United States

Chandra, Amitabh, Maurice Dalton, and Jonathan Holmes. 2013. “Large Increases in Spending on Postacute Care in Medicare to the Potential for Cost Savings in These Settings.” Health Affairs 32 (5): 864-872. Publisher's VersionAbstract

Identifying policies that will cut or constrain US health care spending and spending growth dominates reform efforts, yet little is known about whether the drivers of spending levels and of spending growth are the same. Policies that produce a one-time reduction in the level of spending, for example by making hospitals more efficient, may do little to reduce subsequent annual spending growth. To identify factors causing health care spending to grow the fastest, we focused on three conditions in the Medicare population: heart attacks, congestive heart failure, and hip fractures. We found that spending on postacute care—long-term hospital care, rehabilitation care, and skilled nursing facility care—was the fastest growing major spending category and accounted for a large portion of spending growth in 1994–2009. During that period average spending for postacute care doubled for patients with hip fractures, more than doubled for those with congestive heart failure, and more than tripled for those with heart attacks. We conclude that policies aimed at controlling acute care spending, such as bundled payments for short-term hospital spending and physician services, are likely to be more effective if they include postacute care, as is currently being tested under Medicare’s Bundled Payment for Care Improvement Initiative.

Yanagizawa-Drott, David, and Andreas Madestam. 2012. “Shaping the Nation: The Effect of Fourth of July on Political Preferences and Behavior in the United States”.Abstract

This paper examines whether social interactions and cultural practices affect political views and behavior in society. We investigate the issue by documenting a major social and cultural event at different stages in life: the Fourth of July celebrations in the United States during the 20th century. Using absence of rainfall as a proxy for participation in the event, we find that days without rain on Fourth of July in childhood shift adult views and voting in favor of the Republicans and increase turnout in presidential elections. The effects we estimate are highly persistent throughout life and originate in early age. Rain-free Fourth of Julys experienced as an adult also make it more likely that people identify as Republicans, but the effect depreciates substantially after a few years. Taken together, the evidence suggests that political views and behavior derive from social and cultural experience in early childhood, and that Fourth of July shapes the political landscape in the Unites States.

Chandra, Amitabh, Katherine Baicker, and Jonathan S. Skinner. 2012. “Saving money or just saving lives? Improving the productivity of US health care spending.” Annual Review of Economics 4: 33-56. Publisher's VersionAbstract

There is growing concern over the rising share of the US economy devoted to health care spending. Fueled in part by demographic transitions, unchecked increases in entitlement spending will necessitate some combination of substantial tax increases, elimination of other public spending, or unsustainable public debt. This massive increase in health spending might be warranted if each dollar devoted to the health care sector yielded real health benefits, but this does not seem to be the case. Although we have seen remarkable gains in life expectancy and functioning over the past several decades, there is substantial variation in the health benefits associated with different types of spending. Some treatments, such as aspirin, beta blockers, and flu shots, produce a large health benefit per dollar spent. Other more expensive treatments, such as stents for cardiovascular disease, are high value for some patients but poor value for others. Finally, a large and expanding set of treatments, such as proton-beam therapy or robotic surgery, contributes to rapid increases in spending despite questionable health benefits. Moving resources toward more productive uses requires encouraging providers to deliver and patients to consume high-value care, a daunting task in the current political landscape. But widespread inefficiency also offers hope: Given the current distribution of resources in the US health care system, there is tremendous potential to improve the productivity of health care spending and the fiscal health of the United States.

Chandra, Amitabh, Jonathan Gruber, and Robin McKnight. 2011. “Patient Cost-Sharing and Hospitalization Offsets in the Elderly.” American Economic Review 100 (1): 193-213. Publisher's VersionAbstract

In the Medicare program, increases in cost sharing by a supplemental insurer can exert financial externalities. We study a policy change that raised patient cost sharing for the supplemental insurer for retired public employees in California. We find that physician visits and prescription drug usage have elasticities that are similar to those of the RAND Health Insurance Experiment (HIE). Unlike the HIE, however, we find substantial “offset” effects in terms of increased hospital utilization. The savings from increased cost sharing accrue mostly to the supplemental insurer, while the costs of increased hospitalization accrue mostly to Medicare.

Singhal, Monica, and Erzo FP Luttmer. 2011. “Culture, Context, and the Taste for Redistribution.” American Economic Journal: Economic Policy 3 (1): 157-179. Publisher's VersionAbstract

Is culture an important determinant of preferences for redistribution? To separate culture from the economic and institutional environment ("context"), we relate immigrants' redistributive preferences to the average preference in their birth countries. We find a strong positive relationship that is robust to rich controls for economic factors and cannot easily be explained by selective migration. This effect is as large as that of own household income and appears stronger for those less assimilated into the destination country. Immigrants from high-preference countries are more likely to vote for more pro-redistribution parties. The effect of culture persists strongly into the second generation.

Chandra, Amitabh, Anupam B Jena, and Jonathan S Skinner. 2011. “The pragmatist's guide to comparative effectiveness research.” Journal of Economic Perspectives 25 (2): 27-46. Publisher's VersionAbstract

All developed countries have been struggling with a trend toward health care absorbing an ever-larger fraction of government and private budgets. Adopting any treatment that improves health outcomes, no matter what the cost, can worsen allocative inefficiency by paying dearly for small health gains. One potential solution is to rely more heavily on studies of the costs and effectiveness of new technologies in an effort to ensure that new spending is justified by a commensurate gain in consumer benefits. But not everyone is a fan of such studies and we discuss the merits of comparative effectiveness studies and its cousin, cost-effectiveness analysis. We argue that effectiveness research can generate some moderating effects on cost growth in healthcare if such research can be used to nudge patients away from less-effective therapies, whether through improved decision making or by encouraging beefed-up copayments for cost-ineffective procedures. More promising still for reducing growth is the use of a cost-effectiveness framework to better understand where the real savings lie—and the real savings may well lie in figuring out the complex interaction and fragmentation of healthcare systems.

Chandra, Amitabh, and Jonathan S Skinner. 2011. “Technology growth and expenditure growth in health care”. Publisher's VersionAbstract

In the United States, health care technology has contributed to rising survival rates, yet health care spending relative to GDP has also grown more rapidly than in any other country. We develop a model of patient demand and supplier behavior to explain these parallel trends in technology growth and cost growth. We show that health care productivity depends on the heterogeneity of treatment effects across patients, the shape of the health production function, and the cost structure of procedures such as MRIs with high fixed costs and low marginal costs. The model implies a typology of medical technology productivity: (I) highly cost-effective “home run” innovations with little chance of overuse, such as anti-retroviral therapy for HIV, (II) treatments highly effective for some but not for all (e.g. stents), and (III) “gray area” treatments with uncertain clinical value such as ICU days among chronically ill patients. Not surprisingly, countries adopting Category I and effective Category II treatments gain the greatest health improvements, while countries adopting ineffective Category II and Category III treatments experience the most rapid cost growth. Ultimately, economic and political resistance in the U.S. to ever-rising tax rates will likely slow cost growth, with uncertain effects on technology growth.

Singhal, Monica, Katherine Baicker, and Jeffery Clemens. 2011. “The Rise of the States: U.S. Fiscal Decentralization in the Postwar Period.” Journal of Public Economics 96 (11-12): 1079-1091. Publisher's VersionAbstract

One of the most dramatic changes in the fiscal federalism landscape during the postwar period has been the rapid growth in state budgets, which almost tripled as a share of GDP and doubled as a share of government spending between 1952 and 2006. We argue that the greater role of states cannot be easily explained by changes in Tiebout forces of fiscal competition, such as mobility and voting patterns, and are not accounted for by demographic or income trends. Rather, we demonstrate that much of the growth in state budgets has been driven by changes in intergovernmental interactions. Restricted federal grants to states have increased, and federal policy and legal constraints have also mandated or heavily incentivized state own-source spending, particularly in the areas of education, health and public welfare. These outside pressures moderate the forces of fiscal competition and must be taken into account when assessing the implications of observed revenue and spending patterns.

Hanna, Rema, and Paulina Olivia. 2010. “The Impact of Inspections on Plant-Level Air Emissions.” The B.E. Journal of Economic Analysis & Policy 10 (1): 1-33. Publisher's VersionAbstract

Each year, the United States conducts approximately 20,000 inspections of manufacturing plants under the Clean Air Act. This paper compiles a panel dataset on plant-level inspections, fines, and emissions to understand whether these inspections actually reduce air emissions. We find plants reduce air emissions by fifteen percent, on average, following an inspection under the Clean Air Act. Plants that belong to industries that typically have low abatement costs respond more strongly to an inspection than those who belong to industries with high abatement costs.

Chandra, Amitabh, Jonathan Gruber, and Robin McKnight. 2010. “Patient Cost Sharing in Low Income Populations.” American Economic Review 100 (2): 303-308. Publisher's VersionAbstract

Economic theory suggests that a natural tool to control medical costs is increased consumer cost sharing for medical care. While such cost sharing reduces “full insurance” (wherein patients are indifferent between falling sick or remaining healthy), a greater reliance on coinsurance and copayments can, in theory, stem patient and provider incentives to engage in moral hazard. These issues are particularly salient for low income populations who are at the center of current efforts to expand coverage (among the uninsured in 2008, 38 percent had incomes below the federal poverty line (FPL), and 52 percent had incomes between 100 and 299 percent of the FPL (Kaiser Commission on Medicaid and the Uninsured 2009)). As insurance is expanded to these groups, it is important to understand how they respond to greater levels of patient cost sharing. On the one hand, smarter plan design could help reduce the fiscal pressures associated with insurance expansion. But on the other, it is also possible that low income recipients are unable to cut back on utilization wisely and, consequently, experience hospitalization “offsets” as a result of greater levels of patient cost sharing. In particular, there remains a concern among many that higher cost sharing on primary care will lead to less effective use of primary care, worse health, and, consequently, higher downstream costs at hospitals (the so-called “offset effects”).

Yanagizawa-Drott, David, and Nancy Qian. 2009. “The Strategic Determinants of U.S. Human Rights Reporting: Evidence from the Cold War.” Journal of the European Economic Association 7 (2-3): 446-457. Publisher's VersionAbstract

This paper uses a country-level panel dataset to test the hypothesis that the United States biases its human rights reports of countries based on the latters’ strategic value. We use the difference between the U.S. State Department’s and Amnesty International’s reports as a measure of U.S. "bias". For plausibly exogenous variation in strategic value to the U.S., we compare this bias between U.S. Cold War (CW) allies to non-CW allies, before and after the CW ended. The results show that allying with the U.S. during the CW significantly improves reports on a country’s human rights situation from the U.S. State Department relative to Amnesty International.

Kremer, Michael, and Dan Levy. 2008. “Peer Effects and Alcohol Use among College Students.” Journal of Economic Perspectives 22 (3): 189-206. Publisher's VersionAbstract

This paper examines the extent to which college students who drink alcohol influence their peers. We exploit a natural experiment in which students at a large state university were randomly assigned roommates through a lottery system. We find that on average, males assigned to roommates who reported drinking in the year prior to entering college had a Grade Point Average (GPA) one quarter-point lower than those assigned to nondrinking roommates. The effect of initial assignment to a drinking roommate persists into the second year of college and possibly grows. The effect is especially large for students who drank alcohol themselves in the year prior to college. In contrast to the males, females' GPAs do not appear affected by roommates' drinking prior to college. Furthermore, students' college GPA is not significantly affected by roommates' high school grades, admission test scores, or family background. These findings are more consistent with models in which peers change people's preferences than with models in which peers change people's choice sets. Surprisingly, the policy of segregating drinkers by having substance-free housing could potentially lower average GPA in the university.

Chandra, Amitabh, and Douglas Staiger. 2007. “Productivity Spillovers in Health Care: Evidence from the Treatment of Heart Attacks.” Journal of Political Economy 115 (1): 103-140. Publisher's VersionAbstract

A large literature in medicine documents variation across areas in the use of surgical treatments that is unrelated to outcomes. Observers of this phenomenon have invoked “flat of the curve medicine” to explain it and have advocated for reductions in spending in high‐use areas. In contrast, we develop a simple Roy model of patient treatment choice with productivity spillovers that can generate the empirical facts. Our model predicts that high‐use areas will have higher returns to surgery, better outcomes among patients most appropriate for surgery, and worse outcomes among patients least appropriate for surgery, while displaying no relationship between treatment intensity and overall outcomes. Using data on treatments for heart attacks, we find strong empirical support for these and other predictions of our model and reject alternative explanations such as “flat of the curve medicine” or supplier‐induced demand for geographic variation in medical care.

Pande, Rohini, and Lena Edlund. 2002. “Why Have Women Become Left-Wing? The Political Gender Gap and the Decline in Marriage.” Quarterly Journal of Economics, August 2002 117 (3): 917-961.Abstract

The last three decades have witnessed the rise of a political gender gap in the United States wherein more women than men favor the Democratic party. We trace this development to the decline in marriage, which we posit has made men richer and women poorer. Data for the United States support this argument. First, there is a strong positive correlation between state divorce prevalence and the political gender gap – higher divorce prevalence reduces support for the Democrats among men but not women. Second, longitudinal data show that following marriage (divorce), women are less (more) likely to support the Democratic party