Alcohol Use and Assault: Regression Discontinuity Evidence from the Minimum Legal Drinking Age
by Maggie Hu
Abstract
While it has long been observed that alcohol consumption is a risk factor for violence, the economics literature has up until recently provided minimal persuasive evidence regarding the causal nature of this relationship. In this study, we employ a regression discontinuity (RD) framework to examine how arrest and victimization rates from assault change at age 21, the U.S. minimum legal drinking age (MLDA-21). Utilizing annual FBI arrest data from the past 36 years since 1988, when the last states adopted the MLDA-21, we estimate that for both males and females, reaching the MLDA increases arrest rates for aggravated and other simple assaults by 5 – 8%, with the aggravated assault effect for females restricted to the latter half of the sample period. Analogous effects at slightly older ages are small and insignificant, as well as the effects for demographic and population characteristics expected to trend smoothly across the MLDA-21 threshold. We extend our analysis of assault-related violence by assessing victimization outcomes, particularly the effect of the MLDA-21 nonfatal injury, by leveraging emergency department (ED) data from the CDC’s Web-based Injury Statistics and Query Reporting System (WISQARS) spanning the period 2001–2022. Notably, we observe that ED visits for “struck by or against” assaults rise significantly by 7–10%, indicating increased participation in violent altercations and increased risk of victimization upon obtaining legal access to alcohol. Taken together, these results suggest that alcohol use increases aggression and violent behavior, the consequences of which thereby represent criminal justice and public health costs that would be exacerbated by lowering the MLDA.
Professor Jeffrey DeSimone, Faculty Advisor
JEL Codes: I18, I12, K0, K32
Keywords: Health Economics, Alcohol Policy, Education and Welfare
Long-term Benefits of Breastfeeding: Impact on Education in Indonesia
by Natalie Gulrajani
Abstract
Healthy breastfeeding behaviors have been shown to produce many long-term health benefits including improved cognition. This study uses data from the Indonesian Family Life Survey (IFLS) to assess the longitudinal impact of exclusive breastfeeding duration and early life breastfeeding practices on education. Though a positive correlation was found between breastfeeding duration and years of schooling in naïve regressions, the significance and magnitude of this effect decreased when household fixed effects were added. A stronger correlation was found between early life breastfeeding and schooling, with income-stratified results demonstrating that poorer households are potentially subject to greater benefits.
Professor Erica Field, Faculty Advisor
JEL Codes: I0; I12; I21
Myocardial Infarction, Health Behavior, and the Grossman Model
by Emma Mehlhop
Abstract
This paper contributes an empirical test of Michael Grossman’s model of the demand for health and a novel application of the model to myocardial infarction (MI) incidence. Using data from the University of Michigan’s Health and Retirement Study (HRS), I test Grossman’s assumptions regarding the effects of hourly wage, sex, educational attainment, and age on health demand along with the effects of new variables describing health behaviors, whether or not a respondent is insured, and whether or not they are allowed sufficient paid sick leave. I use logistic regression to estimate health demand schedules using five different health demand indicators: exercise, doctor visits, drinking, smoking, and high BMI. I apply the Cox Proportional Hazard model to examine two equations for the marginal product of health investment both in terms of propensity to prevent death and to prevent MI, one of the leading causes of mortality in the United States. This study considers the effects of the aforementioned health demand indicators, among other factors, on the marginal product of health investment for the prevention of death compared to the prevention of MI. Additionally, there is significant evidence of a negative effect of health insurance on likelihood of exercising regularly, implying some effect of moral hazard on the health demand schedule.
Professor Charles Becker,Faculty Advisor
Professor M. Kate Bundorf, Faculty Advisor
Professor Grace Kim, Faculty Advisor
Professor Frank Sloan, Faculty Advisor
JEL Codes: I1, I10, I12
Assessing the Impacts of an Aging Population on Rising Healthcare and Pharmaceutical Expenditures within the United States
By Rahul Sharma
This paper studies the impact of aging on rising healthcare and pharmaceutical expenditures in the United States with the goal of contextualizing the future burden of public health insurance on the government. Precedent literature has focused on international panels of multiple countries and hasn’t identified significant correlation between age and healthcare expenditures. This paper presents a novel approach of identifying this correlation by using a US sample population to determine if age impacts an individual’s consumption of healthcare services and goods. Results suggest that age has a significant impact on healthcare and pharmaceutical expenditures across private and public insurance.
Advisors: Gilliam D. Saunders-Schmidler and Grace Kim | JEL Codes: H51, H53, I12, I13, I18, I38
The Neighborhood Effect on Health Outcomes for Women in Urban India
By Priyanka Venkannagari
The paper uses 2011 Indian Human Development Survey data to assess the impact of 5 categories of variables on health outcomes. It uses OLS models, interaction terms, instrumental variable models, fixed effects and random effects to investigate the existence of a neighborhood effect on health outcomes for women in urban India. This paper finds that various aspects of health practices, empowerment, amenities and financial security are relevant when looking at health outcomes. Interventions looking to address health outcomes should consider these variables and the compounding neighborhood effect.
Advisor: Charles Becker, Michelle Connolly, Kent Kimbrough | JEL Codes: C36, I1, I12, O18
The Cost-Effectiveness of Shared Medical Appointments for Type II Diabetes at Duke Family Medicine
By Lauren Nahouraii
With increasing healthcare expenditures above the rate of inflation, new health care delivery models are needed. Since care for chronic health conditions accounts for a majority of spending, more cost-effective ways to manage these conditions are especially necessary and could be the most effective in decreasing health care costs. Shared medical appointments (SMAs) are a promising solution because they increase patient education through group appointments while simultaneously increasing productivity by allowing a provider to see patients in a group but bill for them individually. In this study, 38 patient volunteers participated in an SMA as part of a pilot program at Duke Family Medicine (DFM). As part of this program, patients were randomly assigned to groups that offered varying versions of an SMA curriculum over the course of 3 years. Data collected included HbA1c scores, number and type of medications, type of insurance and payments, number and type of visit (including hospital admissions, emergency room visits, primary care and specialty visits), laboratory tests completed, and home address. Data was collected during, after, and for the six months prior to starting the SMAs. Data points from six months prior to the SMAs serve as a control. HbA1c served as the measure of health outcome while the rest of the data was used in estimating the total healthcare costs of control and treatment periods. Any changes in HbA1c were converted into changes in quality adjusted life years (QALYs) for the cost-effectiveness calculations. The estimated total costs and changes in QALYs were used to calculate the average cost-effectiveness of both the control and treatment periods. Given the small sample size, the SMAs appeared to be more cost-effective for patients that attended a majority of the SMA sessions. The cost-effectiveness comparison for all patients was inconclusive. This study’s calculations should be repeated once more patients complete SMAs in order to increase the power of the tests and provide conclusive results for all patients.
Advisor: Tracy Falba, Ralph Snyderman | JEL Codes: I10, I12, I13, I18
Understanding Financial Incentive Health Initiatives: The Impact of the Janani Suraksha Yojana Conditional Cash Transfer Program on Institutional Delivery Rates and Out-of- Pocket Health Expenditure
By Ritika Jain
Demand-side financing is a policy tool used by nations to incentivize utilization of public institutions, and India’s Janani Suraksha Yojana (JSY) is one of the largest such financial incentive programs in the world. The program pays eligible pregnant women to deliver their babies in health institutions partnered with the program. This paper studies the impact of the JSY on changes in mothers’ health-seeking behavior to deliver in-facility and on the out-of-pocket expenditure (OOPE) for delivery that they incur. Using data from the most recent wave of India’s District-Level Household Survey conducted in 2007-08, this paper finds that the overall introduction of the program in districts in India does not lead to significant changes in institutional delivery or out-ofpocket expenditure outcomes. Further analysis of subpopulations shows that marginalized populations are responsive to JSY introduction in their district with increased probability of delivering in-facility of 1.10 – 3.40 percentage points. Lastly, results show that receiving JSY payments leads to a 1.34 percentage point increase in the probability of incurring OOPE, but a 4.81 percent decrease in the amount of OOPE incurred. The JSY is helping to reduce overall out-of-pocket spending on deliveries. However, the majority of program benefits are not reaching poor pregnant women as the JSY aims, communicating the need for improvement in population targeting.
Advisor: Alison Hagy, Kent Kimbrough, Manoj Mohanan | JEL Codes: C22, I12, I18 | Tagged: Conditional Cash Transfer, Demand-side Financing, Difference-in-difference-in-differences, Difference-in-differences, Healthcare Reform, Maternal Health
Integrating Medicare and Medicaid Healthcare Delivery and Reimbursement Policies for Dual Eligible Beneficiaries: A Cost-Efficiency Analysis of Managed Care
By Kan Zhang
The extreme underpricing of Chinese Initial Public Offerings in the early days of the Chinese equity markets was reduced by several reforms instituted by the Chinese government from around 2000 to 2002. These reforms reduced 1-day returns on IPOs from 295% to 72%. The reforms reduced IPO underpricing by decreasing the inequality between IPO supply and demand. These reforms, while announced between 2000 and 2002, likely took until around 2004 to take full effect. In addition to inequality between supply and demand, other factors such as information asymmetry and government/quality signaling contributed to underpricing both before and after the reforms.
Advisor: Frank Sloan, Kent Kimbrough | JEL Codes: D61, I0, I11, I12, I18 | Tagged: Dual Eligibles, Managed Care, Medicare
Possibility of Cost Offset in Expanding Health Insurance Coverage: Using Medical Expenditure Panel Survey 2008
By Catherine Moon
The Patient Protection and Affordable Care Act aims to substantially reduce the number of the
uninsured over time and asserts that the financial burden of extending insurance coverage to the
previously uninsured will be offset by the benefit of the attendant improvement in their health.
Motivated by this policy, I explore whether health-insurance status and type affect one’s likelihood of
improving or maintaining health using the Medical Expenditure Panel Survey data. I build a set of
ordered regression models for health-status transitions under the first-order Markov assumption and
estimate it using maximum likelihood estimation. I perform a series of likelihood ratio tests for pooling to determine whether the latent propensity index is the same between adjacent initial health-status groups. Empirical results imply that expanding health care to the unwillingly uninsured due to severe
economic constraints and extending the scope of public insurance to that of private insurance will lead to improvement or maintenance of health for the relatively healthy population, implying the possibility of cost off-set in the expansion of coverage and the extension of scope.
Advisor: Frank Sloan, Michelle Connolly | JEL Codes: C12, C25, I12, I13, I18 | Tagged: Health Insurance, Health Transition, Ordered Regression Model, Patient Protection and Affordable Care Act (PPACA), Self-Assessed Health Status, Test for Pooling Adjacent Ordinal Categories
Comparative Cost Outcomes Analysis between Coronary Artery Bypass Graft Surgery Versus Drug Eluding Coronary Artery Stenting
by Shivum Agarwal
Abstract
With the recent advent of the drug eluding stent as a possible alternative for coronary artery bypass graft (CABG) surgery, the economics of cardiac healthcare have shifted dramatically. Many doctors are now electing to send their patients to an invasive cardiologist for cardiac catheterization rather than for open heart surgery. However, the debate continues as to whether stenting is a viable alternative to open heart surgery. This study seeks to approach this problem with an economic analysis of the comparative cost‐effectiveness of the two procedures. Using a variety of statistical techniques including conventional mean differences tests and linear probability models, we test the relative effectiveness of the different treatment options.
Professor Lori Leachman, Faculty Advisor
JEL Codes: I1, I12
