention to the regulation of food supply and consumer behavior. A wide range of policy interventions has been proposed and tested since the early 21st century in various countries. The most prominent are food taxation, health education, nutritional labeling, behavioral interventions at point-of-decision, advertising, and regulations of food quality and trade. While the standard neoclassical approach to consumer rationality provides limited arguments in favor of public regulations, the recent development of behavioral economics research extends the scope of regulation to many marketing practices of the food industry. In addition, behavioral economics provides arguments in favor of taxation, easy-to-use front-of-pack labels, and the use of nudges for altering consumer choices. A selective but careful review of the empirical literature on taxation, labeling, and nudges suggests that a policy mixing these tools may produce some health benefits. More specifically, soft-drink taxation, front-of-pack labeling policies, regulations of marketing practices, and eating nudges based on affect or behavior manipulations are often effective methods for reducing unhealthy eating.
The economic research faces important challenges. First, the lack of a proper control group and exogenous sources of variations in policy variables make evaluation very difficult. Identification is challenging as well, with data covering short time periods over which markets are observed around slowly moving equilibrium. In addition, truly exogenous supply or demand shocks are rare events. Second, structural models of consumer choices cannot provide accurate assessment of the welfare benefits of public policies because they consider perfectly rational agents and often ignore the dynamic aspects of food decisions, especially consumer concerns over health. Being able to obtain better welfare evaluation of policies is a priority. Third, there is a lack of research on the food industry response to public policies. Some studies implement empirical industrial organization models to infer the industry strategic reactions from market data. A fruitful avenue is to extend this approach to analyze other key dimensions of industrial strategies, especially decisions regarding the nutritional quality of food. Finally, the implementation of nutritional policies yields systemic consequences that may be underestimated. They give rise to conflicts between public health and trade objectives and alter the business models of the food sector. This may greatly limit the external validity of ex-ante empirical approaches. Future works may benefit from household-, firm-, and product-level data collected in rapidly developing economies where food markets are characterized by rapid transitions, the supply is often more volatile, and exogenous shocks occur more frequently.
Fabrice Etilé and Lisa Oberlander
In the last several decades obesity rates have risen significantly. In 2014, 10.8% and 14.9% of the world’s men and women, respectively, were obese as compared with 3.2% and 6.4% in 1975. The obesity “epidemic” has spread from high-income countries to emerging and developing ones in every region of the world. The rising obesity rates are essentially explained by a rise in total calorie intake associated with long-term global changes in the food supply. Food has become more abundant, available, and cheaper, but food affluence is associated with profound changes in the nutritional quality of supply. While calories have become richer in fats, sugar, and sodium, they are now lower in fiber. The nutrition transition from starvation to abundance and high-fat/sugar/salt food is thus accompanied by an epidemiological transition from infectious diseases and premature death to chronic diseases and longer lives. Food-related chronic diseases have important economic consequences in terms of human capital and medical care costs borne by public and private insurances and health systems.
Technological innovations, trade globalization, and retailing expansion are associated with these substantial changes in the quantity and quality of food supply and diet in developed as well as in emerging and rapidly growing economies. Food variety has significantly increased due to innovations in the food production process. Raw food is broken down to obtain elementary substances that are subsequently assembled for producing final food products. This new approach, as well as improvements in cold chain and packaging, has contributed to a globalization of food chains and spurred an increase of trade in food products, which, jointly with foreign direct investments, alters the domestic food supply. Finally, technological advancements have also favored the emergence of large supermarkets and retailers, which have transformed the industrial organization of consumer markets.
How do these developments affect population diets and diet-related diseases? Identifying the contribution of supply factors to long-term changes in diet and obesity is important because it can help to design innovative, effective, and evidence-based policies, such as regulations on trade, retailing, and quality or incentives for product reformulation. Yet this requires a correct evaluation of the importance and causal effects of supply-side factors on the obesity pandemic. Among others, the economic literature analyzes the effect of changes in food prices, food availability, trade, and marketing on the nutrition and epidemiological transitions. There is a lack of causal robust evidence on their long-term effects. The empirical identification of causal effects is de facto challenging because the dynamics of food supply is partly driven by demand-side factors and dynamics, like a growing female labor force, habit formation, and the social dynamics of preferences.
There are several important limitations to the literature from the early 21st century. Existing studies cover mostly well-developed countries, use static economic and econometric specifications, and employ data that cover short periods of time unmarked by profound shifts in food supply. In contrast, empirical research on the long-term dynamics of consumer behavior is much more limited, and comparative studies across diverse cultural and institutional backgrounds are almost nonexistent. Studies on consumers in emerging countries could exploit the rapid time changes and large spatial heterogeneity, both to identify the causal impacts of shocks on supply factors and to document how local culture and institutions shape diet and nutritional outcomes.
Samuel Berlinski and Marcos Vera-Hernández
A set of policies is at the center of the agenda on early childhood development: parenting programs, childcare regulation and subsidies, cash and in-kind transfers, and parental leave policies. Incentives are embedded in these policies, and households react to them differently. They also have varying effects on child development, both in developed and developing countries. We have learned much about the impact of these policies in the past 20 years. We know that parenting programs can enhance child development, that centre based care might increase female labor force participation and child development, that parental leave policies beyond three months don’t cause improvement in children outcomes, and that the effects of transfers depend much on their design. In this review, we focus on the incentives embedded in these policies, and how they interact with the context and decision makers to understand the heterogeneity of effects and the mechanisms through which these policies work. We conclude by identifying areas of future research.
Nelson Lind and Natalia Ramondo
A recent body of literature on quantitative general equilibrium models links the creation and diffusion of knowledge and technology to openness to international trade and to the activity of multinational firms. The unifying theme of this literature is methodological: productivities are Fréchet random variables and arise from Poisson innovation and diffusion processes for ideas. The main advantage of this modeling strategy is that it delivers closed-form solutions for key endogenous variables that have a direct counterpart in the data (e.g., prices, trade flows). This tractability makes the connection between theory and data transparent, helps clarify the determinants of the gains from openness, and facilitates the calculation of counterfactual equilibria.
Sherry Glied and Richard Frank
Mental health economics addresses problems that are common to all of health economics, but that occur with greater severity in this context. Several characteristics of mental health conditions—age of onset, chronicity, observability, and external effects—make them particularly economically challenging, and a range of policies have evolved to address these problems. The need for insurance—and for social insurance—to address mental health problems has grown. There is an expanding number of effective treatments available for mental health conditions, and these treatments can be relatively costly. The particular characteristics of mental health conditions exacerbate the usual problems of moral hazard, adverse selection, and agency. There is increased recognition, in both the policy and economics literatures, of the array of services and supports required to enable people with severe mental illnesses to function in society’s mainstream. The need for such non-medical services, generates economic problems of cross-system coordination and opportunism. Moreover, the impairments imposed by mental disorders have become more disruptive to the labor market because the nature of work is changing in a manner that creates special disadvantages to people with these conditions. New directions for mental health economics would address these effects.
Charles R. Korsmo
Law and economics has proved a particularly fruitful scholarly approach in the field of mergers and acquisitions. A huge law and economics literature has developed, providing critical insights into merger activity in general and the proper role of corporate and securities law in regulating this activity.
Early economic research examined the motivations for merger activity and the antitrust implications of mergers. Later scholarship elucidated the important disciplining effects on management from merger activity and the market for corporate control. If management performs poorly, causing a firm to become undervalued relative to a well-managed firm, the firm becomes vulnerable to a takeover where management will be replaced. This prospect provides a powerful incentive for management to perform well.
More recent work has revealed the limitations of market discipline on management actions in the merger context, and the corresponding role of corporate law in protecting stockholders. Because a merger is generally the final interaction between management and the other stakeholders in a firm, the typical constraints and mechanisms of accountability that otherwise constrain managerial opportunism may be rendered ineffective. This work has played a central role in informing modern jurisprudence. It has shaped the application of enhanced judicial scrutiny of management actions in the merger context, as embodied in the landmark Delaware cases Unocal and Revlon. The law and economics literature has also made important contribution to more recent developments in stockholder appraisal. The law and economics tradition has also provided a useful framework for evaluating the dynamics of merger litigation, including stockholder appraisal, and the extent to which such litigation can be made to serve a useful role in corporate governance.
Life-cycle choices and outcomes over financial (e.g., savings, portfolio, work) and health-related variables (e.g., medical spending, habits, sickness, and mortality) are complex and intertwined. Indeed, labor/leisure choices can both affect and be conditioned by health outcomes, precautionary savings is determined by exposure to sickness and longevity risks, where the latter can both be altered through preventive medical and leisure decisions. Moreover, inevitable aging induces changes in the incentives and in the constraints for investing in one’s own health and saving resources for old age. Understanding these pathways poses numerous challenges for economic models.
The life-cycle data is indicative of continuous declines in health statuses and associated increases in exposure to morbidity, medical expenses, and mortality risks, with accelerating post-retirement dynamics. Theory suggests that risk-averse and forward-looking agents should rely on available instruments to insure against these risks. Indeed, market- and state-provided health insurance (e.g., Medicare) cover curative medical expenses. High end-of-life home and nursing-home expenses can be hedged through privately or publicly provided (e.g., Medicaid) long-term care insurance. The risk of outliving one’s financial resources can be hedged through annuities. The risk of not living long enough can be insured through life insurance.
In practice, however, the recourse to these hedging instruments remains less than predicted by theory. Slow-observed wealth drawdown after retirement is unexplained by bequest motives and suggests precautionary motives against health-related expenses. The excessive reliance on public pension (e.g., Social Security) and the post-retirement drop in consumption not related to work or health are both indicative of insufficient financial preparedness and run counter to consumption smoothing objectives. Moreover, the capacity to self-insure through preventive care and healthy habits is limited when aging is factored in. In conclusion, the observed health and financial life-cycle dynamics remain challenging for economic theory.
Elisa Tosetti, Rita Santos, Francesco Moscone, and Giuseppe Arbia
The spatial dimension of supply and demand factors is a very important feature of healthcare systems. Differences in health and behavior across individuals are due not only to personal characteristics but also to external forces, such as contextual factors, social interaction processes, and global health shocks. These factors are responsible for various forms of spatial patterns and correlation often observed in the data, which are desirable to include in health econometrics models.
This article describes a set of exploratory techniques and econometric methods to visualize, summarize, test, and model spatial patterns of health economics phenomena, showing their scientific and policy power when addressing health economics issues characterized by a strong spatial dimension. Exploring and modeling the spatial dimension of the two-sided healthcare provision may help reduce inequalities in access to healthcare services and support policymakers in the design of financially sustainable healthcare systems.
Thomas J. Kniesner and W. Kip Viscusi
The value of a statistical life (VSL) is the local tradeoff rate between fatality risk and money. When the tradeoff values are derived from choices in market contexts the VSL serves as both a measure of the population’s willingness to pay for risk reduction and the marginal cost of enhancing safety. Given its fundamental economic role, policy analysts have adopted the VSL as the economically correct measure of the benefit individuals receive from enhancements to their health and safety. Estimates of the VSL for the United States are around $10 million ($2017), and estimates for other countries are generally lower given the positive income elasticity of the VSL. Because of the prominence of mortality risk reductions as the justification for government policies the VSL is a crucial component of the benefit-cost analyses that are part of the regulatory process in the United States and other countries. The VSL is also foundationally related to the concepts of value of a statistical life year (VSLY) and value of a statistical injury (VSI), which also permeate the labor and health economics literatures. Thus, the same types of valuation approaches can be used to monetize non-fatal injuries and mortality risks that pose very small effects on life expectancy. In addition to formalizing the concept and measurement of the VSL and presenting representative estimates for the United States and other countries our Encyclopedia selection addresses the most important questions concerning the nuances that are of interest to researchers and policymakers.
High-dimensional dynamic factor models have their origin in macroeconomics, more specifically in empirical research on business cycles. The central idea, going back to the work of Burns and Mitchell in the 1940s, is that the fluctuations of all the macro and sectoral variables in the economy are driven by a “reference cycle,” that is, a one-dimensional latent cause of variation. After a fairly long process of generalization and formalization, the literature settled at the beginning of the 2000s on a model in which (a) both n, the number of variables in the data set, and T, the number of observations for each variable, may be large; (b) all the variables in the data set depend dynamically on a fixed, independent of n, number of common shocks, plus variable-specific, usually called idiosyncratic, components. The structure of the model can be exemplified as follows:
where the observable variables are driven by the white noise , which is common to all the variables, the common shock, and by the idiosyncratic component . The common shock is orthogonal to the idiosyncratic components , the idiosyncratic components are mutually orthogonal (or weakly correlated). Last, the variations of the common shock affect the variable dynamically, that is, through the lag polynomial . Asymptotic results for high-dimensional factor models, consistency of estimators of the common shocks in particular, are obtained for both and tending to infinity.
The time-domain approach to these factor models is based on the transformation of dynamic equations into static representations. For example, equation () becomes
Instead of the dynamic equation () there is now a static equation, while instead of the white noise there are now two factors, also called static factors, which are dynamically linked:
This transformation into a static representation, whose general form is
is extremely convenient for estimation and forecasting of high-dimensional dynamic factor models. In particular, the factors and the loadings can be consistently estimated from the principal components of the observable variables .
Assumption allowing consistent estimation of the factors and loadings are discussed in detail. Moreover, it is argued that in general the vector of the factors is singular; that is, it is driven by a number of shocks smaller than its dimension. This fact has very important consequences. In particular, singularity implies that the fundamentalness problem, which is hard to solve in structural vector autoregressive (VAR) analysis of macroeconomic aggregates, disappears when the latter are studied as part of a high-dimensional dynamic factor model.
Marjon van der Pol and Alastair Irvine
The interest in eliciting time preferences for health has increased rapidly since the early 1990s. It has two main sources: a concern over the appropriate methods for taking timing into account in economics evaluations, and a desire to obtain a better understanding of individual health and healthcare behaviors. The literature on empirical time preferences for health has developed innovative elicitation methods in response to specific challenges that are due to the special nature of health. The health domain has also shown a willingness to explore a wider range of underlying models compared to the monetary domain. Consideration of time preferences for health raises a number of questions. Are time preferences for health similar to those for money? What are the additional challenges when measuring time preferences for health? How do individuals in time preference for health experiments make decisions? Is it possible or necessary to incentivize time preference for health experiments?
Mostafa Beshkar and Eric Bond
International trade agreements have played a significant role in the reduction of trade barriers that has taken place since the end of World War II. One objective of the theoretical literature on trade agreements is to address the question of why bilateral and multilateral trade agreements, rather than simple unilateral actions by individual countries, have been required to reduce trade barriers. The predominant explanation has been the terms of trade theory, which argues that unilateral tariff policies lead to a prisoner’s dilemma due to the negative effect of a country’s tariffs on its trading partners. Reciprocal tariff reductions through a trade agreement are required to obtain tariff reductions that improve on the noncooperative equilibrium. An alternative explanation, the commitment theory of trade agreements, focuses on the use of external enforcement under a trade agreement to discipline domestic politics.
A second objective of the theoretical literature has been to understand the design of trade agreements. Insights from contract theory are used to study various flexibility mechanisms that are embodied in trade agreements. These mechanisms include contingent protection measures such as safeguards and antidumping, and unilateral flexibility through tariff overhang. The literature also addresses the enforcement of agreements in the absence of an external enforcement mechanism. The theories of the dispute settlement process of the WTO portray it as an institution with an informational role that facilitates the coordination among parties with incomplete information about the states of the world and the nature of the actions taken by each signatory. Finally, the literature examines whether the ability to form preferential trade agreements serves as a stumbling block or a building block to multilateral liberalization.
Urban sprawl in popular sources is vaguely defined and largely misunderstood, having acquired a pejorative meaning. Economists should ask whether particular patterns of urban land use are an outcome of an efficient allocation of resources. Theoretical economic modeling has been used to show that more not less, sprawl often improves economic efficiency. More sprawl can cause a reduction in traffic congestion. Job suburbanization can generally increase sprawl but improves economic efficiency. Limiting sprawl in some cities by direct control of the land use can increase sprawl in other cities, and aggregate sprawl in all cities combined can increase. That urban population growth causes more urban sprawl is verified by empirically implemented general equilibrium models, but—contrary to common belief—the increase in travel times that accompanies such sprawl are very modest. Urban growth boundaries to limit urban sprawl cause large deadweight losses by raising land prices and should be seen to be socially intolerable but often are not. It is good policy to use corrective taxation for negative externalities such as traffic congestion and to implement property tax reforms to reduce or eliminate distortive taxation. Under various circumstances such fiscal measures improve welfare by increasing urban sprawl. The flight of the rich from American central cities, large lot zoning in the suburbs, and the financing of schools by property tax revenues are seen as causes of sprawl. There is also evidence that more heterogeneity among consumers and more unequal income distributions cause more urban sprawl. The connections between agglomeration economies and urban sprawl are less clear. The emerging technology of autonomous vehicles can have major implications for the future of urban spatial structure and is likely to add to sprawl.
Henrik Andersson, Arne Risa Hole, and Mikael Svensson
Many public policies and individual actions have consequences for population health. To understand whether a (costly) policy undertaken to improve population health is a wise use of resources, analysts can use economic evaluation methods to assess the costs and benefits. To do this, it is necessary to evaluate the costs and benefits using the same metric, and for convenience, a monetary measure is commonly used. It is well established that money measures of a reduction in health risks can be theoretically derived using the willingness-to-pay concept. However, because a market price for health risks is not available, analysts have to rely on analytical techniques to estimate the willingness to pay using revealed- or stated-preference methods. Revealed-preference methods infer willingness to pay based on individuals’ actual behavior in markets related to health risks, and they include such approaches as hedonic pricing techniques. Stated-preference methods use a hypothetical market scenario in which respondents make trade-offs between wealth and health risks. Using, for example, a random utility framework, it is possible to directly estimate individuals’ willingness to pay by analyzing the trade-offs they make in the hypothetical scenario. Stated-preference methods are commonly applied using contingent valuation or discrete choice experiment techniques. Despite criticism and the shortcomings of both the revealed- and stated-preference methods, substantial progress has been made since the 1990s in using both approaches to estimate the willingness to pay for health-risk reductions.
Marisa Miraldo, Katharina Hauck, Antoine Vernet, and Ana Wheelock
Major medical innovations have greatly increased the efficacy of treatments, improved patient outcomes, and often reduced the cost of medical care. However, innovations do not diffuse uniformly across and within health systems. Due to the high complexity of medical treatment decisions, variations in clinical practice are inherent to healthcare delivery, regardless of technological advances, new ways of working, funding, and burden of disease. In this article we conduct a narrative literature review to identify and discuss peer-reviewed articles presenting a theoretical framework or empirical evidence of the factors associated with the adoption of innovation and clinical practice.
We find that variation in innovation adoption and medical practice is associated with multiple factors. First, patients’ characteristics, including medical needs and genetic factors, can crucially affect clinical outcomes and the efficacy of treatments. Moreover, differences in patients’ preferences can be an important source of variation. Medical treatments may need to take such patient characteristics into account if they are to deliver optimal outcomes, and consequently, resulting practice variations should be considered warranted and in the best interests of patients. However, socioeconomic or demographic characteristics, such as ethnicity, income, or gender are often not considered legitimate grounds for differential treatment. Second, physician characteristics—such as socioeconomic profile, training, and work-related characteristics—are equally an influential component of practice variation. In particular, so-called “practice style” and physicians’ attitudes toward risk and innovation adoption are considered a major source of practice variation, but have proven difficult to investigate empirically. Lastly, features of healthcare systems—notably, public coverage of healthcare expenditure, cost-based reimbursement of providers, and service-delivery organization, are generally associated with higher utilization rates and adoption of innovation.
Research shows some successful strategies aimed at reducing variation in medical decision-making, such as the use of decision aids, data feedback, benchmarking, clinical practice guidelines, blinded report cards, and pay for performance. But despite these advances, there is uneven diffusion of new technologies and procedures, with potentially severe adverse efficiency and equity implications.