Three essays on the economics of health insurance change, COVID and trust, and suicide with application to South Korea
This thesis consists of three unique essays on diverse topics with a shared emphasis on health behaviors and outcomes. The first essay highlights the healthcare demand response to price schedule changes in Korea’s healthcare market-which runs universal health coverage. The second and third essays each examines the role of both social capital and human capital in mitigating different health related outcomes. The first chapter considers the response of healthcare utilization of those who experience changes in price schedule when they are newly classified as National Health Insurance (NHI) enrollees or Medical Aid type 2 (MA type 2) beneficiaries under Korea’s universal health coverage. By addressing the question within the context of Korea’s healthcare market, where less than 3% of general population list price as a factor limiting access to healthcare services, I avoid over-estimation that may arise if demand response partly reflects unmet needs of participants or patients. To do so, I adapt a differences-in-differences approach to estimate Poisson model and assess the effect of status change on outpatient and inpatient service utilization. I find clear evidence of response to within-individual variations in cost sharing. Results indicate statistically significant (positive and negative) demand responses for outpatient services for status changes from NHI to MA type 2 and from MA type 2 to NHI. As change of status induces change in copayment (from approximately 30% to 15% or lower), the response, controlling for income and other potential cofounders, reflects healthcare demand response to price. In fact, the estimates based on a Poisson fixed effect indicates 26% and 21 % increase and decrease in outpatient service utilization. However, estimates indicate insignificant impact of status change on inpatient service utilization. I suspect that this is due to either different decision processes involved, or difficulty taking advantage of a lowered marginal cost as inpatient service utilization often involves patients with more severe and inevitable health issues. The former possibility arises from differences between decision to contact and intensity of care as in the principal-agent framework of Grossman (1974). The second chapter examines social distancing behavior during the COVID-19 pandemic with respect to preference for trust across countries. Using Falk et al.(2018)’s preference measure for trust across countries around the globe, I examine whether and how social distancing behavior during the COVID-19 pandemic differed by level of preference. By exploiting daily mobile data of Google’s Community Mobility Report, I provide evidence for the significant effects of trust on social distancing around the time of lockdown announcements. As a complementary analysis, I examine how and whether initial social distancing around lockdown announcements are significant predictors of COVID outcome throughout. To do so, I plot trajectories according to initial compliance and estimate latent heterogeneity quantile regression. Main findings of the paper are as follows. First and foremost, findings indicate degree of compliance depends on level of trust during the initial phase of the pandemic. That is, countries with relatively more preference for trust decreases their mobility significantly more before the lockdown announcements. Mobility reduction to parks, retail, and recreation were approximately 10% higher per standard deviation increase in trust. This result is robust to accounting for several confounding factors at the country-level such as the number of COVID-19 deaths, stringency index and mobility index workplace. Secondly, a time series plot of COVID cases against high versus low compliance levels provides suggestive evidence that initial social distancing is a significant predictor of the disease outcome (‘flattening the curve’) during the first few months to at least until June of 2020. Lastly, the significant quantile regression coefficient implies that an additional percentage drop in mobility to parks following stay-at-home orders in March or April decreases the COVID cases by 35/million and 55 /million and 105/million for 50th, 75th and 95th percentile countries, respectively, in September. Though the numbers appear minimal, the coefficient -55 can be interpreted as: if society as a whole decreased visits to the parks by an extra 1 percent, this could have decreased 85 cases per million for the 50th percentile COVID case countries. For high COVID case countries, initial drop in mobility becomes even more important determinant behind COVID cases. Though the number does not appear significant, considering the range of initial mobility response ranges from +10% to -90% across countries, the difference in number of COVID cases can range from (-90) *55 =-4950 to (+10)*55=+550: which makes 4,950 less cases per million or 550 more cases per million. This number is -4,950/million * 60.36 million (Population of Italy) = 298,782 less cases for a country with a population of 60.36 million. The third chapter considers the mediating role of social and human capital between GDP and suicide rate of 189 countries for the period between years 1990-2017. Proxying social capital(integration) with drop in mobility and human capital with average years of schooling, I test, 1) whether GDP actually bears negative association with suicide rate as the Hamermesh and Soss (1974) model implies, 2) whether Durkheim’s hypothesis that social integration lost with economic growth reverses the former relation and 3) whether years of education, through increased rationality, strengthens or weakens the negative or positive relationship between GDP and suicide rate. The findings are as follows. First, GDP-per-capita has a significant negative relationship with total, male, and female suicide rate. Second, high-trust countries decrease suicide risk significantly more than low-trust countries with increases in GDP. Preference for trust index from the Global Preference Survey lowers total suicide risk; perception of corruption lowers suicide risk of males; preference index of World Value Survey lowers female suicide risk. Last, human capital, measured by years of schooling, does not mediate the relationship between GDP and suicide risk. Instead, it reduces the risk of suicide directly; an extra year of schooling reduces the chance of suicide by 2 in 100,000.
COVID-19, Education, Health Insurance, Suicide, Trust, Economics
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