Five Essays in Health and Family Economics

This dissertation consists of five independent chapters contributing to the literature of health and family economics. The main topic concerns how social and family policies impact health and well-being of different generations - children, parents and grandparents. Chapter 2 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. Chapter 3 takes an intergenerational perspective on the effects of an informal childcare setting -- grandparental care -- on parental and child outcomes. 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 mainly null and in few cases negative effects on children’s outcomes. If children three years and older are in full-time daycare or school and, in addition, regularly 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 mothers' satisfaction with leisure. Chapter 4 aims to improve the understanding of the effects of daycare on children's health. 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 age-specific mental and physical health outcomes. 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. Chapter 5 takes a cost perspective on the pension reform analyzed in Chapter 2. 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 in Germany. 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 2.9% 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. Chapter 6 concerns another childcare mode, namely parental care, by analyzing the costs and short-term effects of a home-visiting program on child and maternal outcomes. Home-visiting programs targeting families during pregnancy or shortly after birth can be a powerful tool to promote child and family well-being, in particular for disadvantaged families. However, little evidence exists on the (cost-)effectiveness of these programs in the European context. In this study, we present novel evidence on the costs and effects of Pro Kind, a home-visiting program under the Bremen Initiative to Foster Early Childhood Development (BRISE). BRISE randomly assigns an information and access treatment on the neighborhood level that nudges families in the treatment group to participate in Pro Kind. We exploit this random variation in an instrumental variables (IV) framework combined with entropy balancing to estimate the causal effects of the intervention on several mother and child outcomes during the first seven months of the children's lives. In addition, we provide cost estimates based on self-collected cost data. At this early stage of the intervention and due to data limitations, we cannot deduce meaningful causal effects of Pro Kind on child and maternal outcomes. The cost analysis suggests that Pro Kind is less costly than most comparable early childhood programs. Our analysis builds the basis for future cost-effectiveness and cost-benefit studies.Diese Dissertation besteht aus fünf unabhängigen Kapiteln, die einen Beitrag zur Literatur im Bereich der Gesundheits- und Familienökonomie leisten. Das Hauptthema ist die Frage, wie sich sozial- und familienpolitische Maßnahmen auf die Gesundheit und das Wohlbefinden von verschiedenen Generationen - Kindern, Eltern und Großeltern - auswirken. Kapitel 2 analysiert den kausalen Effekt einer Anhebung des Renteneintrittsalters auf ärztlich diagnostizierte Krankheiten. Unter Verwendung eines Differenz-in-Differenzen-Ansatzes untersuchen wir eine kohortenspezifische Rentenreform für Frauen, die das Renteneintrittsalter um drei Jahre angehoben hat. Die Analyse basiert auf administrativen Gesundheitsdaten, die alle gesetzlich Versicherten in Deutschland abdecken und alle von ambulant tätigen Ärzt*innen gestellte Diagnosen enthalten. Diese detaillierten Daten ermöglichen es uns, ein umfassendes Bild von der Multidimensionalität der Gesundheitseffekte zu erhalten. Die empirischen Ergebnisse spiegeln die Multidimensionalität wider, erlauben aber auch die Ableitung von zwei allgemeinen Schlussfolgerungen. Wir liefern Evidenz dafür, dass die Erhöhung des Renteneintrittsalters sich negativ auf die Gesundheit auswirkt, da die Prävalenz mehrerer Diagnosen, z. B. psychische Erkrankungen, Erkrankungen des Muskel-Skelett-Systems und Adipositas, zunimmt. Im Gegensatz dazu finden wir keine Belege für eine Verbesserung der Gesundheit im Zusammenhang mit einem längerem Arbeitsleben. Diese Ergebnisse sind robust gegenüber Sensitivitätsprüfungen und ändern sich auch nicht, wenn die p-Werte für die große Anzahl getesteter Hypothesen korrigiert werden. Kapitel 3 befasst sich aus einer intergenerationalen Perspektive mit den Auswirkungen einer informellen Kinderbetreuungsform - der Großelternbetreuung - auf elterliche und kindliche Ergebnisvariablen. Großeltern sind in Deutschland, wie in vielen westlichen Ländern, die drittwichtigste Betreuungsform nach den Eltern und Kitas. Ausgehend von einer Zwei-Generationen-Perspektive untersuchen wir die kausalen Auswirkungen dieser Betreuungsform auf die Gesundheit, das sozio-emotionale Verhalten und die schulischen Leistungen der Kinder sowie auf das Wohlbefinden der Eltern. Auf der Grundlage repräsentativer deutscher Paneldatensätze und unter Ausnutzung exogener Variationen in der geografischen Entfernung zu den Großeltern analysieren wir altersspezifische Effekte unter Berücksichtigung alternativer Betreuungsformen. Unsere Ergebnisse deuten hauptsächlich auf Nulleffekte und in wenigen Fällen auf negative Auswirkungen auf die Entwicklung von Kindern hin. Wenn Kinder, die drei Jahre und älter sind, ganztätig eine Kita oder Schule besuchen und zusätzlich regelmäßig von den Großeltern betreut werden, weisen sie mehr gesundheitliche und sozio-emotionale Probleme auf, insbesondere Verhaltensprobleme. Im Gegensatz dazu deuten unsere Ergebnisse auf positive Auswirkungen auf die Zufriedenheit der Eltern mit der Kinderbetreuungssituation und die Zufriedenheit der Mütter mit ihrer Freizeitgestaltung hin. Kapitel 4 zielt darauf ab, das Verständnis für die Auswirkungen von Kindertagesstätten (Kitas) auf die Gesundheit von Kindern zu verbessern. In den letzten Jahrzehnten ist der Anteil der Kleinkinder in Kitas in vielen OECD-Ländern, auch in Deutschland, deutlich gestiegen. Trotz der Bedeutung von Kindergesundheit für die kindliche Entwicklung und den späteren Erfolg im Leben wurden die Auswirkungen des Besuchs einer Kita auf die Gesundheit in der ökonomischen Literatur bisher wenig beachtet. In dieser Studie untersuche ich die Auswirkungen eines massiven Ausbaus der Kindertagesbetreuung in Deutschland auf die altersspezifische psychische und physische Gesundheit von Kindern. Auf der Grundlage einzigartiger administrativer Gesundheitsdaten, die 90% der deutschen Bevölkerung über einen Zeitraum von zehn Jahren abdecken, nutze ich durch den Kita-Ausbau ausgelöste exogene Variation in der Kita-Nutzung. Meine Ergebnisse liefern Belege für eine Substitution von infektiösen Erkrankungen von den ersten Grundschuljahren zu den ersten Jahren in der Kita. Insbesondere stelle ich fest, dass der frühe Besuch einer Kita die Prävalenz von Atemwegs- und Infektionskrankheiten sowie die Inanspruchnahme von Gesundheitsleistungen bei Eintritt in die Kita (1 bis 2 Jahre) um 5 bis 6 Prozent erhöht. Im Grundschulalter (6--10 Jahre) sinkt die Prävalenz um ähnliche Größenordnungen. Ich finde keine Belege für Auswirkungen eines Kita-Besuchs auf psychische Störungen, Adipositas, Verletzungen, Sehprobleme oder Gesundheitskosten. Eine Heterogenitätsanalyse zeigt, dass die Auswirkungen bei Kindern aus benachteiligten Gebieten ausgeprägter sind, Sehprobleme früher erkannt werden und die Fettleibigkeit bei diesen Kindern abnimmt. In Kapitel 5 wird die in Kapitel 2 analysierte Rentenreform aus einer Kostenperspektive betrachtet. Wir verwenden einzigartige Gesundheitsdaten, die die ambulante Versorgung und die damit verbundenen Kosten abdecken, um die Gesundheitskosten einer beträchtlichen Anhebung des Renteneintrittsalters in Deutschland zu quantifizieren. Zur Identifizierung nutzen wir eine umfangreiche kohortenspezifische Rentenreform, die ein Frühverrentungsprogramm für alle nach 1951 geborenen Frauen abschaffte. Unsere Ergebnisse zeigen, dass die Gesundheitskosten in der von der Erhöhung des Renteneintrittsalters direkt betroffenen Altersgruppe (Frauen im Alter von 60-62 Jahren) signifikant um etwa 2,9% steigen. Wir zeigen ferner, dass der Kostenanstieg hauptsächlich von den folgenden Facharztgruppen verursacht wird: Augenärzt*innen, Allgemeinmediziner*innen, Neurologie, Orthopädie und Radiologie. Obwohl die Auswirkungen auf individueller Ebene signifikant und bedeutsam sind, zeigen wir, dass der Anstieg der Gesundheitskosten im Vergleich zu den positiven fiskalischen Auswirkungen der Rentenreform moderat ist. Konkret schätzen wir einen Gesamtanstieg der Gesundheitskosten von etwa 7,7 Millionen Euro für 1952 geborene Frauen im Alter von 60-62 Jahren, was weniger als 2% der gesamten positiven fiskalischen Auswirkungen der Rentenreform ausmacht. Kapitel 6 befasst sich mit einer anderen Form der Kinderbetreuung, nämlich der elterlichen Betreuung, indem die Kosten und kurzfristigen Auswirkungen eines Hausbesuchsprogramms auf die Ergebnisse von Kindern und Müttern analysiert werden. Hausbesuchsprogramme, die sich an Familien während der Schwangerschaft oder kurz nach der Geburt richten, können ein wirksames Instrument zur Förderung des Wohlergehens von Kindern und Familien sein, insbesondere für benachteiligte Familien. Es gibt jedoch nur wenige Hinweise auf die (Kosten-) Effektivität dieser Programme im europäischen Kontext. In dieser Studie präsentieren wir neue Erkenntnisse über die Kosten und Auswirkungen von Pro Kind, einem Hausbesuchsprogramm im Rahmen der Bremer Initiative zur Förderung der frühkindlichen Entwicklung (BRISE). Im Rahmen von BRISE werden zufällig (randomisiert auf Stadteilebene) einige Familien über Pro Kind informiert und ihnen wird der Zugang zu diesem Programm erleichtert. Somit werden diese Familienangeregt an Pro Kind teilzunehmen. Wir nutzen diese zufällige Variation in einem Instrumentalvariablen (IV)-Ansatz in Kombination mit entropy balancing, um die kausalen Effekte der Intervention auf verschiedene Ergebnisse von Müttern und Kindern während der ersten sieben Lebensmonate der Kinder zu schätzen. Darüber hinaus liefern wir Kostenschätzungen auf der Grundlage selbst erhobener Kostendaten. In diesem frühen Stadium der Intervention und aufgrund von Datenbeschränkungen können wir keine aussagekräftigen kausalen Effekte von Pro Kind auf die Ergebnisse bei Kindern und Müttern ableiten. Die Kostenanalyse legt nahe, dass \textit{Pro Kind} weniger kostspielig ist als die meisten vergleichbaren frühkindlichen Programme. Unsere Analyse bildet die Grundlage für künftige Kosten-Effektivitäts- und Kosten-Nutzen-Studien

Building Health across Generations: Unraveling the Impact of Early Childcare on Maternal Health

In contemporary households, women often shoulder most organisation and caregiving responsibilities leading them to play a crucial role in family dynamics. While previous research has established that public early childcare affects child outcomes and maternal employment, less attention has been given to its effects on maternal health despite its relevance within the household. This study investigates the impact of public early childcare on maternal shortand long-term health. Based on administrative health records covering 90% of the German population over a decade, we leverage the exogenous variation in childcare coverage rates across counties and time induced by a major German early childcare expansion. Our results reveal an intra-household transmission of communicable diseases: mothers experience 4-8% more infections and 2-4% more respiratory diseases for a 10 percentage point rise in childcare coverage rates when their children are 1-2 years old. In contrast, mothers benefit from reductions in obesity and anaemia, and heterogeneity analyses show a lower prevalence of moodand stress-related disorders for multiparous and older mothers. The policy implications of our findings extend beyond the health impacts of early childcare on mothers and shed light on the broader dynamics within families

The effects of an increase in the retirement age on health care costs: evidence from administrative data

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 in Germany. 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 2.9% 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

Oma und Opa gefragt? Veränderungen in der Enkelbetreuung - Wohlbefinden von Eltern - Wohlergehen von Kindern

Die Publikation fasst die Ergebnisse eines zweijährigen Forschungsprojekts zusammen, das sich mit wichtigen Fragestellungen zu den Auswirkungen der Großelternbetreuung auf die kindliche Entwicklung beschäftigt

The macroeconomic impact of increasing investments in malaria control in 26 high malaria burden countries : an application of the updated EPIC model

Background Malaria remains a major public health problem. While globally malaria mortality affects predominantly young children, clinical malaria affects all age groups throughout life. Malaria not only threatens health but also child education and adult productivity while burdening government budgets and economic development. Increased investments in malaria control can contribute to reduce this burden but have an opportunity cost for the economy. Quantifying the net economic value of investing in malaria can encourage political and financial commitment. Methods We adapted an existing macroeconomic model to simulate the effects of reducing malaria on the gross domestic product (GDP) of 26 high burden countries while accounting for the opportunity costs of increased investments in malaria. We compared two scenarios differing in their level of malaria investment and associated burden reduction: sustaining malaria control at 2015 intervention coverage levels, time at which coverage levels reached their historic peak and scaling-up coverage to reach the 2030 global burden reduction targets. We incorporated the effects that reduced malaria in children and young adolescents may have on the productivity of working adults and on the future size of the labour force augmented by educational returns, skills, and experience. We calibrated the model using estimates from linked epidemiologic and costing models on these same scenarios and from published country-specific macroeconomic data. Results Scaling-up malaria control could produce a dividend of US$ 152 billion in the modelled countries, equivalent to 0.17% of total GDP projected over the study period across the 26 countries. Assuming a larger share of malaria investments is paid out from domestic savings, the dividend would be smaller but still significant, ranging between 0.10% and 0.14% of total projected GDP. Annual GDP gains were estimated to increase over time. Lower income and higher burden countries would experience higher gains. Conclusion Intensified malaria control can produce a multiplied return despite the opportunity cost of greater investments

The Effects of an Increase in the Retirement Age on Health - Evidence from Administrative Data

This study analyzes the causal effect of an increase in the retirement age on health. We exploit a sizable cohort-specific pension reform for women using two complementary empirical approaches – a Regression Discontinuity Design and 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 since there is no significant evidence for a reduction in the prevalence of any health outcome we consider. These findings hold for both identification strategies, are robust to sensitivity checks, and do not change when correcting for multiple hypothesis testing

COVID-19 Associated Contact Restrictions in Germany: Marked Decline in Children’s Outpatient Visits for Infectious Diseases without Increasing Visits for Mental Health Disorders

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

Does Grandparenting Pay off for the Next Generations? Intergenerational Effects of Grandparental Care

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 mainly null and in few cases negative effects on children’s outcomes. If children three years and older are in full-time daycare or school and, in addition, regularly 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