Changing the way the elderly live: Evidence from the home health care market in the United States

I examine how decreases in government coverage of home health care visits to the elderly in the United States have affected their living arrangements. Specifically, I exploit geographic variation in the Medicare Home Health Care reimbursement rate that arose as a result of legislation passed in 1997 and I identify its impact on the living arrangements of older Medicare beneficiaries. I find that less generous reimbursement policies lead to a greater fraction of elderly giving up independent living. Baseline-model estimates suggest that a decline in reimbursement of one visit per user leads to a 0.98% increase in the fraction of elderly Medicare beneficiaries living in shared living arrangements, that is, living with somebody else, rather than alone or with only the spouse. This estimate implies that a decline in reimbursement of 5.1 visits per Medicare beneficiary increases the fraction of elderly that live in shared living arrangements by 1.12 percentage points. Such an increase is consistent with the time-series increase in the fraction of elderly that live in shared living arrangements between 1997 and 2000.     

In-work policies in Europe: Killing two birds with one stone?

Generous social assistance has been held responsible for inactivity traps and social exclusion in several European countries, hence the recent trend of promoting employment through in-work transfers. Yet, the relative consensus on the need for ‘making work pay’ policies is muddied by a number of concerns relative to the design of the reforms and the treatment of the family dimension. Relying on EUROMOD, a EU-15 integrated tax-benefit microsimulation software, we simulate two types of in-work benefits. The first one is means-tested on family income, in the fashion of the British Working Family Tax Credit, while the second is a purely individualized policy. Both reforms are built on the same cost basis (after behavioral responses) and simulated in three European countries suspected to experience large poverty traps, namely Finland, France and Germany. The potential labor supply responses to the reforms and the subsequent redistributive impacts are assessed for each country using a structural discrete-choice model. We compare how both reforms achieve poverty reduction and social inclusion (measured as the number of transitions into activity). All three countries present different initial conditions, including existing tax-benefit systems and distribution of incomes and wages. These sources of heterogeneity are exploited together with different labor supply elasticities to explain the cross-country differences in the impact of the reforms.     

Economic evaluation of nivolumab for the treatment of second-line advanced squamous NSCLC in Canada: a comparison of modeling approaches to estimate and extrapolate survival outcomes

Background Lung cancer is the most common type of cancer in the world and is associated with significant mortality. Nivolumab demonstrated statistically significant improvements in progression-free survival (PFS) and overall survival (OS) for patients with advanced squamous non-small cell lung cancer (NSCLC) who were previously treated. The cost-effectiveness of nivolumab has not been assessed in Canada. A contentious component of projecting long-term cost and outcomes in cancer relates to the modeling approach adopted, with the two most common approaches being partitioned survival (PS) and Markov models. The objectives of this analysis were to estimate the cost-utility of nivolumab and to compare the results using these alternative modeling approaches.

Methods Both PS and Markov models were developed using docetaxel and erlotinib as comparators. A three-health state model was used consisting of progression-free, progressed disease, and death. Disease progression and time to progression were estimated by identifying best-fitting survival curves from the clinical trial data for PFS and OS. Expected costs and health outcomes were calculated by combining health-state occupancy with medical resource use and quality-of-life assigned to each of the three health states. The health outcomes included in the model were survival and quality-adjusted-life-years (QALYs).

Results Nivolumab was found to have the highest expected per-patient cost, but also improved per-patient life years (LYs) and QALYs. Nivolumab cost an additional $151,560 and $140,601 per QALY gained compared to docetaxel and erlotinib, respectively, using a PS model approach. The cost-utility estimates using a Markov model were very similar ($152,229 and $141,838, respectively, per QALY gained).

Conclusions Nivolumab was found to involve a trade-off between improved patient survival and QALYs, and increased cost. It was found that the use of a PS or Markov model produced very similar estimates of expected cost, outcomes, and incremental cost-utility.     

COVID-19 and Ethnic Inequalities in England and Wales*

The economic and public health crisis created by the COVID-19 pandemic has exposed existing inequalities between ethnic groups in England and Wales, as well as creating new ones. We draw on current mortality and case data, alongside pre-crisis labour force data, to investigate the relative vulnerability of different ethnic groups to adverse health and economic impacts. After accounting for differences in population structure and regional concentration, we show that most minority groups suffered excess mortality compared with the white British majority group. Differences in underlying health conditions such as diabetes may play a role; so too may occupational exposure to the virus, given the very different labour market profiles of ethnic groups. Distinctive patterns of occupational concentration also highlight the vulnerability of some groups to the economic consequences of social distancing measures, with Bangladeshi and Pakistani men particularly likely to be employed in occupations directly affected by the UK's ‘lockdown’. We show that differences in household structures and inequalities in access to savings mean that a number of minority groups are also less able to weather short-term shocks to their income. Documenting these immediate consequences of the crisis reveals the potential for inequalities to become entrenched in the longer term.     

A structural model for early exit of older men in Belgium

In this article, we propose a structural model of the retirement decision for older workers in Belgium. We model the exit paths available through the various available schemes. Our framework allows exploiting all information on possible exit paths and also better identifying preferences and constraints. Results based upon Belgian microsimulation data from 2001 for private sector workers fits rather well-observed behavior. Simulations of hypothetical reforms illustrate the potential effects of changing social security rules.     

Network Externality and the Coordination Problem

We show that Rohlfss (1974) model is a special case of a spatial monopoly model á la Hotelling (1929) with uniform consumer distribution and quadratic transportation costs, where location is exogenous and the good yields no intrinsic utility. By relaxing these assumptions, we prove that the coordination problem typically thought to affect markets for network goods may not arise in general. Endogenizing location makes it easier for the monopolist to extract consumer surplus but also to cover the entire market. We also show that the main conclusions remain qualitatively unmodified if consumer distribution is triangular.revised version received September 16, 2003     

Vertically Differentiated Monopoly with a Positional Good

We analyse positional effects in a monopoly market with vertical differentiation, comparing monopoly and social planning. The provision of quality under monopoly depends upon the relative size of positional effects and the hedonic evaluation of quality. An elitarian equilibrium where quality increases in the level of positional concern emerges under monopoly, only if the market is sufficiently rich. Under social planning, quality increases in the level of positional externality, independently of market affluency. As long as partial market coverage obtains under both regimes, the monopoly deadweight loss decreases as the positional externality becomes more relevant.     

Subsidies on low-skilled workers’ social security contributions: the case of Belgium

In recent decades, many “Making Work Pay” policies have been implemented in OECD countries. These policies aim at improving the financial incentives for work, while maintaining high levels of social protection. Examples include the Earned Income Tax Credit in the USA and the Working Families’ Tax Credit in the UK. While these policies are proven to be quite effective with respect to poverty alleviation, many worry that they may discourage labor supply on the intensive margin. We consider an alternative measure implemented in Belgium: the Workbonus, which subsidizes social security contributions for low-skilled workers. This program differs from other measures in that the eligibility and the level of the subsidy are based on full-time equivalent earnings. The instrument therefore distinguishes between low skill and low effort and avoids the above-mentioned disincentive effect. We assess the effects of the Workbonus on labor supply using a particular discrete-choice labor supply model, in which individuals are assumed to choose among jobs belonging to individual-specific latent choice sets. In particular, we compare the Workbonus with a tax credit system temporarily implemented in Belgium in 2001–2004. Results show that both measures have a positive impact on labor supply. However, the Workbonus is more efficient in terms of cost per additional full-time equivalent position created and avoids the “part-time trap” implicit in the tax credit system.     

Interpreting Wage Gaps of Disabled Men: The Roles of Productivity and of Discrimination

Using the UK Labour Force Survey, we study wage gaps for disabled men after the introduction of the Disability Discrimination Act. We estimate wage gaps at the mean and at different quantiles of the wage distribution and decompose them into a part explained by differences in workers' and job characteristics, a part that can be ascribed to health‐related reduced productivity, and a residual part. The large original wage gaps reduce substantially when we control for differences in education and occupation, although significant residuals remain. However, when we isolate productivity differences between disabled and nondisabled workers, the residual wage gap becomes insignificant in most cases.     

Network Externalities and the Overprovision of Quality by a Monopolist

We investigate the behavior of a monopolist supplying a vertically differentiated good with network externalities. Assuming a convex unit cost of quality improvements, we show that the presence of network externalities may yield oversupply of quality compared with the social optimum, when partial market coverage emerges at equilibrium. Overall, the incentive to expand output increases in the extent of network externalities, thereby partially counterbalancing the social damage produced by the quality distortion.