2024
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Gawain Heckley, Dennis Petrie
2024-18
This paper presents a flexible method, Parameter Estimation by Raw Moments (PERM), to evaluate a policy’s impact on parameters of the distribution of outcomes. Such parameters include the variance (E[Y2]-E[Y]2), skewness and covariance. While many studies estimate the mean (first moment), PERM extends this to estimate higher order moments, enabling calculation of distribution parameter treatment effects. Two implementations are discussed: regression with controls and DiD with staggered rollout. Applying PERM DiD to a Swedish school reform shows it reduced education inequality but increased earnings variance resulting in a lower covariance between education and earnings.
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Nicole Black, Anthony Harris, David W. Johnston, and Trong-Anh Trinh
2024-17
To improve access to affordable mental healthcare, Australia introduced a national, publicly-funded program in 2006 to subsidise psychological services, which were previously privately funded. Theory suggests that by increasing demand, subsidies should incentivise providers to expand supply, either by entering the workforce or by increasing hours. However, expansion depends on supply constraints, particularly in non-metropolitan areas with pronounced workforce shortages. This study examines the program’s effects on the size, work hours, demographic composition, earnings, and location of practising psychologists. Using a difference-in-differences approach with census data and Australian Tax Office records, we find that the program: (1) increased the supply of practising psychologists by 47% within five years, with minimal effect on average hours worked per psychologist; (2) raised psychologists’ annual personal incomes by 17%; and (3) increased the likelihood of psychologists working in non-metropolitan areas by 8%, supporting broader access to mental healthcare.
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Muhammad Fikru Rizal, David W. Johnston, Nicole Black, Rohan Sweeney
2024-16
In many low and middle-income countries (LMICs), a high proportion of people with mental health needs do not receive treatment, contributing to a significant “treatment gap”. Despite this, there is limited robust evidence on the socioeconomic factors that shape mental healthcare use in these settings. Using data from over 400,000 adults in Indonesia, this study examines how wealth, education, and health insurance coverage influence the likelihood of accessing mental healthcare among those with probable depression. Indonesia is an important context for this analysis because undertreatment and stigma are particularly severe. We find that only 9.3% of those identified as having probable depression receive treatment. Wealth and health insurance are positively associated with the probability of mental healthcare utilisation, while education is not. The wealth gradient diminishes at the highest income levels, and we show this is possibly due to increased stigma. These findings underscore the importance of reducing financial barriers, such as through public health insurance expansion and reducing stigma to address the mental health treatment gap in LMICs.
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Rosanne Freak-Poli, Stephen P. Jenkins, Michael A. Shields, and Trong-Anh Trinh
2024-15
Despite a substantial literature on the links between social relationships and mortality, the size of the relative risks from loneliness, social isolation, and living alone, remain controversial. Further research is therefore important given demographic changes meaning that more people are living alone, for longer, and with chronic health conditions. Using 19 waves of high-quality Australian longitudinal data we provide new evidence using multiple measures of social relationships, model specifications, and adjustments for confounding. We focus on chronic measures of (poor) social relationships and provide separate estimates by gender. We find that both functional and structural aspects of social relationships are independently strongly associated with all-cause mortality. We estimate a hazard ratio for loneliness of 1.41, which is greater for males (1.55) than females (1.24). These hazard ratios are larger than found for social isolation (1.19). We also find a strong relationship between being an active member of a club and reduced mortality risk, but no evidence that living alone is an independent risk factor. We provide useful comparisons with the mortality risks associated with smoking and household income. Overall, our findings suggest that interventions should focus on reducing both loneliness and social isolation, as well as encouraging active social participation.
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Nicole Black, David W. Johnston, Martin Knapp, Michael A. Shields, and Gloria H.Y. Wong
2024-14
For people experiencing mental health problems, timely access to high-quality healthcare is imperative for improving outcomes. However, limited availability of services, high out-of-pocket costs, insufficient health literacy and stigmatising attitudes may mean people do not receive the necessary treatment. We analyse Australian longitudinal data to document the extent and predictors of horizontal inequity in mental healthcare use among people with a newly developed mild or moderate mental disorder. Importantly, we compare people with similar health, residing in the same area, thus controlling for differences in healthcare needs and availability of services. Results suggest that mental healthcare use is not significantly associated with household income or financial hardship. In contrast, we find significant inequities by educational attainment, with university graduates around 50% more likely to receive mental healthcare than high-school dropouts. These findings are robust across subsamples and alternative modelling approaches, including panel data models with individual fixed- effects. Additional explorations of the education gradient suggest a potential pathway through mental health-specific knowledge and attitudes.
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Miao Guo, Yang Li, Minghao Wu and Terence C. Cheng
2024-13
This study analyzes the effects of China’s long-term care insurance (LTCI) benefit design on household consumption and intergenerational support. The program provides two benefit options: in-kind benefits (or services) and cash allowances. We introduce a conceptual framework to analyze economic decision making under the two types of LTCI benefits. Using an empirical framework that exploits variations in LTCI benefit designs across China’s pilot cities, we find that both types of LTCI benefits increase household consumption and reduce medical expenditure. Specifically, ‘mixed’ benefits households – those with a choice between in-kind and cash benefits – significantly increase spending on food and housing, while households receiving services spend more on housing, transport, and clothing. Additionally, in-kind benefit recipients report receiving lower informal care from their children, implying a substitution with formal care. Households with mixed benefits experience a decline in financial support from children, suggesting a crowding-out of intergenerational transfers. Finally, we estimate income and substitution effects that are implicit in recipients’ behavior to analyze welfare implications under China’s LTCI.
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Nicole Black, David W. Johnston, Michael A. Shields, and Trong-Anh Trinh
2024-12
We study the extent of horizontal inequity in children’s mental healthcare use in Australia, where universal insurance aims to provide equitable access to needed treatment, regardless of ability to pay. We use linked longitudinal survey data and administrative records that measure the need for mental healthcare – via screening questionnaires and general practitioner (GP) diagnosis – and use of mental health professionals and medication. Using between- and within-child approaches, we find that conditional on need, children from lower income families are significantly less likely to receive services from clinical psychologists than children from higher income households. However, we see little evidence of income inequities in receiving mental health services from GPs or general psychologists. We show that differences in out-of-pocket fees are a likely explanation. The findings highlight that specific support to low-income families is needed to reduce inequities in accessing a complete range of mental health services.
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Nicole Black, Johannes Kunz
2024-11
Language proficiency is a crucial skill for immigrants that influences their social integration and their children’s development. This study examines the intergenerational effects of limited English proficiency (LEP) on children’s health and health care utilisation. We mitigate potential selection issues arising from insurance coverage by examining Australian-born children who are all covered under a universal public health insurance scheme. We use Australian population Census and longitudinal survey data linked to administrative health care records, and variation in parent’s language acquisition, based on their age at arrival into Australia. We find that parental LEP has a strong and positive effect on children’s use of general practitioners, but no effect on their use of other healthcare services, or on their physical or mental health. We explore several possible supply- and demand-side explanations.
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Michelle Escobar Carías, Nicole Black, David Johnston, Rohan Sweeney, Fiona S. Barker, Rosnaena, Syaidah Syamsul, Taniela Waka
2024-10
We document gender differences in children’s time investments in education, labour, and leisure in an understudied population of children living in urban informal settlements. Using within-settlement and within-sibling comparisons, we find that boys spend significantly less time than girls on schooling and homework and more time on leisure activities. We also find that caregivers invest less time in helping their sons with reading and homework than their daughters. One possible explanation is that girls spend more time on domestic work. As a result, as the share of girls in the household increases, primary caregivers spend less time on domestic work and more time on other activities such as teaching children. We find that the gender gaps in time use are more pronounced among children whose parents have lower schooling and more financial constraints.
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Daniel Avdic, Johannes S. Kunz, Susan J. Méndez, Maria Wiśniewska
2024-09
We study how the diffusion of telemedicine technology impacted the quality and rates of antibiotic prescriptions using Australian survey data from primary care physicians linked to administrative records on their service provision. We classify physicians based on their relative use of telemedicine consultations in response to the introduction of government-subsidised telemedicine during the COVID-19 pandemic and relate their rates of antibiotic prescriptions to indicators of pre- scribing quality before and after lockdown periods in a difference-in-differences design. Our results suggest that more frequent users of telemedicine prescribe relatively fewer antibiotics while keeping prescribing quality largely unchanged. We interpret these findings as evidence that telemedicine can enhance efficiency of service provision in primary care settings.
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Wang-Sheng Lee, Umair Khalil, David Johnston
2024-08
This paper estimates the impacts of religiosity on criminal activity using a city-wide shock to religious sentiment from a 2015 Papal visit. Using daily data on all reported offences between 2010 and 2015 in Philadelphia at the census tract level and a difference-in-differences approach, we demonstrate significant reductions in less serious crimes in the week of the visit and for several weeks following. Reductions are particularly pronounced for drug offences and in historically Christian areas. Notably, similar crime effects are not found for President Obama’s 2015 visit, suggesting changes in police deployment do not drive results.
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Johannes Kunz, Carol Propper, Trong-Anh Trinh
2024-07
Digital access may bring important health gains, particularly where physical infrastructure is limited. We examine the impact of internet access in Indonesia on health outcomes using the COVID-19 pandemic as a health shock. We utilize sub-national data on mobile broadband, COVID-19 spread, and an instrumental variable approach using lightning strikes as an exogenous shock to connectivity. Access to 3G internet significantly reduced the transmission of COVID-19. Areas with internet access had approximately 45% fewer cases. Regions with higher literacy and capacity for telework benefited significantly more. These findings offer novel insights into how digital infrastructure affects public health outcomes.
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Stephen Hoskins, David W. Johnston, Johannes S. Kunz, Michael A. Shields, Kevin E. Staub
2024-06
Despite being widely used in health economics, dynamic models of health and healthcare typically assume that the persistence in these outcomes is the same for every individual. Understanding the extent and drivers of heterogeneity in persistence is essential for the design and evaluation of health interventions because persistence determines the dynamics and overall long-run effects of such interventions. This paper explores individual-level heterogeneity in the persistence of health outcomes. Using simple regression methods that do not place any restriction on the distribution of the heterogeneity in persistence, the paper documents substantial heterogeneity in health, medical expenditures, and healthcare use. We show that neglecting this heterogeneity leads to estimates that overstate the average persistence and can bias the coefficients of covariates. We find that between 75% and 87% of individuals display persistence and that this persistence is related to the individuals’ personality and socio-economic characteristics.
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Stephen Hoskins, David W. Johnston, Johannes S. Kunz, Michael A. Shields, Kevin E. Staub
2024-05
Using a high-frequency panel survey, we examine the sensitivity of estimated self-reported well-being (SWB) dynamics to using monthly, quarterly, and yearly data. This is an important issue if SWB is to be used to evaluate policy. Results from autoregressive models that account for individual-level heterogeneity indicate that the estimated persistence using yearly data is near zero. However, estimated persistence from monthly and quarterly data is substantial. We estimate that persistence to shocks typically lasts around six months and has a net present value of 75–80 per cent of the contemporaneous effect. Estimates are similar for different domains of SWB.
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Sofia Amaral-Garcia, Mattia Nardotto, Carol Propper, and Tommaso Valletti
2024-04
We examine the effect of internet diffusion on the uptake of an important public health intervention: the measles, mumps and rubella (MMR) vaccine. We study England between 2000 and 2011 when internet diffusion spread rapidly and there was a high profile medical article (falsely) linking the MMR vaccine to autism. OLS estimates suggest internet diffusion led to an increase in vaccination rates. This result is reversed after allowing for endogeneity of internet access. The effect of internet diffusion is sizable. A one standard deviation increase in internet penetration led to around a 20% decrease in vaccination rates. Localities characterised by higher proportions of high skilled individuals and lower deprivation levels had a larger response to internet diffusion. These findings are consistent with higher skilled and less deprived parents responding faster to false information that the vaccine could lead to autism.