Research

The Effects of an Increase in the Retirement Age on Health – Evidence from Administrative Data (with Johannes Geyer, Peter Haan and Anna Hammerschmid). The Journal of the Economics of Ageing, 2022.

This study analyzes the causal effect of an increase in the retirement age on official health diagnoses. We exploit a sizable cohort-specific pension reform for women using a Difference-in-Differences approach. The analysis is based on official records covering all individuals insured by the public health system in Germany and including all certified diagnoses by practitioners. This enables us to gain a detailed understanding of the multi-dimensionality in these health effects. The empirical findings reflect the multi-dimensionality but allow for deriving two broader conclusions. We provide evidence that the increase in the retirement age negatively affects health outcomes as the prevalence of several diagnoses, e.g., mental health, musculoskeletal diseases, and obesity, increases. In contrast, we do not find support for an improvement in health related to a prolonged working life. These findings are robust to sensitivity checks, and do not change when correcting for multiple hypothesis testing. 

The Effects of an Increase in the Retirement Age on Health Care Costs - Evidence from Administrative Data (with Johannes Geyer, Peter Haan and Anna Hammerschmid). The European Journal of Health Economics, 2023.

In this paper, we use unique health record data that cover outpatient care and the associated costs to quantify the health care costs of a sizable increase in the retirement age. For the identification we exploit a sizable  cohort-specific pension reform which abolished an early retirement program for all women born after 1951. Our results show that health care costs significantly increase by about 3.2% in the age group directly affected by the increase in the retirement age (women aged 60-62).  We further show that the cost increase is mainly driven by the following specialist groups: Ophthalmologists, general practitioners (GPs), neurology, orthopedics, and radiology. While the effects are significant and meaningful on the individual level, we show that the increase in health care costs is modest relative to the positive fiscal effects of the pension reform. Specifically, we estimate an aggregate increase in the health costs of about 7.7 million Euro for women born in 1952 aged 60-62 which amounts to less than 2% of the overall positive fiscal effects of the pension reform. 

Replication of Atwood's (2022) "The Long-Term Effects of Measles Vacciniation on Earnings and Employment (with Mathias Huebener, Andreas Leibing, Jan Marcus and Shushanik Margaryan). Journal of Comments and Replications in Economics (2023).

Atwood (2022) analyzes the effects of the 1963 U.S. measles vaccination on longrun labor market outcomes, using a generalized difference-in-differences approach. We reproduce the results of this paper and perform a battery of robustness checks. Overall, we confirm that the measles vaccination had positive labor market effects. While the negative effect on the likelihood of living in poverty and the positive effect on the probability of being employed are very robust across the different specifications, the headline estimate-the effect on earnings-is more sensitive to the exclusion of certain regions and survey years. 

The Early Bird Gets the Germs? The Impact of Early Daycare Attendance on Children's Health. R&R at European Economic Review. This version: March 2024

Over the past decades, the share of very young children in daycare has increased significantly in many OECD countries, including Germany. Despite the relevance of child health for child development and later life success, the effect of early daycare attendance on health has received little attention in the economic literature. In this study, I investigate the impact of a large daycare expansion in Germany on children's dynamic mental and physical health outcomes by age. Based on a unique set of administrative health records covering 90% of the German population over a period of ten years, I exploit exogenous variation in daycare attendance induced by the expansion. My results provide evidence for the substitution of illness spells from the first years of elementary school to the first years of daycare. Specifically, I find that early daycare attendance increases the prevalence of respiratory and infectious diseases and healthcare consumption when entering daycare (1--2 years) by 5--6 percent. At elementary school age (6--10 years), the prevalence decreases by similar magnitudes. I do not find evidence for an effect of daycare attendance on mental disorders, obesity, injuries, vision problems, or healthcare costs. Heterogeneity analysis indicates more pronounced effects for children from disadvantaged areas, earlier detection of vision problems, and a reduction in obesity in these children.

Building Health across Generations: Childbirth, Childcare and Maternal Health (with Laia Bosque-Mercader) 

Family dynamics and institutions play significant roles in shaping individuals' health. We evaluate the short- and long-term effects of (1) motherhood and (2) public early childcare on maternal health. Our results align with an intra-household disease spread from children to mothers in the first years after childbirth, which is further amplified by childcare availability. Additionally, mothers exhibit deteriorated mental health from the medium run, particularly concerning depression diagnoses, due to the psychological demands of motherhood. In contrast, our findings reveal long-term improvements for most health conditions after childbirth, which is supported by childcare provision. Specifically, childcare availability leads to persistent reductions in non-communicable diseases such as obesity, back pain, and hypertension, and, for multiparous and older mothers, in mental health.

Does Grandparenting Pay off for the Next Generations? Intergenerational Effects of Grandparental Care (with C. Katharina Spieß and Elena Ziege). R&R at Health Economics. This version: October 2021

Grandparents act as the third largest caregiver after parental care and daycare in Germany, as in many Western societies. Adopting a double-generation perspective, we investigate the causal impact of this care mode on children’s health, socio-emotional behavior, and school outcomes, as well as parental well-being. Based on representative German panel data sets, and exploiting arguably exogenous variations in geographical distance to grandparents, we analyze age-specific effects, taking into account alternative care modes. Our results suggest null or negative effects on children’s outcomes: If children three years and older are in full-time daycare or school and, in addition, cared for by grandparents, they have more health and socio-emotional problems, in particular conduct problems. In contrast, our results point to positive effects on parental satisfaction with the childcare situation and leisure. The effects for mothers correspond to an increase of 11 percent in satisfaction with the childcare situation and 14 percent in satisfaction with leisure, compared to the mean, although the results differ by child age. While the increase in paternal satisfaction with the childcare situation is, at 21 percent, even higher, we do not find an effect on paternal satisfaction with leisure. 

Beyond Hot Flashes: The Career Cost of Menopause (with Sara Abrahamsson and Martin Flatø) 

Menopause marks a crucial juncture in women's lives and careers. We provide novel evidence on the effects of menopause onset on labor market and health outcomes. Combining Norwegian registry data with survey data on self-reported menopause age, we apply a stacked difference-in-differences design. Our findings show declines in earnings, increased sick leave, and more diagnoses related to menopause. Additionally, women without symptoms, and those with mild symptoms who seek care, do not experience earnings losses. Moreover, timely healthcare-seeking and treatment onset can mitigate earnings losses. These results suggest that policies promoting menopause awareness could alleviate individual and societal burdens.

Spousal death, survivor benefits and health (with Julie Tréguier)

The macroeconomic impact of increasing investments in malaria control in 26 high malaria burden countries: an application of the updated EPIC model (with Edith Patouillard, Seoni Han, Jeremy Lauer and Jean-Louis Arcand). International Journal of Health Policy and Management (accepted).

The relationship between malaria and growth has been extensively studied and debated but with limited attention to the underlying mechanisms. The Economic Projections of Illness and Cost model (EPIC) was used to project the macroeconomic impact of scaling-up investments in malaria control through the direct and indirect effects that investing in health has on two production factors: labour and physical capital. EPIC, a human-capital-augmented Solow model assumes that the gross domestic product is determined by the accumulation of physical capital and the size of the labour force, augmented by education and work experience. EPIC was calibrated to 26 high malaria burden countries and the net annual difference in aggregated GDP between two scenarios estimated. One scenario considered increased investments to achieve 90% coverage of malaria control interventions by 2030 at a total cost of US$38 billion, whilst another assumed increased investments to sustain 2015 coverage accounting for population growth until 2030, at a cost of US$74 billion. The macroeconomic impact of increasing investments by US$36 billion whilst averting an additional 11.7 million deaths and 59.5 million years lost to disability was estimated across the studied countries and period. EPIC was updated by introducing uncertainty and sensitivity analyses. The incremental investment and associated health improvements could translate into an aggregated GDP gain of US$202 (95%CI 201-204) billion equivalent to an average annual GDP gain of 0.1348% (95%CI 0.1346-0.1351). Lower income and higher burden countries would experience higher gains whilst lower gains would be expected the higher the share of  investments coming out of national savings.  Increasing investments in malaria towards universal health coverage does not crowd out the accumulation of physical capital. Whilst applied here to a single disease, EPIC may be used to make the case for investing in health as a whole.

COVID-19 Associated Contact Restrictions in Germany: Marked Decline in Children’s Outpatient Visits for Infectious Diseases without Increasing Visits for Mental Health Disorders (with Berthold Koletzko, C. Katharina Spiess). Children, 2021.  

Children have a low risk for severe COVID-19 infections, but indirect consequences of the pandemic may affect their health. We evaluated nationwide data on children’s outpatient visits before and during the first wave of the COVID-19 pandemic in Germany. Data from the National Association of Statutory Health Insurance Physicians for all children with statutory health insurance and at least one physician’s office visit between January 2019 and June 2020 were evaluated for total visits and selected diagnoses for the 2nd quarter of 2019 (8.29 million children, controls) and the 2nd quarter of 2020 (8.5 million, pandemic). Outpatient visits per child fell by 18% during the first wave of the pandemic. Outpatient visits associated with diagnosed infections fell markedly by 51%, particularly for children up to age 5 years for gastroenteritis (73%), otitis media (71%), and streptococcal angina (78%). Outpatient visits for diagnosed chronic physical disorders (diabetes, celiac disease, and hay fever) and mental and behavioral disorders showed little change. Reduced contact between children appears to markedly reduce infection transmission. Infection risks in educational settings should be attenuated after the pandemic through targeted education and counseling and appropriate relationship prevention measures to improve quality of life and opportunities for children and to reduce stress and lost work time for parents. 

Patient-level costs in margin re-excision for breast-conserving surgery (with Yasmin Grant, Rashed Al-Khudairi, Edward St John, Alexander Carter, Deborah Cunningham, R. Al-Mufti, Katy Hogben, D.J. Hadjiminas, Paul Thiruchelvam, Daniel Leff). Journal of British Surgery, 2019. 

High rates of reoperation following breast-conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re-excision costs and compare the direct patient-level costs between patients undergoing successful BCS versus reoperations after BCS. The study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient-Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85. The median QHES score was 47 (i.q.r. 32·5–79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234–11786 and $655–9136 respectively. Over a 12-month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752–18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001). The systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high-quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.