Matteo M. Galizzi and Daniel Wiesen
The state-of-the-art literature at the interface between experimental and behavioral economics and health economics is reviewed by identifying and discussing 10 areas of potential debate about behavioral experiments in health. By doing so, the different streams and areas of applications of the growing field of behavioral experiments in health are reviewed, by discussing which significant questions remain to be discussed, and by highlighting the rationale and the scope for the further development of behavioral experiments in health in the years to come.
Nikolaus Robalino and Arthur Robson
Modern economic theory rests on the basic assumption that agents’ choices are guided by preferences. The question of where such preferences might have come from has traditionally been ignored or viewed agnostically. The biological approach to economic behavior addresses the issue of the origins of economic preferences explicitly. This approach assumes that economic preferences are shaped by the forces of natural selection. For example, an important theoretical insight delivered thus far by this approach is that individuals ought to be more risk averse to aggregate than to idiosyncratic risk. Additionally the approach has delivered an evolutionary basis for hedonic and adaptive utility and an evolutionary rationale for “theory of mind.” Related empirical work has studied the evolution of time preferences, loss aversion, and explored the deep evolutionary determinants of long-run economic development.
In many countries of the world, consumers choose their health insurance coverage from a large menu of often complex options supplied by private insurance companies. Economic benefits of the wide choice of health insurance options depend on the extent to which the consumers are active, well informed, and sophisticated decision makers capable of choosing plans that are well-suited to their individual circumstances.
There are many possible ways how consumers’ actual decision making in the health insurance domain can depart from the standard model of health insurance demand of a rational risk-averse consumer. For example, consumers can have inaccurate subjective beliefs about characteristics of alternative plans in their choice set or about the distribution of health expenditure risk because of cognitive or informational constraints; or they can prefer to rely on heuristics when the plan choice problem features a large number of options with complex cost-sharing design.
The second decade of the 21st century has seen a burgeoning number of studies assessing the quality of consumer choices of health insurance, both in the lab and in the field, and financial and welfare consequences of poor choices in this context. These studies demonstrate that consumers often find it difficult to make efficient choices of private health insurance due to reasons such as inertia, misinformation, and the lack of basic insurance literacy. These findings challenge the conventional rationality assumptions of the standard economic model of insurance choice and call for policies that can enhance the quality of consumer choices in the health insurance domain.
Deborah J. Street and Rosalie Viney
Discrete choice experiments are a popular stated preference tool in health economics and have been used to address policy questions, establish consumer preferences for health and healthcare, and value health states, among other applications. They are particularly useful when revealed preference data are not available. Most commonly in choice experiments respondents are presented with a situation in which a choice must be made and with a a set of possible options. The options are described by a number of attributes, each of which takes a particular level for each option. The set of possible options is called a “choice set,” and a set of choice sets comprises the choice experiment. The attributes and levels are chosen by the analyst to allow modeling of the underlying preferences of respondents. Respondents are assumed to make utility-maximizing decisions, and the goal of the choice experiment is to estimate how the attribute levels affect the utility of the individual. Utility is assumed to have a systematic component (related to the attributes and levels) and a random component (which may relate to unobserved determinants of utility, individual characteristics or random variation in choices), and an assumption must be made about the distribution of the random component. The structure of the set of choice sets, from the universe of possible choice sets represented by the attributes and levels, that is shown to respondents determines which models can be fitted to the observed choice data and how accurately the effect of the attribute levels can be estimated. Important structural issues include the number of options in each choice set and whether or not options in the same choice set have common attribute levels. Two broad approaches to constructing the set of choice sets that make up a DCE exist—theoretical and algorithmic—and no consensus exists about which approach consistently delivers better designs, although simulation studies and in-field comparisons of designs constructed by both approaches exist.
Jason M. Fletcher
Two interrelated advances in genetics have occurred which have ushered in the growing field of genoeconomics. The first is a rapid expansion of so-called big data featuring genetic information collected from large population–based samples. The second is enhancements to computational and predictive power to aggregate small genetic effects across the genome into single summary measures called polygenic scores (PGSs). Together, these advances will be incorporated broadly with economic research, with strong possibilities for new insights and methodological techniques.
Ingela Alger and Donald Cox
Which parent can be expected to be more altruistic toward their child, the mother or father? All else equal, can we expect older generation members to be more solicitous of younger family members or vice versa? Policy interventions often target recipients by demographic status: more money being put in the hands of mothers, say, or transfers of income from young to old via public pensions. Economics makes predictions about pecuniary incentives and behavior but tends to be agnostic about how, say, a post-menopausal grandmother might behave, just because she is a post-menopausal grandmother. Evolutionary theory fills this gap by analyzing how preferences of family members emerge from the Darwinian exigencies of “survive and reproduce.” Coin of the realm is so-called “inclusive fitness,” reproductive success of oneself plus that of relatives, weighted by closeness of the relationship. Appending basic biological traits onto considerations of inclusive fitness generates predictions about preferences of family members. A post-menopausal grandmother with a daughter just starting a family is predicted to care more about her daughter than the daughter cares about her, for example. Evolutionary theory predicts that mothers tend to be more altruistic toward children than fathers, and that close relatives would be inclined to provide more support to one another than distant relatives. An original case study is provided, which explains the puzzle of diverging marriage rates by education in terms of heterogeneity in preferences for commitment. Economists are justifiably loathe to invoke preferences to explain trends, since preference-based explanations can be concocted to explain just about anything. But the evolutionary approach does not permit just any invocation of preferences. The dictates of “survive and reproduce” sharply circumscribe the kinds of preference-related arguments that are admissible.
Maria Soledad Martinez Peria and Mu Yang Shin
The link between financial inclusion and human development is examined here. Using cross-country data, the behavior of variables that try to capture these concepts is examined and preliminary evidence of a positive association is offered. However, because establishing a causal relationship with macro-data is difficult, a thorough review of the literature on the impact of financial inclusion, focusing on micro-studies that can better address identification is conducted. The literature generally distinguishes between different dimensions of financial inclusion: access to credit, access to bank branches, and access to saving instruments (i.e., accounts). Despite promising results from a first wave of studies, the impact of expanding access to credit seems limited at best, with little evidence of transformative effects on human development outcomes. While there is more promising evidence on the impact of expanding access to bank branches and formal saving instruments, studies show that some interventions such as one-time account opening subsidies are unlikely to have a sizable impact on social and economic outcomes. Instead well-designed interventions catering to individuals’ specific needs in different contexts seem to be required to realize the full potential of formal financial services to enrich human lives.
Punishment has been regarded as an important instrument to sustain human cooperation. A great deal of experimental research has been conducted to understand human punishment behavior, in particular, informal peer punishment. What drives individuals to incur cost to punish others? How does punishment influence human behavior?
Punishment behavior has been observed when the individual does not expect to meet the wrongdoers again in the future and thus has no monetary incentive to punish. Several reasons for such retributive punishment have been proposed and studied. Punishment can be used to express certain values, attitudes, or emotions. Egalitarianism triggers punishment when the transgression leads to inequality. The norm to punish the wrongdoers may also lead people to incur costs to punish even when it is not what they intrinsically want to do.
Individuals sometimes punish wrongdoers even when they are not the victim. The motivation underlying the third-party punishment can be different than the second-party punishment. In addition, restricting the punishment power to a third party can be important to mitigate antisocial punishment when unrestricted second-party peer punishment leads to antisocial punishments and escalating retaliation.
It is important to note that punishment does not always promote cooperation. Imposing fines can crowd out intrinsic motivation to cooperate when it changes people’s perception of social interactions from a generous, non-market activity to a market commodity and leads to more selfish profit-maximizing behavior. To avoid the crowding-out effect, it is important to implement the punishment in a way that it sends a clear signal that the punished behavior violates social norms.
Jacob K. Goeree, Philippos Louis, and Jingjing Zhang
Majority voting is the predominant mechanism for collective decision making. It is used in a broad range of applications, spanning from national referenda to small group decision making. It is simple, transparent, and induces voters to vote sincerely. However, it is increasingly recognized that it has some weaknesses. First of all, majority voting may lead to inefficient outcomes. This happens because it does not allow voters to express the intensity of their preferences. As a result, an indifferent majority may win over an intense minority. In addition, majority voting suffers from the “tyranny of the majority,” i.e., the risk of repeatedly excluding minority groups from representation. A final drawback is the “winner-take-all” nature of majority voting, i.e., it offers no compensation for losing voters. Economists have recently proposed various alternative mechanisms that aim to produce more efficient and more equitable outcomes. These can be classified into three different approaches. With storable votes, voters allocate a budget of votes across several issues. Under vote trading, voters can exchange votes for money. Under linear voting or quadratic voting, voters can buy votes at a linear or quadratic cost respectively. The properties of different alternative mechanisms can be characterized using theoretical modeling and game theoretic analysis. Lab experiments are used to test theoretical predictions and evaluate their fitness for actual use in applications. Overall, these alternative mechanisms hold the promise to improve on majority voting but have their own shortcomings. Additional theoretical analysis and empirical testing is needed to produce a mechanism that robustly delivers efficient and equitable outcomes.
Ching-to Albert Ma and Henry Y. Mak
Health services providers receive payments mostly from private or public insurers rather than patients. Provider incentive problems arise because an insurer misses information about the provider and patients, and has imperfect control over the provider’s treatment, quality, and cost decisions. Different provider payment systems, such as prospective payment, capitation, cost reimbursement, fee-for-service, and value-based payment, generate different treatment quality and cost incentives. The important issue is that a payment system implements an efficient quality-cost outcome if and only if it makes the provider internalize the social benefits and costs of services. Thus, the internalization principle can be used to evaluate payment systems across different settings.
The most common payment systems are prospective payment, which pays a fixed price for service rendered, and cost reimbursement, which pays according to costs of service rendered. In a setting where the provider chooses health service quality and cost reduction effort, prospective payment satisfies the internalization principle but cost reimbursement does not. The reason is that prospective payment forces the provider to be responsible for cost, but cost reimbursement relieves the provider of the cost responsibility. Beyond this simple setting, the provider may select patients based on patients’ cost heterogeneity. Then neither prospective payment nor cost reimbursement achieves efficient quality and cost incentives. A mixed system that combines prospective payment and cost reimbursement performs better than each of its components alone.
In general, the provider’s preferences and available strategies determine if a payment system may achieve internalization. If the provider is altruistic toward patients, prospective payment can be adjusted to accommodate altruism when the provider’s degree of altruism is known to the insurer. However, when the degree of altruism is unknown, even a mixed system may fail the internalization principle. Also, the internalization principle fails under prospective payment when the provider can upcode patient diagnoses for more favorable prices. Cost reimbursement attenuates the upcoding incentive. Finally, when the provider can choose many qualities, either prospective payment and cost reimbursement should be combined with the insurer’s disclosure on quality and cost information to satisfy the internalization principle.
When good healthcare quality is interpreted as a good match between patients and treatments, payment design is to promote good matches. The internalization principle now requires the provider to bear benefits and costs of diagnosis effort and treatment choice. A mixed system may deliver efficient matching incentives. Payment systems necessarily interact with other incentive mechanisms such as patients’ reactions against the provider’s quality choice and other providers’ competitive strategies. Payment systems then become part of organizational incentives.
José Luis Pinto-Prades, Arthur Attema, and Fernando Ignacio Sánchez-Martínez
Quality-adjusted life years (QALYs) are one of the main health outcomes measures used to make health policy decisions. It is assumed that the objective of policymakers is to maximize QALYs. Since the QALY weighs life years according to their health-related quality of life, it is necessary to calculate those weights (also called utilities) in order to estimate the number of QALYs produced by a medical treatment. The methodology most commonly used to estimate utilities is to present standard gamble (SG) or time trade-off (TTO) questions to a representative sample of the general population. It is assumed that, in this way, utilities reflect public preferences. Two different assumptions should hold for utilities to be a valid representation of public preferences. One is that the standard (linear) QALY model has to be a good model of how subjects value health. The second is that subjects should have consistent preferences over health states. Based on the main assumptions of the popular linear QALY model, most of those assumptions do not hold. A modification of the linear model can be a tractable improvement. This suggests that utilities elicited under the assumption that the linear QALY model holds may be biased. In addition, the second assumption, namely that subjects have consistent preferences that are estimated by asking SG or TTO questions, does not seem to hold. Subjects are sensitive to features of the elicitation process (like the order of questions or the type of task) that should not matter in order to estimate utilities. The evidence suggests that questions (TTO, SG) that researchers ask members of the general population produce response patterns that do not agree with the assumption that subjects have well-defined preferences when researchers ask them to estimate the value of health states. Two approaches can deal with this problem. One is based on the assumption that subjects have true but biased preferences. True preferences can be recovered from biased ones. This approach is valid as long as the theory used to debias is correct. The second approach is based on the idea that preferences are imprecise. In practice, national bodies use utilities elicited using TTO or SG under the assumptions that the linear QALY model is a good enough representation of public preferences and that subjects’ responses to preference elicitation methods are coherent.
Iñigo Hernandez-Arenaz and Nagore Iriberri
Gender differences, both in entering negotiations and when negotiating, have been proved to exist: Men are usually more likely to enter into negotiation than women and when negotiating they obtain better deals than women. These gender differences help to explain the gender gap in wages, as starting salaries and wage increases or promotions throughout an individual’s career are often the result of bilateral negotiations.
This article presents an overview of the literature on gender differences in negotiation. The article is organized in four main parts. The first section reviews the findings with respect to gender differences in the likelihood of engaging in a negotiation, that is, in deciding to start a negotiation. The second section discusses research on gender differences during negotiations, that is, while bargaining. The third section looks at the relevant psychological literature and discusses meta-analyses, looking for factors that trigger or moderate gender differences in negotiation, such as structural ambiguity and cultural traits. The fourth section presents a brief overview of research on gender differences in non- cognitive traits, such as risk and social preferences, confidence, and taste for competition, and their impact in explaining gender differences in bargaining. Finally, the fifth section discusses some policy implications.
An understanding of when gender differences are likely to arise on entering into negotiations and when negotiating will enable policies to be created that can mitigate current gender differences in negotiations. This is an active, promising research line.
Ana Balsa and Carlos Díaz
Health behaviors are a major source of morbidity and mortality in the developed and much of the developing world. The social nature of many of these behaviors, such as eating or using alcohol, and the normative connotations that accompany others (i.e., sexual behavior, illegal drug use) make them quite susceptible to peer influence. This chapter assesses the role of social interactions in the determination of health behaviors. It highlights the methodological progress of the past two decades in addressing the multiple challenges inherent in the estimation of peer effects, and notes methodological issues that still need to be confronted. A comprehensive review of the economics empirical literature—mostly for developed countries—shows strong and robust peer effects across a wide set of health behaviors, including alcohol use, body weight, food intake, body fitness, teen pregnancy, and sexual behaviors. The evidence is mixed when assessing tobacco use, illicit drug use, and mental health. The article also explores the as yet incipient literature on the mechanisms behind peer influence and on new developments in the study of social networks that are shedding light on the dynamics of social influence. There is suggestive evidence that social norms and social conformism lie behind peer effects in substance use, obesity, and teen pregnancy, while social learning has been pointed out as a channel behind fertility decisions, mental health utilization, and uptake of medication. Future research needs to deepen the understanding of the mechanisms behind peer influence in health behaviors in order to design more targeted welfare-enhancing policies.
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.