Relative Parental Earnings within Schools and ADHD diagnoses (with Kurt Lavetti)
[Job Market Paper]
Around 10\% of US school-age children are diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). Schools are settings where diagnostic information about behavior is implicitly judged relative to peers. We examine how a child's position in the parental earnings distribution of their school cohort affects ADHD diagnosis. We exploit Utah's insurance claims linked to parental earnings and school attendance boundaries. We show that children with similar parental earnings are less likely to be diagnosed when their family ranks higher in the parental earnings distribution of their school cohort. We estimate the causal effect of this rank using transitions to junior high and high school. At the transitions, several schools feed into one, and otherwise similar children, in terms of parental earnings and pre-transition characteristics, end up with different ranks. A 10 percentage-point higher rank in the first year of junior high decreases the probability of diagnosis by 8.4\%. In high school, the effects are concentrated among those younger in their grade. Part of the rank effect operates through re-sorting across primary care providers: higher rank moves children toward providers who are less likely to diagnose. We confirm that we measure diagnostic behavior using providers' exit in an IV design. ADHD diagnosis depends on their relative position among their classmates beyond their parental resources.
The Costs of Administrative Transitions on Child Mortality: Evidence from a Decentralization Reform (with Fernanda Rojas-Ampuero) [Draft]
Reject and Resubmit at the Journal of Human Resources
In the 1980s, a policy reform in Chile shifted the administration of public services from a centralized to a local system, placing municipalities in charge of primary care establishments. We exploit the reform’s staggered implementation and pre-reform utilization rates to study how differential exposure affected child mortality and birth outcomes. We combine birth records with archival data on the dates when each primary care establishment was transferred to its local municipality. Our results indicate that greater exposure to the reform led to higher infant mortality during the implementation period, accompanied by worse birth outcomes, including low birth weight. Consistent with disruption during the transition, municipalities that transferred most of their establishments within two months experienced greater increases in infant mortality.
The Impacts of Hospital Financial Incentives on Patient and Provider Responses and Outcomes [Draft]
I study a government program designed to encourage preventive surgeries in public hospitals through an age-based, non-linear incentive scheme, using administrative data from Chile. By exploiting age thresholds, I provide evidence that public hospitals reallocate surgeries toward healthier patients in the incentivized age range, at the expense of sicker patients outside of it. Additionally, I show that high-income patients with access to both public and private hospitals respond by opting out of the public system when they fall outside of the incentivized age range. Motivated by these facts, I develop and estimate a dynamic model of hospital and patient responses to financial incentives that allows me to quantify the effects of alternative policies and explore how they differ by patient income. My estimates suggest that eliminating the non-linearity in incentives reduces the long-run incidence of patient health complications by as much as 13.8% among low-income patients. Among high-income patients, the impacts on downstream health are much smaller, as they maintain access to care regardless of the incentive scheme by being able to access both public and private providers. These results suggest that provider financial incentives may have significant consequences for health disparities.
Work in Progress
Sorting on Survival Gains Under Cost Exposure (with Wei Xiong) [draft available upon request]
This paper examines whether patients choose private care based on expected survival gains, when government-sponsored health care is capacity constrained and access to private providers entails cost exposure. We estimate marginal treatment effects of private surgical care on mortality while allowing for unobserved sorting on gains. Using individual-level hospital discharge data from Chile, we exploit a continuous instrument to identify heterogeneity in the mortality effect of private care along patients' propensity to select into private care. We find negative sorting: cost exposure screens out precisely the patients with the largest expected mortality reductions. Our finding highlights the central role of financial protection in allocating high-risk patients to life-saving medical capacity.
The Life-course of Native American Health Disparities: Evidence from Population-Wide Claims Data (With Cynthia Colen, Kurt Lavetti and Trevon Logan) [slides available upon request]
This paper documents the age trajectory of chronic conditions by race, with special focus on American Indians. We exploit Utah's administrative insurer data, which covers virtually all adults under 65 in the state, regardless of employment. The data covers nearly the entire American Indian population in Utah, both on and off reservations, allowing us to study an urban American Indian population largely missed by other data sources. We show that disparities in chronic health conditions emerge at age 30 for American Indian men and by the mid-20s for American Indian women, far earlier than Black-White gaps. The sharpest and earliest divergence is in chronic mental health conditions ( depression, bipolar disorder, and schizophrenia). Given these age patterns, interventions targeted at "older age" conditions might arrive too late for American Indians.
Research In Progress
More Than Just Mom: Cascading Effects of the Child Penalty (with Kurt Lavetti, Yolunda Nabors, and Maya Rossin-Slater)