Working papers series

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.

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Nicole Black, Lachlan Deer, David W. Johnston, and Johannes S. Kunz

2023-08

Peer-to-peer support is often a critical component of mental health programs, but evidence on the effect of peer-based support programs at scale is limited. Using quasi-experimental methods, we examine whether a prominent peer-based support campaign, “R U OK? Day”, affects short-term mental health outcomes in Australia. Using variation in daily records and differences in the campaign’s intensity over nine years, we find no evidence that “R U OK? Day” reduces suicides and suicidal behaviours in the month after the campaign. However, we find positive effects on mental wellbeing, particularly among middle-aged males, with improved social support the likely mechanism. Our results provide evidence that peer support campaigns may be a practical, low-cost approach to improve population mental wellbeing.

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Sundar Ponnusamy and Mohammad Abbas Hakeem

2023-07

We examine the association between ethnic inequality and various key health outcomes for a global set of developed and developing countries. Our results show that higher ethnic inequality is associated with a poor state of public health, such as higher child and maternal mortality, increased stillbirths and child stunting, and reduced life expectancy at birth. This set of effects is found to be predominant mainly in developing countries, and Sub-Saharan African countries. Results remain robust to the inclusion of various other measures of inequality, ethnic composition indices, geographic endowments, and other relevant controls. We argue that lower contraceptive usage and poor vaccination rates are potential mechanisms through which ethnic inequality affects health outcomes. Policies targeted at improving public health may need to focus more on these key intermediate channels in ethnic minority regions.

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Nicole Black, Danusha Jayawardana, and Gawain Heckley

2023-06

Children’s time investments in various activities may be important for reducing socioeconomic status (SES) gaps in educational and mental health outcomes. Using time use diaries of Australian children aged 4-14, we find children from low SES backgrounds spend more time on digital media and less time on cognitively stimulating out-of-school activities, organised or for leisure. This difference contributes about 4% to the observed SES gap in numeracy skills. The contribution is larger for males, older age groups, and when the cumulative effect on learning is considered. No clear results are found for literacy skills and mental health outcomes.

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Johannes Kunz and Anna Zhu

2023-05

We study the effect of reducing welfare assistance on migrants’ long-term integration in Australia. The policy postponed a migrant’s eligibility for benefits during their first two years in the country. It mainly affected mothers and was announced after their arrival. Using a regression discontinuity design and 21 years of administrative welfare data, we find significant reductions in welfare receipt, where the gap widened over time, and stabilized in the long run. Benefit receipt amounts reduced by 28%, and time-on-benefits by 19%, particularly in the unemployment and disability categories. We observe larger treatment effects for mothers from disadvantaged backgrounds.

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Sofia Amaral-Garcia, Mattia Nardotto, Carol Propper and Tommaso Valletti

2023-04

We study the effect of internet diffusion on the uptake of the measles, mumps and rubella (MMR) vaccine for children in England between 2000 and 2011. OLS estimates suggest that internet diffusion led to an increase in vaccinations but this result is reversed once we instrument for internet access. We find that the effect of internet diffusion on vaccination rates is sizable: a change of one standard deviation in internet take up determined an approximately 20% decrease in vaccination rate. We also find that areas with a higher proportion of high skilled individuals and lower deprivation levels are those with a higher response to internet diffusion in terms of the reduction in MMR vaccination rates. These findings are consistent with higher skilled and less deprived parents responding faster to false information circulated at the time that the vaccine could lead to autism. Even though this information has been proven to be wrong, these parents were those absorbing it more.

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Coen van de Kraats, Titus Galama and Maarten Lindeboom

2023-03

We provide evidence that the social norm (expectation) of work has a detrimental causal effect on the mental well-being of individuals not able to abide by it. Using SHARE data on men aged 50+ from 10 European countries, we identify the social norm of work effect in a difference-in-differences model that compares mental well-being scores of unemployed / disabled individuals (the treatment group) with those of employed / retired individuals (the control group) at varying levels of the fraction of retirees of comparable age. The initial mental well-being gap at age 50 is large, with unemployed / disabled men experiencing substantially lower levels of mental well-being, comparable to, e.g., the detriment of being widowed. Beyond age 50, the mental well-being of unemployed and disabled men improves as peers of comparable age retire, and full convergence occurs generally at an age that is slightly above the normal retirement age, when everyone has retired.

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Hai-Anh Dang, Trong-Anh Trinh and Paolo Verme

2023-02

Hardly any evidence exists on the effects of mental illness on refugee labor outcomes. We offer the first study on this topic in the context of Australia, one of the host countries with the largest number of refugees per capita in the world. Analyzing the Building a New Life in Australia longitudinal survey, we exploit the variations in traumatic experiences of refugees interacted with post-resettlement time periods to causally identify the impacts of refugee mental health. We find that worse mental health, as measured by a one-standard-deviation increase in the Kessler mental health score, reduces the probability of employment by 14.1% and labor income by 26.8%. We also find some evidence of adverse impacts of refugees’ mental illness on their children’s mental health and education performance. These effects appear more pronounced for refugees that newly arrive or are without social networks, but they may be ameliorated with government support.

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Johannes S. Kunz, Carol Propper, Kevin E. Staub and Rainer Winkelmann

2023-01

We examine variation in US hospital quality across ownership, chain membership, and market concentration. We use a new measure of quality derived from the penalties imposed on hospitals under the flagship Hospital Readmissions Reduction Program. We document a robust and sizable negative for-profit quality gap: for-profit hospitals are consistently of lower quality. We find that a substantial part of the gap is related to being located in less competitive markets. This reduction occurs most for hospitals that are part of large national chains. For such hospitals we find no quality gap in fully competitive markets.

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