I examine the impacts of (unconditional) cash transfers on adult mortality, exploiting eligibility rules for a universal pension income program in Mexico for identification. Using differences-in-differences estimates with the universe of vital statistics data between 2002 and 2011, I estimate a 5% increase in mortality associated with participation in the universal pension program, driven by changes in deaths attributable to cardiovascular/circulatory disease. The positive income-mortality elasticity contrasts with recent work from low and middle income countries that show decreases in mortality in response to income transfers in later life, but is consistent with other evidence on cash transfers and risk factors for chronic disease. I hypothesize the findings may be explained by increase in food consumption, changes in diet, and retirement transitions. The results have important implications for the design of welfare programs, particularly those targeted towards aging populations, and add nuance to our understanding of socioeconomic determinants of health.

In recent decades there has been much debate on the extent to which income inequality affects health outcomes. The majority of studies in this literature have examined the relationship between income distribution and health outcomes in the contexts of high-income nations. This dissertation evaluates both the ecological and individual-level relationship between income inequality and mortality in the context of a middle-income country, Costa Rica. The Costa Rican case is particularly interesting because its strong social safety net, political organization, and history limit the effects of income inequality on health through indirect channels. Using 20 years of household data, this study begins by documenting changes in income inequality at the canton level. These data reveal that on average inequality has been growing at an annual rate of 0.5%. Using these inequality data, Vital Statistics Mortality records, and longitudinal methods, this study next examines whether cantons with greater growth in inequality also experienced increasing mortality. The analyses indicate that there is no relationship between changes in income inequality and changes in all-cause mortality; however, a relationship does exist for specific causes of death. Area-level inequality was found to be associated with an increase in suicide mortality rates, and a decrease in cardiovascular, respiratory cancer, and breast cancer mortality rates. At the individual-level survival analysis was applied to a new census-mortality linked dataset that allows for a 20-year prospective follow-up. These individual level analyses also test whether income inequality disproportionately affects the poor. In the case of all-cause mortality, the results suggest that there is no association between income inequality and time to death for either the entire sample or for the poor. Contrary to expectations the magnitudes of the estimated effects indicate that residents living in areas with increasing income inequality had a survival advantage for cardiovascular mortality, which further confirms the results found at the ecological level. Overall, this study finds that while inequality has been increasing in Costa Rica, it had limited effect on mortality, indicating that in an environment where safety net services are available, the negative effects of income inequality may be limited to suicide mortality.

Immigrants are more likely to be low income than their US-born peers, but they face more barriers to enrolling in government safety net programs. Children of immigrants, the majority of whom are US citizens, are less likely to enroll in some programs designed to protect their health and welfare. This dissertation explores issues of immigrant families’ engagement with public health insurance and nutritional assistance programs in three chapters.

The first chapter describes levels and time trends of immigrant families’ participation in key safety net programs. The study covers the years 1996 to 2013 using data from the Survey of Income and Program Participation (SIPP) and the New Immigrant Survey (NIS). For children, the study presents data and regression-adjusted estimates of the associations between being from an immigrant family, and having likely undocumented family members, and participation in each of five safety net programs: the Food Stamps Program; National School Lunch Program; School Breakfast Program; Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and public health insurance.

The second chapter evaluates the effects of six state policies that implemented early Affordable Care Act (ACA) adult Medicaid expansions. The analysis focuses on citizen adults of immigrant and native families. It uses the American Community Survey (ACS) from 2008 to 2013 and a difference-in-differences method with synthetic control states to estimate the effects of the expansions on insurance coverage outcomes for citizen adults of immigrant and native family backgrounds. The policies produced a range of responses, from a 2 percentage point public insurance coverage increase in California to an 8 percentage point increase in Connecticut. There was some evidence of private insurance crowd-out in Connecticut, the District of Columbia, and Minnesota, but there were also net reductions in uninsurance for most states. Responses to the new policies were slightly lower among young adults than for the full adult population. In general, insurance coverage changes did not measurably differ among individuals from immigrant families as compared with those from native families.

The third chapter analyzes public health insurance expansions for children. Medicaid expansions have the potential to greatly increase coverage for children in immigrant families, who have low levels of private insurance and high uninsurance rates. However, take-up may be lower in immigrant families than native families due to poor information and “chilling” anti-immigrant sentiment. I estimate take-up from 1996 to 2013 using instrumental variables regression and data from the Survey of Income and Program Participation (SIPP). This study finds that new eligibility for public insurance produces a 9-to-13 percentage point increase in public coverage among children of immigrants, which is indistinguishable from the 11-to-12 percentage point increase among children of natives. These findings reject a strong chilling effect, although the question will be important to revisit in the changing policy environment.

The role of the public primary care network in accessing primary care services in Chile

by

Maria S Martinez Gutierrez

Doctor of Philosophy in Health Services and Policy Analysis

University of California, UC Berkeley

Professor William Dow, Chair

The present study examines the hypothesis that patients receiving care in the public sector in Chile have better access to primary care services, especially preventive services, than patients in the private sector. Although the hypothesis might appear counterintuitive, since worldwide public health facilities are typically underfunded, overcrowded and present deficiencies in quality, Chile's strong network of public primary healthcare facilities (similar to other Latin American countries such as Costa Rica and Uruguay), may help to explain this hypothesis.

This dissertation addresses the following over-arching research question: is using the public system as a preferred venue for accessing primary care services associated with higher utilization of primary care services?

First, it was determined that type of health insurance could be used as a proxy of choice of private provider i.e. being enrolled in a public health plan directed to the poor which restricted provision of services only to the public sector (Fonasa A) was associated with choosing a public provider most of the time. Next, the association of type of health insurance with utilization of primary care services, controlling for all relevant variables from the Andersen model of healthcare access, was analyzed. Regressions were fitted using nationally representative survey data. In depth interview and focus groups were conducted with patients and healthcare providers to complement quantitative findings.

Regression results for utilization of services showed that, in terms of preventive care utilization, using the public system was associated with higher utilization of preventive services in adult and older women, but there was no association found for other age/sex groups. Since people who use the private sector may have been getting their preventive care in other settings such a specialty care clinics an ambulatory care indicator was added as a dependent variable as a sensitivity analysis. For both infants and older people-groups that use intensively the healthcare system-there are no differences in ambulatory healthcare utilization across insurance types. For other age groups using the public healthcare system was associated with lower utilization of ambulatory care services.

In summary, the evidence found in this dissertation suggests that 1) Isapre members and people enrolled in public health plans other than Fonasa A use the private healthcare sector more frequently and 2) although some population groups that use the private system have higher utilization of ambulatory care services there are no differences in preventive services utilization for any population group. In light of these findings, proposals to further expand private health insurance coverage or use of private providers in the Chilean population should take into consideration that this could lead not only to care focused on curative versus preventive services but also to a less efficient distribution of primary care services, since some of the people that need primary care services may be substituting preventive services for specialist services, which are more expensive and less comprehensive than preventive visits.

Research has documented that consumers often have imperfect information about the health insurance plans from which they are asked to choose, but we know less about the sources of that information. Given the difficulty in obtaining reliable information from independent sources, consumers may draw on their peers for recommendations. This dissertation investigates the role of social learning in health insurance selection, using longitudinal data from the University of California on plan choices of employees and peers in their department. The data from 2011 to 2016 span a major change in the insurance choice set, which aids in the statistical identification of social learning effects among both incumbent employees as well as new hires. I start by documenting the high similarity in plan choices within peer groups, suggesting the possibility of strong peer effects, and then use a variety of approaches to test for potential confounding from unobserved heterogeneity. I employ a discrete choice conditional logit estimator to formally model plan choice behavior, finding that a 10 percentage point increase in the share of peers who select a particular insurance plan will lead to a 14 percentage point increase in the probability that an individual will choose the same plan. This large effect on plan choice is equivalent to lowering the monthly premium by 18 percent. I then use this model to simulate employer strategies that could exploit social learning to better promote the employer's insurance objectives. For illustration, I conduct counterfactual analyses of incentives to promote adoption of a new consumer-driven insurance plan. At the actuarially fair premium in this setting, demand for a consumer-driven plan is low, and social learning further discourages take-up. However, with sufficient premium subsidies, the model projects that the social learning effects will become positive and can be harnessed by employers to more effectively achieve their cost and insurance coverage goals.

This dissertation examines the impact of a healthcare reform that aimed to provide universal access to care for a specific set of diseases in Chile. By investigating the impact of the Explicit Health Guarantees program on mortality and health care outcomes, we hope to contribute to understanding the effectiveness of alternative health reforms and their potential for improving health outcomes in Latin America and beyond. The findings are based on Chile’s complete death and inpatient records and a difference-in-differences research design. The study reveals a 4.4% decline in deaths from the diseases covered by the reform, with a more significant effect observed in diseases that are more responsive to healthcare, declining by 7.1%. The reform resulted in over 1,000 deaths averted per year. Furthermore, the reform led to a 16.3% increase in surgeries and a 6.9% decrease in in-hospital deaths related to the covered conditions. Falsification models find no significant mortality effects on these covered diseases in other Latin American countries in these same years, thus strengthening the causal interpretation of our findings. Finally, we focus on socioeconomic, demographic, and geographic patterns of the reform’s effects. The study found that public healthcare providers’ patients benefited more than private clinics, which helped narrow some of the well-known socioeconomic disparities. Although the reform targeted sex-specific diseases, the study found no significant differences in the mortality reduction by sex, but important differences between age groups. Notably, and despite the fact that the increase in surgeries is similar for those between 0 and 49 and those above 80, the proportionate decrease in deaths between ages 0 and 49 was almost four times larger than the decrease in deaths among those above 80. In addition, the study found that the reform did not significantly affect deaths in the Capital city, which had the best pre-reform access to care but decreased deaths elsewhere. Overall, the reform led to a 0.29-year increase in life expectancy.

The quality of a nation's healthcare system depends heavily on physicians. Particularly in the U.S., a significant portion of a physician's job involves balancing among three often competing interests: their own financial self-interest, patients' economic or health interests, and the interests of the payers representing the larger healthcare system. Physician choices in the face of these tradeoffs depend on physicians’ underlying social preferences regarding factors including altruism and efficiency, on which previous literature has provided little direct insight.

We measure the social preferences of a sample of 503 medical students from schools around the U.S. using an experimental approach. The approach allows us to decompose social preferences into two qualitatively different tradeoffs: the tradeoff between self-interest and other’s benefit (altruism), and the tradeoff between equality and efficiency. The experimental design consists of a set of computer-based revealed preference decision problems, which ask the experimental subjects to allocate real money between themselves and an anonymous person. We also collect rich individual-level information for the same sample from a survey we fielded. We examine heterogeneity in social preferences of medical students by expected specialty choice, with particular emphasis on specialty choice. Large variation in income and practice patterns across specialties in the U.S. means that in certain specialties, less altruistic behavior of physicians can yield significant financial gains, and less regard for efficiency can potentially lead to excessive waste.

We find substantial heterogeneity in altruistic preferences among experimental subjects. Medical students with a lower degree of altruism are significantly more likely to choose high-income specialties: the half of the sample who are less altruistic in the experiment chooses specialties that earn on average around $40,000 more annually than their more altruistic peers. This altruism measure is more predictive of specialty than a wide range of other characteristics, including parental income, student loan amount and Medical College Admission Test (MCAT) score. We also find that this altruism measure predicts students' self-reported likelihood of practicing medicine in an underserved area.

In low-and middle-income countries (LMICs), women often struggle to access health services through the perinatal period. In addition to supply-side geographical access and financial barriers, in many settings there are also constraints arising from a combination of complex family structures, low female agency, social norms, and a lack of information on the importance of seeking timely care. This combination of factors makes it challenging for policymakers to improve maternal and infant health, as typical policies focus on the supply-side, i.e. reducing cost of care, and improving accessibility. This dissertation presents results from three empirical studies conducted in India on the role of household members in decision-making in accessing perinatal care.

The first paper examines the dynamics between new mothers and their caregivers (spouse, mother, and mother-in-law) in making caregiving decisions for postnatal maternal and infant care. The second paper uses a randomized controlled trial to investigate the impact of targeted health messaging and social learning on antenatal care visits and iron and folic acid tablet consumption among pregnant women co-residing with their mothers-in-law. The third paper uses a cluster randomized trial to evaluate the effectiveness of a mobile messaging service delivering postnatal care information to households, and its impact on maternal and infant health outcomes.

In the first paper, I find that birthing women are more likely to name their caregivers (rather than themselves) as sole decision-makers for infant and maternal care, though agreement between the mother and caregiver on who is the decision-maker is low. I also find that the identity of the primary caregiver significantly affects maternal mental well-being, with lower well-being when the primary caregiver is their mother-in-law. The second paper demonstrates that involving mothers-in-law in a health messaging education intervention increases health-seeking behaviors and improves post-delivery outcomes. In the third paper, I find that a mobile messaging service delivering postnatal care information to the entire household has a positive impact on maternal and infant health outcomes.

Collectively, these papers highlight the importance of considering the influence of family members, particularly the mother-in-law, in designing effective health interventions in LMICs. However, further research is needed to understand the factors that influence behaviors and to develop ways to address and modify strongly held priors and social norms that may hinder health-seeking behaviors. Additionally, this research focuses on the perinatal period, but future avenues of research can explore how this dynamic affects other health behaviors such as family planning and childhood nutrition, as well as resulting morbidity.

A key aim of health policy is to ensure that patients are able to access high quality care when appropriate while minimizing the over-use of unnecessary treatments. Achieving this balance requires aligned decision-making between patients and providers, which can be hindered if incentives are incompatible with this aim. I study how patient and pharmacist decision-making in the context of malaria case management is affected by financial incentives. I test whether incentives for rapid tests and high quality antimalarials (ACTs) only to malaria-positive cases targeted to patients (demand-side), providers (supply-side), or both (hybrid) improve malaria case management and align incentives towards socially-optimal antimalarial use. Using a cluster randomized trial in 140 pharmacies in malaria-endemic zones in Kenya, I randomize patient discounts and pharmacist performance incentives and compare their effectiveness and cost-effectiveness to the status quo standard of care. I find that both patient subsidies and pharmacy incentives for diagnostic testing significantly increase usage of testing and may encourage malaria positive individuals to purchase ACTs, and report results from unadjusted models here. Patient subsidies increase the likelihood that a symptomatic patient takes a rapid test by 25 percentage points (p=0.046), from a control group mean of 8 percent. Provider incentives and the hybrid approach increase the likelihood of rapid test uptake by 20 (p=0.008) and 25 (p<0.001) percentage points, respectively, which is indistinguishable from the demand-side approach. I also find that all arms improve ACT targeting by more than 200%: patient subsidies, pharmacy incentives, and the hybrid arm increase the likelihood that a patient purchases ACTs with a diagnostic test by 7 percentage points compared to a control group mean of 6 percent (p=0.244, 0.088, 0.032, for patient subsidies, pharmacy incentives, and hybrid arms, respectively). I find that both demand- and supply-side incentives reduce the likelihood that a patient purchases malaria treatment without a confirmatory diagnosis by between 17-19 percentage points, compared to 81 percent in the control group. Taken together, these results suggest that appropriately calibrated and targeted financial incentives are promising for improving malaria case management in a pharmacy setting. Additionally, the fact that supply- and demand-side incentives lead to comparable effects on diagnostic testing and treatment targeting suggests that both patients and pharmacists are effective channels for incentive targeting.