We use data from the Veterans Administration to examine the efficacy of primary care providers (PCPs). Leveraging quasi-random assignment of veterans to PCPs, we measure effectiveness using ambulatory care sensitive conditions (ACSC) and hospitalizations/emergency department (ED) visits for mental health or circulatory conditions. PCPs variation along these dimensions predicts future outcomes. For example, a one standard deviation improvement in mental health effectiveness reduces patient risk of death by 3.8% and lowers costs by 4.4% over the next three years. More effective PCPs do more with less: their patients have fewer primary care visits, specialist referrals, lab panels, or imaging tests.

We study the effects of prenatal exposure to violent crime on infant health, using New York City crime records linked to mothers' addresses in birth records data. We address endogeneity of assault exposure with three strategies and find that in utero assault exposure significantly increases the incidence of adverse birth outcomes. We calculate that the annual social cost of assault during pregnancy in the United States is more than $3.8 billion. Since infant health predicts long-term wellbeing and disadvantaged women are disproportionately likely to be domestic abuse victims, violence in utero may be an important channel for intergenerational transmission of inequality.

Using a unique data set linking preschool blood lead levels, birth, school, and detention records for 125,000 children born between 1990 and 2004 in Rhode Island, we estimate the impact of lead on school suspension and juvenile detention. Sibling fixed-effect models suggest that omitted variables related to family disadvantage do not bias OLS estimates. However, measurement error does. We use IV methods that exploit local (within-neighborhood), variation in lead exposure deriving from road proximity and the deleading of gasoline. For boys, a 1 unit increase in lead increased the probability of suspension from school by 6% and detention by 57%.

In the 1980s and 1990s many states adopted tort reforms. It has been argued that these reforms have reduced the practice of defensive medicine arising from excess tort liability. We find that this does not appear to be true for a large and important class of cases—childbirth in the United States. Using data from national vital statistics natality files on millions of individual births from 1989 to 2001, we ask whether specific tort reforms affect the types of procedures that are performed, and the health outcomes of mothers and their infants. We find that reform of the Joint and Several Liability rule (or the “deep pockets rule”) reduces complications of labor and procedure use, whereas caps on noneconomic damages increase them. We show that these results are consistent with a model of tort reform that explicitly allows for variations in patient condition.

Socioeconomic Status and Child Health: Why Is the Relationship Stronger for Older Children? by Janet Currie and Mark Stabile. Published in volume 93, issue 5, pages 1813-1823 of American Economic Review, December 2003

CHILDREN;POVERTY

The authors provide direct evidence on the effect of health insurance on health outcomes by examining the dramatic increases in the eligibility of pregnant women for the Medicaid program between 1979 and 1992. They find that the 30-percentage-point rise in Medicaid eligibility significantly lowered the incidence of low birth weight and infant mortality. Targeted changes in Medicaid eligibility that were restricted to specific low-income groups had much larger effects on birth outcomes than broader expansions of eligibility to women with higher income levels because of much lower take-up of this entitlement by the latter group. Copyright 1996 by University of Chicago Press.

Treatment for depression is complex, requiring decisions that may involve trade-offs between exploiting treatments with the highest expected value and experimenting with treatments with higher possible payoffs. Using patient claims data, we show that among skilled doctors, using a broader portfolio of drugs predicts better patient outcomes, except in cases where doctors' decisions violate loose professional guidelines. We introduce a behavioral model of decision making guided by our empirical observations. The model's novel feature is that the trade-off between exploitation and experimentation depends on the doctor's diagnostic skill. The model predicts that higher diagnostic skill leads to greater diversity in drug choice and better matching of drugs to patients even among doctors with the same initial beliefs regarding drug effectiveness. Consistent with the finding that guideline violations predict poorer patient outcomes, simulations of the model suggest that increasing the number of possible drug choices can lower performance.

Mortality is a crucial indicator of well-being, and recent mortality trends have been a subject of public debate in many Western countries. This paper compares mortality inequality in Canada and the United States over the period 1990/91 through 2010/11. In Canada, mortality inequality remained constant among the youngest but increased for men over 24 and women over 14. In contrast, in the United States, mortality inequality fell for children and youth and either modestly increased or held steady at older ages. By 2010/11, the initially higher US rates of infant and child mortality had almost converged to their Canadian counterparts.

That prenatal events can have life-long consequences is now well established. Nevertheless, research on the fetal origins hypothesis is flourishing and has expanded to include the early childhood (postnatal) environment. Why does this literature have a “second act?” We summarize the major themes and contributions driving the empirical literature since our 2011 reviews, and try to interpret the literature in light of an overarching conceptual framework about how human capital is produced early in life. One major finding is that relatively mild shocks in early life can have substantial negative impacts, but that the effects are often heterogeneous reflecting differences in child endowments, budget constraints, and production technologies. Moreover, shocks, investments, and interventions can interact in complex ways that are only beginning to be understood. Many advances in our knowledge are due to increasing accessibility of comprehensive administrative data that allow events in early life to be linked to long-term outcomes. Yet, we still know relatively little about the interval between, and thus about whether it would be feasible to identify and intervene with affected individuals at some point between early life and adulthood. We do know enough, however, to be able to identify some interventions that hold promise for improving child outcomes in early life and throughout the life course. (JEL I12, J13, J16, Q51, Q53)