Effects of the Blair/Brown NHS Reforms on Socioeconomic Equity in Health Care

The central objectives of the ‘Blair/Brown’ reforms of the English NHS in the 2000s were to reduce hospital waiting times and improve the quality of care. However, critics raised concerns that the choice and competition elements of reform might undermine socioeconomic equity in health care. By contrast, the architects of reform predicted that accelerated growth in NHS spending combined with increased patient choice of hospital would enhance equity for poorer patients. This paper draws together and discusses the findings of three large-scale national studies designed to shed empirical light on this issue. Study one developed methods for monitoring change in neighbourhood level socioeconomic…

How important is culture to understand political protest?

Abstract The literature considers nonviolent protests among the most important predictors of transitions towards democracy and democratic reforms. This study addresses the conditionsmaking countries more likely to experience nonviolent instead of violent forms of protest. While the literature emphasizes economic and political predictors of protest at the country level, we expand the study of nonviolent-vs-violent protest by incorporating cultural predictors. To do so, we use a newly developed time-pooled cross-sectional database covering an established set of orientations from the World Values Survey, known as “emancipative values”. Estimating the prevalence of these values at the country l…

Accounting for Interdependent Risks in Vulnerability Assessment of Refugees

The United Nations’ Vulnerability Assessment Framework (VAF) of refugees encompasses a set of indicators of the living conditions in refugee camps in Lebanon and Jordan; it assumes the independence among its components. In this paper we maintain the importance to account for existing interdependencies, and provide a definition of vulnerability for high income countries. The proposed “vulnerability scale”, based on the estimated joint risk of social isolation, economic deprivation and bad health, is a useful tool to address interventions toward selected groups of more vulnerable refugees. Analyses are based upon the survey of refugees carried on in Germany in 2016. Germany is the first count…

Measuring change in health care equity using small area administrative data – evidence from the English NHS 2001-8

This study developed a method for measuring change in socio-economic equity in health care utilisation using small area level administrative data. Our method provides more detailed information on utilisation than survey data but only examines socio-economic differences between neighbourhoods rather than individuals. The context was the English NHS from 2001 to 2008, a period of accelerated expenditure growth and pro-competition reform. Hospital records for all adults receiving non-emergency hospital care in the English NHS from 2001 to 2008 were aggregated to 32,482 English small areas with mean population about 1,500 and combined with other small area administrative data. Regression models…

Additional file 1: of What is the impact of rerouting a cancer diagnosis from emergency presentation to GP referral on resource use and survival? Evidence from a population-based study

Technical Appendix. Description of the Basu-Manning estimator used in the statistical analysis. (DOCX 23 kb)

Testing for Asymmetric Information in Insurance Markets: A Multivariate Ordered Regression Approach

The positive correlation (PC) test is the standard procedure used in the empirical literature to detect the existence of asymmetric information in insurance markets. This article describes a new tool to implement an extension of the PC test based on a new family of regression models, the multivariate ordered logit, designed to study how the joint distribution of two or more ordered response variables depends on exogenous covariates. We present an application of our proposed extension of the PC test to the Medigap health insurance market in the United States. Results reveal that the risk–coverage association is not homogeneous across coverage and risk categories, and depends on individual so…

The democratization process: An empirical appraisal of the role of political protest

Abstract This paper analyses the role of peaceful and violent protest in the democratization process. We interpret the democratization process as a sequence of phases so as to allow citizens' and elites' preferences for democracy to vary according to the particular phase that a country is experiencing. By doing so we jointly model the probability of protest and of moving through different phases of democracy taking into account time-constant and time-varying unobserved heterogeneity. In particular, we develop a multivariate finite mixture model that introduces a latent variable to capture unobservable factors. On a sample of 171 countries from 1971 to 2010, we provide evidence that protest …

We made it to Germany … and now? Interdependent risks of vulnerability for refugees in a high-income country

Refugees are perceived as a category of people that are ‘vulnerable’ per se. However, once they have arrived in (high-income) hosting countries and are supported by a welfare state, vulnerability needs to be rethought, as they face new challenges and potential sources of inequality. In this paper, we have measured vulnerability as the probability of experiencing jointly three interdependent risks: social isolation, financial worries and poor health. For this purpose, we estimated a trivariate logit model to evaluate how individual and household characteristics are associated with vulnerability and also made inferences regarding the residual association between pairs of risks, conditionally …

BEHIND THE ATKINSON INDEX: MEASURING EQUALITY OF OPPORTUNITY IN HEALTH

This paper proposes a new approach to the measurement of equality of opportunity in health, based on the path independent Atkinson index of equality. The proposed decomposition is applied both to the ex-ante and the ex-post methodologies recently adopted by the literature. The approach is applied to the measurement of equality of opportunity in health using ten waves of the British Household Panel Survey. Results confirm that socioeconomic background is an important factor determining individual health in adulthood while the incidence of equality of opportunity is around one third of the overall equality according to a substantial stable pattern over years. Our findings also depict that dif…

What is the impact of rerouting a cancer diagnosis from emergency presentation to GP referral on resource use and survival? Evidence from a population-based study

Background Studies on alternative routes to diagnosis stimulated successful policy interventions reducing the number of emergency diagnoses and associated mortality risk. A dearth of evidence on the costs of such interventions might prevent new policies from achieving more ambitious targets. Methods We conducted a retrospective cohort study on the population of colorectal (88,051), breast (90,387), prostate (96,219), and lung (97,696) cancer patients diagnosed after a GP referral or an emergency presentation and reported in the Cancer Registry of England. Resource use and survival were compared 1 year before and 5 years after diagnosis (3 years for lung), including the costs of GP referrals…

The welfare cost of unpriced heterogeneity in insurance markets

We consider the welfare loss of unpriced heterogeneity in insurance markets, which results when private information or regulatory constraints prevent insurance companies to set premiums reflecting expected costs. We propose a methodology which uses survey data to measure this welfare loss. After identifying some “types” which determine expected risk and insurance demand, we derive the key factors defining the demand and cost functions in each market induced by these unobservable types. These are used to quantify the efficiency costs of unpriced heterogeneity. We apply our methods to the US Long-Term Care and Medigap insurance markets, where we find that unpriced heterogeneity causes substan…

Measuring equity in health: a normative decomposition

This paper proposes a new approach to the measurement of equality of opportunity in health, based on the path independent Atkinson index of equality. The proposed decomposition is applied both to the ex-ante and the ex-post methodologies recently adopted by the literature. The approach is applied to the measurement of equality of opportunity in health using ten waves of the British Household Panel Survey. Results confirm that socioeconomic background is an important factor determining individual health in adulthood while the incidence of equality of opportunity is around one third of the overall equality according to a substantial stable pattern over years. Our findings also depict that dif…

Socioeconomic determinants of persistence in poor subjective health

This paper aims at contributing to the constantly growing literature on the dynamics of (self assessed) health. Using the eight waves of the Health and Retirement Study, targeting elderly Americans over the age of 50, we measure persistence in bad health using an index borrowed from the literature on persistent poverty. This new approach, which is totally non parametric in the way it defines the relationship (for each individual and along the time) among years of poor and not poor health, allows to catch some interesting links between the subjective health and several factors such as education, life styles and socioeconomic status that may have a long-lasting influence on an individual’s he…

REPORTING HETEROGENEITY IN SUBJECTIVE HEALTH MEASURES: AN EXTENDED LATENT CLASS APPROACH

Do Reduced Hospital Mortality Rates Lead to Increased Utilization of Inpatient Emergency Care?:A Population-Based Cohort Study

OBJECTIVES: To measure the impact of the improvement in hospital survival rates on patients' subsequent utilization of unplanned (emergency) admissions.DATA SOURCES/STUDY SETTING: Unplanned admissions occurring in all acute hospitals of the National Health Service in England between 2000 and 2009, including 286,027 hip fractures, 375,880 AMI, 387,761 strokes, and 9,966,246 any cause admissions.STUDY DESIGN: Population-based retrospective cohort study. Unplanned admissions experienced by patients within 28 days, 1 year, and 2 years of discharge from the index admission are modeled as a function of hospital risk-adjusted survival rates using patient-level probit and negative binomial models. …

How consistent are perceptions of inequality?

Abstract Despite recent empirical evidence on the importance of perceived inequality, its analysis is still underexplored. In this paper we study whether unobserved perceptions of inequality are reflected in observed individual opinions in a consistent fashion. Inconsistency is relevant to ealuate the level of agreement that individuals share with respect to different domains of inequality. Using the wave from the 2009 International Social Survey Program in the US, we show that inequality is a complicated concept prone to inconsistencies and propose a testing procedure to an empirical appraisal. We find that inconsistencies exist though they may not extend to all the domains of inequality. …

Modelling Unobserved Heterogeneity in Health and Health Care: an Extended Latent Class Approach

Reporting heterogeneity in health: an extended latent class approach

This article explores how individual socio-economic characteristics affect unobserved heterogeneity in self-reporting behaviour and health production using a multivariate finite mixture model. Results show a positive relationship between objective and subjective observable health indicators and true health and support the existence of self-reporting bias related to socio-economic characteristics and individual life styles.

Ex-ante and ex-post measurement of equality of opportunity in health: a normative decomposition.

This paper proposes and discusses two different approaches to the definition of inequality in health: the ex-ante and the ex-post approach. It proposes strategies for measuring inequality of opportunity in health based on the path-independent Atkinson equality index. The proposed methodology is illustrated using data from the British Household Panel Survey; the results suggest that in the period 2000–2005, at least one-third of the observed health equalities in the UK were equalities of opportunity.

EX-ANTE AND EX-POST MEASUREMENT OF EQUALITY OF OPPORTUNITY IN HEALTH: A NORMATIVE DECOMPOSITION

This paper proposes and discusses two different approaches to the definition of inequality in health: the ex-ante and the ex-post approach. It proposes strategies for measuring inequality of opportunity in health based on the path-independent Atkinson equality index. The proposed methodology is illustrated using data from the British Household Panel Survey; the results suggest that in the period 2000–2005, at least one-third of the observed health equalities in the UK were equalities of opportunity. Copyright © 2013 John Wiley & Sons, Ltd.

MACROECONOMI EFFECTS OF PUBLIC HEALTH EXPENDITURE IN THE UNITED STATES

The Effect Of Supplemental Insurance On Health Care Demand With Multiple Information: A Latent Class Analysis

The Medicare program, which provides insurance coverage to the elderly in the United States, does not protect them fully against high out-of-pocket costs. For this reason private supplementary insurance, named Medigap, has been available to cover Medicare gaps. This paper studies how Medigap affects the utilization of health care services. The decision to take out supplemental insurance is likely to be infuenced by unobservable attributes such as actual risk type and insurance preferences. Empirical appraisals to this problem typically rely on the recursive bivariate probit. We exploit the Health and Retirement Study data and some recent advances on latent class analysis to jointly model th…

The role of collective action for the emergence and consolidation of democracy

AbstractThe role of citizens' collective action for the emergence and consolidation of democracy is generally analysed within bottom-up theories. However, top-down theories show that elites might impede or promote both democracy and collective action through a set of strategies which are often unobserved and vary over time. Democratic persistence and change require then to be assessed in a dynamic framework which considers both citizens and elites' strategies. For such reason, on a large sample of countries in the period 1971–2014, we jointly estimate the probability of collective action and democracy using a Structural Dynamic Model. This allows us to account for the dynamic nature of the …

Uncontrolled diabetes and health care utilisation:A bivariate latent Markov model approach

Although uncontrolled diabetes (UD) or poor glycaemic control is a widespread condition with potentially life-threatening consequences, there is sparse evidence of its effects on health care utilisation. We jointly model the propensities to consume health care and UD by employing an innovative bivariate latent Markov model that allows for dynamic unobserved heterogeneity, movements between latent states and the endogeneity of UD. We estimate the effects of UD on primary and secondary health care consumption using a panel dataset of rich administrative records from Spain and measure UD using a biomarker. We find that, conditional on time-varying unobservables, UD does not have a statisticall…

Incentive and Selection Effects of Medigap Insurance on Inpatient Care

The Medicare program, which provides insurance coverage to the elderly in the United States, does not protect them fully against high out-of-pocket costs. For this reason private supplementary insurance, named Medigap, has been available to cover Medicare gaps. This paper studies how Medigap affects the utilization of inpatient care, separating the incentive and selection effects of supplementary insurance. For this purpose, we use two alternative estimation methods: a standard recursive bivariate probit and a discrete multivariate finite mixture model. We find that estimated incentive effects are modest and quite similar across models. On the other hand, there seems to be very significant …

The dynamic interdependence in the demand of primary and emergency secondary care: A hidden Markov approach

This paper develops an extension of the class of finite mixture models for longitudinal count data to the bivariate case by using a trivariate reduction technique and a hidden Markov chain approach. The model allows for disentangling unobservable time-varying heterogeneity from the dynamic effect of utilisation of primary and secondary care and measuring their potential substitution effect. Three points of supports adequately describe the distribution of the latent states suggesting the existence of three profiles of low, medium and high users who shows persistency in their behaviour, but not permanence as some switch to their neighbour's profile.

Organizzazione aziendale del'SSN e cenni di economia sanitaria

Hospital readmission rates: signal of failure or success?

AbstractHospital readmission rates are increasingly used as signals of hospital performance and a basis for hospital reimbursement. However, their interpretation may be complicated by differential patient survival rates. If patient characteristics are not perfectly observable and hospitals differ in their mortality rates, then hospitals with low mortality rates are likely to have a larger share of un-observably sicker patients at risk of a readmission. Their performance on readmissions will then be underestimated. We examine hospitals’ performance relaxing the assumption of independence between mortality and readmissions implicitly adopted in many empirical applications. We use data from th…

La scienza delle finanze in Italia. Una prospettiva storica siciliana

Characterization of Human γδ T Lymphocytes Infiltrating Primary Malignant Melanomas

T lymphocytes are often induced naturally in melanoma patients and infiltrate tumors. Given that gamma delta T cells mediate antigen-specific killing of tumor cells, we studied the representation and the in vitro cytokine production and cytotoxic activity of tumor infiltrating gamma delta T cells from 74 patients with primary melanoma. We found that gamma delta T cells represent the major lymphocyte population infiltrating melanoma, and both V delta 1(+) and V delta 2(+) cells are involved. The majority of melanoma-infiltrating gamma delta cells showed effector memory and terminally-differentiated phenotypes and, accordingly, polyclonal gamma delta T cell lines obtained from tumor-infiltrat…

Uno sguardo alle famiglie

Identification of plasma biomarkers for discrimination between tuberculosis infection/disease and pulmonary non tuberculosis disease.

We used the Luminex Bead Array Multiplex Immunoassay to measure cytokines, chemokines and growth factors responses to the same antigens used for RD1-based Interferon γ Release Assay (IGRA) test. Seventy-nine individuals, 27 active TB, 32 latent infection subsets, 20 individuals derivative purified protein (PPD) negative (subjects that do not have any indurative cutaneous reaction after 72 hrs of intradermal injection of PPD) and with other pulmonary disease were retrospectively studied. Forty-eight analytes were evaluated by Luminex Assay in plasma obtained from whole blood stimulated cells. The diagnostic accuracies of the markers detected were evaluated by ROC curve analysis and by the co…

The unobserved pattern of material hardship and health among older Americans

This paper investigates the relationship between self-reported health and material hardship among older Americans. Differently from income-based measures, material hardship provides a more specific description of the concrete adversities faced by the elderly. We have used the last six waves of the Health and Retirement Study to explore the relative contributions of state dependence, unobserved heterogeneity and time-specific shocks on reporting poor health, experiencing food insecurity and medication cutbacks. We have used a Latent Markov model to estimate a multivariate non-linear system of equations for panel data allowing time-varying unobserved heterogeneity. Our results reveal a high s…

An Empirical Analysis of the Determinants of Perceived Inequality

Perception of inequality is important for the analysis of individuals' motivations and decisions and for policy assessment. Despite the broad range of analytic gains that it grants, our knowledge about measurement and determinants of perception of inequality is still limited, since it is intrinsically unobservable, multidimensional, and essentially contested. Using a novel econometric approach, we study how observable individual characteristics affect the joint distribution of a set of indicators of perceived inequality in specific domains. Using data from the International Social Survey Programme, we shed light on the associations among these indicators and how they are affected by covaria…

Age, morbidity, or something else? A residual approach using microdata to measure the impact of technological progress on health care expenditure

This study measures the increment of health care expenditure (HCE) that can be attributed to technological progress and change in medical practice by using a residual approach and microdata. We examine repeated cross-sections of individuals experiencing an initial health shock at different point in time over a 10-year window and capture the impact of unobservable technology and medical practice to which they are exposed after allowing for differences in health and socioeconomic characteristics. We decompose the residual increment in the part that is due to the effect of delaying time to death, that is, individuals surviving longer after a health shock and thus contributing longer to the dem…

Testing for Asymmetric Information in Insurance Markets: A Multivariate Ordered Regression Approach

The positive correlation (PC) test is the standard procedure used in the empirical literature to detect the existence of asymmetric information in insurance markets. This article describes a new tool to implement an extension of the PC test based on a new family of regression models, the multivariate ordered logit, designed to study how the joint distribution of two or more ordered response variables depends on exogenous covariates. We present an application of our proposed extension of the PC test to the Medigap health insurance market in the United States. Results reveal that the risk–coverage association is not homogeneous across coverage and risk categories, and depends on individual so…

Does hospital competition harm equity? Evidence from the English National Health Service

Increasing evidence shows that hospital competition under fixed prices can improve quality and reduce cost. Concerns remain, however, that competition may undermine socio-economic equity in the utilisation of care. We test this hypothesis in the context of the pro-competition reforms of the English National Health Service progressively introduced from 2004 to 2006. We use a panel of 32,482 English small areas followed from 2003 to 2008 and a difference in differences approach. The effect of competition on equity is identified by the interaction between market structure, small area income deprivation and year. We find a negative association between market competition and elective admissions …

Un approccio ordinale alla misurazione delle grandezze sociali: un’analisi empirica

Measuring change in health care equity using small-area administrative data – Evidence from the English NHS 2001–2008

This study developed a method for measuring change in socio-economic equity in health care utilisation using small-area level administrative data. Our method provides more detailed information on utilisation than survey data but only examines socio-economic differences between neighbourhoods rather than individuals. The context was the English NHS from 2001 to 2008, a period of accelerated expenditure growth and pro-competition reform. Hospital records for all adults receiving non-emergency hospital care in the English NHS from 2001 to 2008 were aggregated to 32,482 English small areas with mean population about 1500 and combined with other small-area administrative data. Regression models …

Risk Preference Heterogeneity and Multiple Demand for Insurance

We examined the relationship between unobserved risk preferences and four insurance purchase decisions: health Medigap insurance, long-term insurance, life insurance and annuity. Standard economic theory assumes that individuals take decision over a set of risky domains according to their own risk preferences which are stable across decision contexts. This assumption of context-invariant risk preference has caused debate in the literature concerning its validity. Using data from the Health and Retirement Study, we exploit latent class analysis to identify conditional on predicted and realized risk how heterogeneity in risk preferences affects multiple insurance demand. Our results provide e…

Short-run and long-run persistence of bad health among elderly

We study the health dynamics among older Americans using ten waves of the Health and Retirement Study following a spell-approach and a regression-based approach. The former is fully non parametric synthesizing the sequences of health status into a Health Persistence Index. The latter approach relies on a Latent Markov (LM) model capturing persistence in poor health by modelling time-varying unobserved heterogeneity. Our results show that only few elders experiences persistently a poor health status. The higher values of the index are consistently observed with the main socio-demo-economic risk factors. Moreover LM model indicates the existence of three unobserved groups differing in their p…

Empirical definition of social types in the analysis of inequality of opportunity: a latent classes approach

The empirical analysis of inequality of opportunity centres on disparities between social types, defined by the exposure to circumstances beyond individual control. Despite this, its main theoretical foundation—the Roemer model—does not indicate how to carry out, in practice, the required partition of the population into such types. This paper operationalises this definition of social types using a latent classes approach. Our specification is embedded in a probabilistic extension of the canonical Roemer model, which assumes that the relevant population consists of a finite number of latent types, from which each individual can be treated as a random draw. This makes possible the use of the…

Latent class models for multiple ordered categorical health data: testing violation of the local independence assumption

Latent class models are now widely applied in health economics to analyse heterogeneity in multiple outcomes generated by subgroups of individuals who vary in unobservable characteristics, such as genetic information or latent traits. These models rely on the underlying assumption that associations between observed outcomes are due to their relationship to underlying subgroups, captured in these models by conditioning on a set of latent classes. This implies that outcomes are locally independent within a class. Local independence assumption, however, is sometimes violated in practical applications when there is uncaptured unobserved heterogeneity resulting in residual associations between c…