Journal of Economic Perspectives

In this paper, we report results from surveys in which enumerators made unannounced visits to primary schools and health clinics in Bangladesh, Ecuador, India, Indonesia, Peru and Uganda and recorded whether they found teachers and health workers in the facilities. Averaging across the countries, about 19 percent of teachers and 35 percent of health workers were absent. The survey focused on whether providers were present in their facilities, but since many providers who were at their facilities were not working, even these figures may present too favorable a picture. For example, in India, one-quarter of government primary school teachers were absent from school, but only about one-half of the teachers were actually teaching when enumerators arrived at the schools. We will provide background on education and health care systems in developing; analyze the high absence rates across sectors and countries; investigate the correlates, efficiency, and political economy of teacher and health worker absence; and consider implications for policy.

Absent providers are a major problem both for public health facilities and primary schools in many developing countries. For example, in India, absence rates for teachers are over 24 percent, and for health providers they are over 40 percent. This paper presents evidence on a number of innovative strategies to reduce absenteeism in government- and nongovernmental organization-run schools and health facilities. These strategies were implemented in Kenya and India over the past few years and have been evaluated using the randomized evaluation methodology. The strategies involved alternative levers to fight absence. Some tried to improve incentives for providers, either through rewards and punishments implemented by external monitors, or through facilitating a more active involvement of those who expect to benefit from the service. Others are based on the idea that the providers are discouraged by the lack of interest among the potential beneficiaries in what they are being offered; these strategies aim at increasing the demand for the services as a way of putting more pressure on the providers. The results of these efforts, taken together, shed light not only on ways to address the problem of absence in the public sector, but also on the underlying reasons for this phenomenon.

Gaining entrance to a four-year college or university, particularly a selective institution, has become increasingly competitive over the last several decades. We document this phenomenon and show how it has varied across different parts of the student ability distribution and across region, with the most pronounced increases in competition being found among higher-ability students and in the Northeast. Additionally, we explore how the college preparatory behavior of high school seniors has changed in response to the growth in competition. We also discuss the theoretical implications of increased competition on longer-term measures of learning and achievement and attempt to test them empirically; the evidence and related literature, while limited, suggests little long-term benefit.

This paper provides an overview of recent work on quality measurement of medical care and its correlates in four low and middle-income countries-India, Indonesia, Tanzania, and Paraguay. The authors describe two methods-testing doctors and watching doctors-that are relatively easy to implement and yield important insights about the nature of medical care in these countries. The paper discusses the properties of these measures, their correlates, and how they may be used to evaluate policy changes. Finally, the authors outline an agenda for further research and measurement.

This paper first outlines an organizing framework for considering how health and schooling affect labor productivity and growth, and how household and community factors can in turn affect the demand for these human capital investments. Both cross-country growth models and various aspects of microeconomic studies of individual productivity as related to education and health are discussed. The conclusion offers some tentative leads for policy in this area based on existing research, and an agenda for future research.

Since 1999, health care costs have been growing faster than national income. This rapid growth has occurred as the ability of private and public purchasers to reduce service utilization and bargain for lower prices has fallen, insurers have recouped lost profits through higher premiums, and new technologies have driven up costs throughout the sector. Private insurance market responses to these rising costs may lead to reductions in the number of people with insurance and to increased fragmentation of the insurance market. Over time, technological change in medicine both increases costs and improves the quality of care. The challenge for public policy is to maintain insurance and some degree of equity in the face of these rising costs.

There are two approaches to reducing the burden of sickness and death associated with the human immunodeficiency virus (HIV), which leads to acquired immunodeficiency syndrome (AIDS): treatment and prevention. Despite large international aid flows for HIV/AIDS, the needs for prevention and treatment in low- and middle-income countries outstrip the resources available. Thus, it becomes necessary to set priorities. With limited resources, should the focus of efforts to combat HIV/AIDS be on prevention or treatment? I discuss the range of prevention and treatment alternatives and examine their cost effectiveness. I consider various arguments that have been raised against the use of cost-effectiveness analysis in setting public policy priorities for the response to HIV/AIDS in developing countries. I conclude that promoting AIDS treatment using antiretrovirals in resource-constrained countries comes at a huge cost in terms of avoidable deaths that could be prevented through interventions that would substantially lower the scale of the epidemic.

The U.S. health system has been described as the most competitive, heterogeneous, inefficient, fragmented, and advanced system of care in the world. In this paper, we consider two questions: First, is the U.S. health care system productively efficient relative to other wealthy countries, in the sense of producing better health for a given bundle of hospital beds, physicians, nurses, and other factor inputs? Second, is the U.S. allocatively efficient relative to other countries, in the sense of providing highly valued care to consumers? For both questions, the answer is most likely no. Although no country can claim to have eliminated inefficiency, the U.S. has fragmented care, high administrative costs, and stands out with regard to heterogeneity in treatment because of race, income, and geography. The U.S. health care system is also more likely to pay for diagnostic tests, treatments, and other forms of care before effectiveness is established and with little consideration of the value they provide. A number of proposed reforms that are designed to ameliorate shortcomings of the U.S. health care system, such as quality improvement initiatives and coverage expansions, are unlikely by themselves to reduce expenditures. Addressing allocative inefficiency is a far more difficult task but central to controlling costs.

The federal government's Medicare program did not provide general prescription drug coverage for the first 40 years of its existence. Thus, more than 30 percent of the 44 million elderly and disabled beneficiaries of the program lacked insurance coverage for prescribed medications. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established a voluntary outpatient prescription drug benefit known as Medicare Part D. This program took effect in 2006 and represents the largest expansion of an entitlement program since the start of Medicare itself. The design of Part D is of particular interest to economists for at least three reasons: First, the program has the potential to affect significantly both the health and the economic well-being of the more than 44 million individuals currently enrolled in Medicare. Second, Part D has substantially increased government spending on health care despite the projections that such spending was already on an unsustainable path. Third, Part D represents an ambitious attempt to use market mechanisms in the delivery of a large-scale entitlement program. Part D has been controversial. In this paper, we aim to shed light on the various issues raised by the Part D program, including the incentives inherent in the competition among plans, the forces that affect drug prices, and the sustainability of Part D in the face of adverse selection and moral hazard. We conclude that Part D has succeeded in a number of important ways, however, substantial room for improvement remains.

During 2006, the Gallup Organization conducted a World Poll that used an identical questionnaire for national samples of adults from 132 countries. I analyze the data on life satisfaction and on health satisfaction and look at their relationships with national income, age, and life-expectancy. The analysis confirms a number of earlier findings and also yields some new and different results. Average life satisfaction is strongly related to per capita national income. High-income countries have greater life-satisfaction than low-income countries. Each doubling of income is associated with almost a one-point increase in life satisfaction on a scale from 0 to 10 and, unlike most previous findings, the effect holds across the range of international incomes; if anything, it is slightly stronger among rich countries. Conditional on the level of national per capita income, the effects of economic growth on life satisfaction are negative, not positive as would be predicted by previous discussion and previous micro-based empirical evidence. Neither life satisfaction nor health satisfaction responds strongly to objective measures of health, such as life expectancy or the prevalence of HIV infection, so that neither provides a reliable indicator of population well-being over all domains, or even over health.

Asbestos was once referred to as a miracle mineral' for its ability to withstand heat and it was used in thousands of products. But exposure to asbestos causes cancer and other diseases. As of the beginning of 2001, 600,000 individuals had filed lawsuits for asbestos-related diseases against more than 6,000 defendants. 85 firms have filed for bankruptcy due to asbestos liabilities and several insurers have failed or are in financial distress. More than $54 billion has been spent on the litigation higher than any other mass tort. Estimates of the eventual cost of asbestos litigation range from $200 to $265 billion. The paper examines the history of asbestos regulation and asbestos liability and argues that it was liability rather than regulation that eventually caused producers to eliminate asbestos from most products by the late 1970s. But despite the disappearance of asbestos products from the marketplace, asbestos litigation continued to grow. Plaintiffs' lawyers used forum-shopping to select the most favorable state courts techniques for mass processing of claims, and substituted new defendants when old ones went bankrupt. Because representing asbestos victims was extremely profitable, lawyers had an incentive to seek out large numbers of additional plaintiffs, including many claimants who were not harmed by asbestos exposure. The paper contrasts asbestos litigation to other mass torts involving personal injury and concludes that asbestos was unique in a number of ways, so that future mass torts are unlikely to be as big. However new legal innovations developed for asbestos are likely to make future mass torts larger and more expensive. I explore two mechanisms-- bankruptcies and class action settlements--that the legal system has developed to resolve mass torts and show that neither has worked for asbestos litigation. The first, bankruptcy by individual asbestos defendants, exacerbates the litigation by spreading it to non-bankrupt defendants. The second, a class action settlement, is impractical for asbestos litigation because of the large number of defendants. As a result, Congressional legislation is needed and the paper discusses the compensation fund approach that Congress is currently considering.

This feature contains short articles on topics that are currently on the agendas of policy-makers, thus illustrating the role of economic analysis in illuminating current debates. Suggestions for future columns and comments on past ones should be sent to C. Eugene Steuerte, c/o Journal of Economic Perspectives, The Urban Institute, 2100 M Street NW, Washington, D.C. 20037. ■ Roger Feldman is Blue Cross Professor of Health Insurance, Division of Health Services Research and Policy, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Kenneth E. Thorpe is Robert W. Woodruff Professor, Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia. Bradley Gray is Assistant Professor of Health Economics, Institute for Government and Public Affairs, School of Public Health, University of Illinois at Chicago, Chicago, Illinois.

When economists investigate long-term trends and socioeconomic differences in the standard of living or quality of life, they have traditionally focused on monetary measures such as gross domestic product--which has occupied center stage for over 50 years. In recent decades, however, scholars have increasingly recognized the limitations of monetary measures while seeking useful alternatives. This essay examines the unique and valuable contributions of four biological measures--life expectancy, morbidity, stature, and certain features of skeletal remains--to understand levels and changes in human well-being. People desire far more than material goods and in fact they are quite willing to trade or give up material things in return for better physical or psychological health. For most people, health is so important to their quality of life that it is useful to refer to the "biological standard of living." Biological measures may be especially valuable for historical studies and for other research circumstances where monetary measures are thin or lacking. A concluding section ruminates on the future evolution of biological approaches in measuring happiness.

Why is the rate of teen childbearing is so unusually high in the United States as a whole, and in some U.S. states in particular? U.S. teens are two and a half times as likely to give birth as compared to teens in Canada, around four times as likely as teens in Germany or Norway, and almost ten times as likely as teens in Switzerland. A teenage girl in Mississippi is four times more likely to give birth than a teenage girl in New Hampshire—and 15 times more likely to give birth as a teen compared to a teenage girl in Switzerland. We examine teen birth rates alongside pregnancy, abortion, and “shotgun” marriage rates as well as the antecedent behaviors of sexual activity and contraceptive use. We demonstrate that variation in income inequality across U.S. states and developed countries can explain a sizable share of the geographic variation in teen childbearing. Our reading of the totality of evidence leads us to conclude that being on a low economic trajectory in life leads many teenage girls to have children while they are young and unmarried. Teen childbearing is explained by the low economic trajectory but is not an additional cause of later difficulties in life. Surprisingly, teen birth itself does not appear to have much direct economic consequence. Our view is that teen childbearing is so high in the United States because of underlying social and economic problems. It reflects a decision among a set of girls to “drop-out” of the economic mainstream; they choose nonmarital motherhood at a young age instead of investing in their own economic progress because they feel they have little chance of advancement.

This brief paper explores the likely effects of government-imposed global budget caps, such as those in the Clinton administration proposal, on health care spending. It argues that health reform proposals that guarantee universal access to a basic package of medical benefits create a substantial new constituency for higher health care outlays. Political and potential legal pressures to expand rather than limit the set of guaranteed benefits, coupled with an expansion of the number of individuals with health insurance coverage, make it unlikely that global budget targets will succeed in reducing the rate of health care spending growth. Copyright 1994 by American Economic Association.

We evaluate the introduction of monetary incentives in the market for live and cadaveric organ donations. We show that monetary incentives would increase the supply of organs for transplant sufficiently to eliminate the very large queues in organ markets, and the suffering and deaths of many of those waiting, without increasing the total cost of transplant surgery by more than about 12 percent. We build on the value-of-life literature and other parts of economic analysis to estimate the equilibrium cost of live transplants for kidneys and livers. We also show that market price for kidneys will be determined by the cost of live donations, even though most organs will come from cadavers.

President Nixon declared what came to be known as the "war on cancer" in 1971 in his State of the Union address. At first the war on cancer went poorly: despite a substantial increase in resources, age-adjusted cancer mortality increased by 8 percent between 1971 and 1990, twice the increase from 1950 through 1971. However, between 1990 and 2004, age-adjusted cancer mortality fell by 13 percent. This drop translates into an increase in life expectancy at birth of half a year—roughly a quarter of the two-year increase in life expectancy over this time period and a third of the increase in life expectancy at age 45. The decline brings cancer mortality to its lowest level in 60 years. In the war on cancer, optimism has replaced pessimism. In this paper, I evaluate the reasons for the reduction in cancer mortality. I highlight three factors as leading to improved survival. Most important is cancer screening: mammography for breast cancer and colonoscopy for colorectal cancer. These technologies have had the largest impact on survival, at relatively moderate cost. Second in importance are personal behaviors, especially the reduction in smoking. Tobacco-related mortality reduction is among the major factors associated with better health, likely at a cost worth paying. Third in importance, and more controversial, are treatment changes. Improvements in surgery, radiation, and chemotherapy have contributed to improved survival for a number of cancers, but at high cost. The major challenge for cancer care in the future is likely to be the balancing act between what we are able to do and what it makes sense to pay for.

There are four rationales for health care reform: increasing the efficiency of health delivery; reforming the market for health insurance; providing universal coverage; and reducing the federal deficit. These goals are reflected in most reform proposals. Achieving these goals involves several problems, however. Paying for universal coverage may lead to labor supply or demand reductions. In addition, reform involves large federal risks that must be dealt with through deficit financing, reduced benefits, or lower subsidies. Copyright 1994 by American Economic Association.

The U.S. pharmaceutical industry has again become the focus of considerable controversy. In understanding the economics underlying this industry, distinctions between short, medium and long-run costs are critical, as is that between economic and accounting costs. Consumers' heterogeneous valuations create strong incentives for non-uniform pricing and targeted marketing. The conflict between static efficiency (price new drugs low, near short-run marginal cost) and dynamic efficiency (price new drugs high, maintain incentives for innovation) is deep and enduring. This trade-off is becoming more severe as the relative costs of bringing new drugs to market have increased sharply.

The health care industry is being transformed. Large firms are merging and acquiring other firms. Alliances and contractual relations between players in this market are shifting rapidly. Within the next few years, many markets are predicted to be dominated by a few large firms. Antitrust enforcement authorities like the Department of Justice and the Federal Trade Commission, as well as courts and legislators at both the federal and state levels, are struggling with the implications of these changes for the nature and consequences of competition in health care markets. In this paper we summarize the nature of the changes in the structure of the health care industry. We focus on the markets for health insurance, hospital services, and physician services. We then discuss the potential implications of the restructuring of the health care industry for competition, efficiency, and public policy. As will become apparent, this area offers a number of intriguing questions for inquisitive researchers.

The papers in this symposium focus on two major issues of health economics in the context of President Clinton's Health Security Act: cost containment and labor market effects of financing insurance. The act proposes to limit public and private spending; a key issue is the extent to which, without a limit but with a standardized basic plan, supplementary insurance will exist to allow scope for individual choice. The act's financing will have an ambiguous effect on labor supply but will encourage formation of small, low-wage firms. Several features, including community rating and standardization of dependent coverage, imply substantial redistribution. Copyright 1994 by American Economic Association.

Hardly a week goes by without a front-page newspaper article on rising health care costs and the uninsured. In this article, I focus mainly on costs, arguing that the issue has been somewhat misconceived: while the level of medical care spending in the U.S. is a cause for concern, the welfare losses associated with rises in that level of spending may not be as large as the public rhetoric can make them seem. In fact, cost containment may not be as urgent as is widely supposed, and some proposed "cost containment" policies may result in welfare losses for the insured and even increase the number of uninsured

Many goods and services can be readily provided through a series of unconnected transactions, but in health care close coordination over time and within care episodes improves both health outcomes and efficiency. Close coordination is problematic in the US health care system because the financing and delivery of care is distributed across a variety of distinct and often competing entities, each with its own objectives, obligations and capabilities. These fragmented organizational structures lead to disrupted relationships, poor information flows, and misaligned incentives that combine to degrade care quality and increase costs. We illustrate our argument with examples taken from the insurance and the hospital industries, and discuss possible responses to the problems resulting from organizational fragmentation.

In this paper we provide a context for evaluating the goals and effectiveness of current disability policy. We review the Social Security Disability Insurance and Supplemental Security Income programs and examine trends in disability benefit receipt and employment among working-age people with disabilities. We discuss the difficulties in crafting efficient and equitable programs for this difficult to target, heterogeneous population. We conclude that changes in policy rather than in underlying health are most likely behind the increases in disability benefit receipt and the declines in employment of working-age people with disabilities over the 1990s business cycle. This feature contains short articles on topics that are currently on the agendas of policymakers, thus illustrating the role of economic analysis in illuminating current debates. Suggestions for future columns and comments on past ones should be sent to C. Eugene Steuerle, c/o Journal of Economic Perspectives, The Urban Institute, 2100 M Street NW, Washington, D.C. 20037.

Under the Clinton proposal, states choose a single payer or large regional alliances, where individuals choose from all plans in the market. This should give the high administrative costs of individual choice, not those of group choice. States should have another option--small alliances offering limited, group-based choice. Clinton proposes comprehensive insurance for all, with courts enforcing coverage for all medically necessary services not explicitly excluded. Covered services are not coordinated with resources available. Eventually, rationing will be needed. Less comprehensive basic coverage is an additional tool for rationing and decreases the government's role in determining health spending. Copyright 1994 by American Economic Association.

The financing arrangements embodied in the Clinton health reform plan involve some important differences in the way in which public goods are usually financed. The subsidies to small, low-wage firms mandated to provide benefits distort markets in both labor and products, and offer incentives for the creation of small firms. In addition, the financing scheme implicitly envisions a head tax on families at modest income levels but offers a possible rationale for it. Nevertheless, the main reason for many of the financing features appears to be an attempt to hold down the apparent budgetary cost of universal coverage. Copyright 1994 by American Economic Association.

Following an acrimonious health care reform debate involving charges of "death panels," in 2010, Congress explicitly forbade the use of cost-effectiveness analysis in government programs of the Patient Protection and Affordable Care Act. In this context, comparative effectiveness research emerged as an alternative strategy to understand better what works in health care. Put simply, comparative effectiveness research compares the efficacy of two or more diagnostic tests, treatments, or health care delivery methods without any explicit consideration of costs. To economists, the omission of costs from an assessment might seem nonsensical, but we argue that comparative effectiveness research still holds promise. First, it sidesteps one problem facing cost-effectiveness analysis--the widespread political resistance to the idea of using prices in health care. Second, there is little or no evidence on comparative effectiveness for a vast array of treatments: for example, we don't know whether proton-beam therapy, a very expensive treatment for prostate cancer (which requires building a cyclotron and a facility the size of a football field) offers any advantage over conventional approaches. Most drug studies compare new drugs to placebos, rather than "head-to-head" with other drugs on the market, leaving a vacuum as to which drug works best. Finally, the comparative effectiveness research can prove a useful first step even in the absence of cost information if it provides key estimates of treatment effects. After all, such effects are typically expensive to determine and require years or even decades of data. Costs are much easier to measure, and can be appended at a later date as financial Armageddon draws closer.

This paper draws on international evidence on medical spending to examine what the United States can learn about making its healthcare system more efficient. We focus primarily on understanding contemporaneous differences in the level of spending, generally from the 2000s. Medical spending differs across countries either because the price of services differs (for example, a coronary bypass surgery operation may cost more in the United States than in other countries) or because people receive more services in some countries than in others (for example, more bypass surgery operations). Within the price category, there are two further issues: whether factors earn different returns across countries and whether more clinical or administrative personnel are required to deliver the same care in different countries. We first present the results of a decomposition of healthcare spending along these lines in the United States and in Canada. We then delve into each component in more detail—administrative costs, factor prices, and the provision of care received—bringing in a broader range of international evidence when possible. Finally, we touch upon the organization of primary and chronic disease care and discuss possible gains in that area.

More than 80 percent of nonelderly U.S. adults are insured against the risk of disabling physical or mental illness by Social Security Disability Insurance (SSDI). This article evaluates the causes of the extraordinary growth in SSDI enrollment, considers its fiscal ramifications, and discusses potential policy responses. While aggregate population health has improved by most measures in recent decades, the rate of SSDI receipt among nonelderly adults has nearly doubled since 1984. We project that SSDI receipt will rise by an additional seventy percent before reaching a steady state rate of approximately 6.5 percent of adults between the ages of 25 and 64, with cash benefit payments exceeding $150 billion annually (excluding Medicare). We trace the rapid expansion of SSDI to: (1) congressional reforms to disability screening in 1984 that enabled workers with low mortality disorders such as back pain, arthritis and mental illness to more readily qualify for benefits; (2) a rise in the after-tax DI income replacement rate, which strengthened the incentives for workers to seek benefits; (3) and a rapid increase in female labor force participation that expanded the pool of insured workers. Notably, the aging of the baby boom generation has contributed little to the growth of SSDI to date. Among several avenues for reducing SSDI growth, we suggest that the most promising are revamping the disability appeals process--in which the Social Security Administration currently loses nearly three-quarters of all appeals--and reducing the attractiveness of DI benefits for work-capable disabled individuals by providing additional access to public health insurance. By contrast, previous efforts to reduce the SSDI rolls by discontinuing benefits or by providing stronger return-to-work incentives have proved remarkably unsuccessful.

We re-present and re-examine the analysis from the famous RAND Health Insurance Experiment from the 1970s on the impact of consumer cost sharing in health insurance on medical spending. We begin by summarizing the experiment and its core findings in a manner that would be standard in the current age. We then examine potential threats to the validity of a causal interpretation of the experimental treatment effects stemming from different study participation and differential reporting of outcomes across treatment arms. Finally, we re-consider the famous RAND estimate that the elasticity of medical spending with respect to its out-of-pocket price is -0.2, emphasizing the challenges associated with summarizing the experimental treatment effects from non-linear health insurance contracts using a single price elasticity.

Pharmaceuticals have greatly improved health in developing countries, but many people in developing countries do not obtain even inexpensive pharmaceuticals and little pharmaceutical R&D is oriented toward products needed by developing countries, such as a malaria vaccine. Access to existing products could be improved by facilitating differential pricing, for example by subsidizing donation programs, and reforming health care delivery. R&D incentives could be improved if rich countries or international organization committed to purchase needed products when they are developed and make them available to the poor.

Organ transplantation is one of the greatest technological achievements of modern medicine, but the ability of patients to benefit from transplantation is limited by shortages of transplantable organs. The median waiting time for patients placed on the kidney transplant waiting list is over three years. Median waiting times for hearts and livers are seven months and two years, respectively. From 1995 to 2005, the number of patients placed on the waiting list for organ transplants grew at an annualized rate of 4 percent per year. As a result of the growth in the demand for organs, many observers have questioned whether the current system is capable of providing enough transplantable organs. Transplant physicians and policymakers are seriously debating proposals to pay donors and their families and to change the legal regime governing the process of obtaining consent to donation. This paper provides an overview of the rules and practices that govern the organ procurement system and reviews proposals to increase donation rates, with a focus on deceased donors.

The Amethyst Initiative, signed by more than 100 college presidents and other higher education officials calls for a reexamination of the minimum legal drinking age in the United States. A central argument of the initiative is that the U.S. minimum legal drinking age policy results in more dangerous drinking than would occur if the legal drinking age were lower. A companion organization called Choose Responsibility explicitly proposes "a series of changes that will allow 18-20 year-olds to purchase, possess and consume alcoholic beverages." Does the age-21 drinking limit in the United States reduce alcohol consumption by young adults and its harms, or as the signatories of the Amethyst Initiative contend, is it "not working"? In this paper, we summarize a large and compelling body of empirical evidence which shows that one of the central claims of the signatories of the Amethyst Initiative is incorrect: setting the minimum legal drinking age at 21 clearly reduces alcohol consumption and its major harms. We use a panel fixed effects approach and a regression discontinuity approach to estimate the effects of the minimum legal drinking age on mortality, and we also discuss what is known about the relationship between the minimum legal drinking age and other adverse outcomes such as nonfatal injury and crime. We document the effect of the minimum legal drinking age on alcohol consumption and estimate the costs of adverse alcohol-related events on a per-drink basis. Finally we consider implications for the correct choice of a minimum legal drinking age.

The costs of comprehensively genotyping human subjects have fallen to the point where major funding bodies, even in the social sciences, are beginning to incorporate genetic and biological markers into major social surveys. How, if at all, should economists use and combine molecular genetic and economic data from these surveys? What challenges arise when analyzing genetically informative data? To illustrate, we present results from a "genome-wide association study" of educational attainment. We use a sample of 7,500 individuals from the Framingham Heart Study; our dataset contains over 360,000 genetic markers per person. We get some initially promising results linking genetic markers to educational attainment, but these fail to replicate in a second large sample of 9,500 people from the Rotterdam Study. Unfortunately such failure is typical in molecular genetic studies of this type, so the example is also cautionary. We discuss a number of methodological challenges that face researchers who use molecular genetics to reliably identify genetic associates of economic traits. Our overall assessment is cautiously optimistic: this new data source has potential in economics. But researchers and consumers of the genoeconomic literature should be wary of the pitfalls, most notably the difficulty of doing reliable inference when faced with multiple hypothesis problems on a scale never before encountered in social science.

Government intervention in insurance markets is ubiquitous and the theoretical basis for such intervention, based on classic work from the 1970s, has been the problem of adverse selection. Over the last decade, empirical work on selection in insurance markets has gained considerable momentum. This research finds that adverse selection exists in some insurance markets but not in others. And it has uncovered examples of markets that exhibit "advantageous selection"—a phenomenon not considered by the original theory, and one that has different consequences for equilibrium insurance allocation and optimal public policy than the classical case of adverse selection. Advantageous selection arises when the individuals who are willing to pay the most for insurance are those who are the most risk averse (and so have the lowest expected cost). Indeed, it is natural to think that in many instances individuals who value insurance more may also take action to lower their expected costs: drive more carefully, invest in preventive health care, and so on. Researchers have taken steps toward estimating the welfare consequences of detected selection and of potential public policy interventions. In this essay, we present a graphical framework for analyzing both theoretical and empirical work on selection in insurance markets. This graphical approach provides both a useful and intuitive depiction of the basic theory of selection and its implications for welfare and public policy, as well as a lens through which one can understand the ideas and limitations of existing empirical work on this topic.

Only a few rich nations are currently at replacement levels of fertility and many are considerably below. We believe that changes in the status of women are driving fertility change. At low levels of female status, women specialize in household production and fertility is high. In an intermediate phase, women have increasing opportunities to earn a living outside the home yet still shoulder the bulk of household production. Fertility is at a minimum in this regime due to the increased opportunity cost in women's foregone wages with no decrease in time allocated to childcare. We see the lowest fertility nations (Japan, Spain, Italy) as being in this regime. At even higher levels of women's status, men begin to share in the burden of child care at home and fertility is higher than in the middle regime. This progression has been observed in the US, Sweden and other countries. Using ISSP and World Values Survey data we show that countries in which men perform relatively more of the childcare and household production (and where female labor force participation was highest 30 years ago) have the highest fertility within the rich country sample. Fertility and women's labor force participation have become positively correlated across high income countries. The trend in men's household work suggests that the low fertility countries may see increases in fertility as women's household status catches up to their workforce opportunities. We also note that as the poor nations of the world undergo the demographic transition they appear to be reducing fertility faster and further than the current rich countries did at similar levels of income. By examining fertility differences between the rich nations we may be able to gain insight into where the world is headed.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

The U.S. medical malpractice liability system has two principal objectives: to compensate patients who are injured through the negligence of healthcare providers and to deter providers from practicing negligently. In practice, however, the system is slow and costly to administer. It both fails to compensate patients who have suffered from bad medical care and compensates those who haven't. According to opinion surveys of physicians, the system creates incentives to undertake cost-ineffective treatments based on fear of legal liability--to practice "defensive medicine." The failures of the liability system and the high cost of health care in the United States have led to an important debate over tort policy. How well does malpractice law achieve its intended goals? How large of a problem is defensive medicine and can reforms to malpractice law reduce its impact on healthcare spending? The flaws of the existing system have led a number of states to change their laws in a way that would reduce malpractice liability--to adopt "tort reforms." Evidence from several studies suggests that wisely chosen reforms have the potential to reduce healthcare spending significantly with no adverse impact on patient health outcomes.

How has the economic risk of health spending changed over time for U.S. households? We describe trends in aggregate health spending in the United States and how private insurance markets and public insurance programs have changed over time. We then present evidence from Consumer Expenditure Survey microdata on how the distribution of household spending on health -- that is, out-of-pocket payments for medical care plus the household's share of health insurance premiums -- has changed over time. This distribution has shifted up over time -- households spend more on medical care and insurance than they used to -- but for the purposes of measuring change in risk, it is not the mean but the dispersion of this distribution that is of interest. We consider two measures of dispersion that serve as proxies for household risk: the standard deviation of the distribution of household health spending and the ratio of the 90th percentile of spending to the median (the so-called "90/50 gap"). We find, surprisingly, that neither has increased despite the rapid rise in aggregate health spending. This conclusion holds true for broad subgroups of the population (for example, the nonelderly as a group) but not for some narrowly-defined subgroups (for example, low-income families with children). We next consider how much risk households should face, from the perspective of economic efficiency. Household risk may not have changed much over the past several decades, but do we have any evidence that this level represents either too much or too little risk? Finally, we discuss implications for public policy -- in particular, for current debates over expanding health insurance coverage to the uninsured.

This paper presents an overview of the Medicare reform debate. I begin by reviewing some of the features of Medicare and then turn to a discussion of reforms, both on the benefits side and on the financing side of the program. The reform proposals raise difficult policy and political issues, and could have important implications for the federal budget, the efficiency of the health sector, and the well-being of the elderly and disabled.

The term "grade inflation" covers a multitude of phenomena, some of which are even alleged to be sins. Continuing increases in average grades have been widely documented in many universities over the last several decades. Also widely documented, and often associated with grade inflation, are systematic differences in grade levels by field of study, with a common belief that the sciences and math grade harder than the social sciences, which in turn grade harder than the humanities -- and that economics behaves more like the natural sciences than like the social sciences. The general persistence of these relative differences in grades seem to us to be more interesting and more difficult to explain than the persistence of modest grade inflation in general, and they are the principal focus of this paper. Why, for example, should average grades in English be much higher than average grades in chemistry? And what is going on when relative grades change, when a department's grading practices change markedly relative to other departments? We explore such questions using detailed data on grades at the University of Michigan from Fall 1992 through Winter 2008.

In this paper, we explore the role patient incentives play in slowing healthcare spending growth. Evidence suggests that while patients do indeed respond to financial incentives, cost-sharing does not uniformly improve value; rather, cost-sharing provisions must be deliberately structured and targeted to reduce care of low marginal value. Other mechanisms may be helpful in targeting particular populations or types of utilization. The spillover effects between privately insured and publicly insured populations as well as market imperfections suggest a potential role for public policy in promoting insurance design that slows spending growth while increasing the health that each dollar buys.

This paper focuses on a broad movement toward a fundamentally different way of paying healthcare providers. The approach reaches beyond the old dichotomies about whether healthcare providers are reimbursed on a fee-for-service or a "capitated" or per-person payment. Instead, these reforms seek to create direct linkages between payments to healthcare providers and measures of the quality and efficiency of care. After an overview of payment reforms for healthcare providers and their welfare implications, this paper discusses a range of empirical studies. These often small-scale studies suggest that provider payment reforms in conjunction with greater attention to improving measurements of care quality and outcomes can have a significant impact on quality of care and, in some cases, resource use and costs of care.

The paper describes how changes in the inequality of lifetimes have contributed to changes in the social distribution of welfare. I address the following questions: How can we measure inequality of lifetimes? How has this kind of inequality changed over time? How is this inequality related to increased longevity? How do these trends differ across and within countries? Unequal longevity was once a major source of social inequality, perhaps even more important in some sense than income inequality, for a long time. But over the last century, this inequality has declined drastically in high-income countries and is now comparatively trivial.

Public policies are often made without much recourse to economic reasoning. Economists are sometimes unaware of what is happening in the world of public affairs. As a result, both the quality of public decision making and the role that economists play in it are less than optimal. This feature contains short articles on topics that are currently on the agendas of policymakers, thus illustrating the role of economic analysis in illuminating current debates. Suggestions for future columns and comments on past ones should be sent to Daniel Weinberg, c/o Journal of Economic Perspectives, HHES Division, Bureau of the Census, Department of Commerce, Washington, D.C. 20233.

Some studies suggest that people can maintain their cognitive abilities through "mental exercise." This has not been unequivocally proven. Retirement is associated with a large change in a person's daily routine and environment. In this paper, we propose two mechanisms how retirement may lead to cognitive decline. For many people retirement leads to a less stimulating daily environment. In addition, the prospect of retirement reduces the incentive to engage in mentally stimulating activities on the job. We investigate the effect of retirement on cognition empirically using cross-nationally comparable surveys of older persons in the United States, England, and 11 European countries in 2004. We find that early retirement has a significant negative impact on the cognitive ability of people in their early 60s that is both quantitatively important and causal. Identification is achieved using national pension policies as instruments for endogenous retirement.

Government appears to both promote and mistrust nonprofit organizations in the health sector. Tax exemptions, subsidies, and preferential treatment in contracts support these organizations. Legislation that links the supply of charity care to tax exemptions demonstrates mistrust. In this paper, the authors argue that information asymmetries lie at the heart of the current discomfort with tax policy toward nonprofit health-care providers. The authors examine current policy in terms of the rationale for the exemption of nonprofit health-care organizations from taxes as well as the ability of government to monitor performance of these organizations. Copyright 1994 by American Economic Association.

Adult obesity is a growing problem. From 1962 to 2006, obesity prevalence nearly tripled to 35.1 percent of adults. The rising prevalence of obesity is not limited to a particular socioeconomic group and is not unique to the United States. Should this widespread obesity epidemic be a cause for alarm? From a personal health perspective, the answer is an emphatic "yes." But when it comes to justifications of public policy for reducing obesity, the analysis becomes more complex. A common starting point is the assertion that those who are obese impose higher health costs on the rest of the population—a statement which is then taken to justify public policy interventions. But the question of who pays for obesity is an empirical one, and it involves analysis of how obese people fare in labor markets and health insurance markets. We will argue that the existing literature on these topics suggests that obese people on average do bear the costs and benefits of their eating and exercise habits. We begin by estimating the lifetime costs of obesity. We then discuss the extent to which private health insurance pools together obese and thin, whether health insurance causes obesity, and whether being fat might actually cause positive externalities for those who are not obese. If public policy to reduce obesity is not justified on the grounds of external costs imposed on others, then the remaining potential justification would need to be on the basis of helping people to address problems of ignorance or self-control that lead to obesity. In the conclusion, we offer a few thoughts about some complexities of such a justification.

People, no matter how rational they are, usually act on the basis of incomplete information. If they are rational they recognize their own ignorance and reflect carefully on what they know and what they do not know, before choosing how to act. Furthermore, when rational agents interact, they also think about what the others know, and what the others know about what they know, before choosing how to act. Failing to do so can be disastrous. When the notorious evil genius Professor Moriarty confronts Sherlock Holmes for the first time he shows his ability to think interactively by remarking that "all I have to say has already crossed your mind"; Holmes, even more adept at that kind of thinking responds "then possibly my answer has crossed yours." On account of Moriarty's limited mastery of interactive epistemology, he let Holmes and Watson escape from the train at Canterbury, a mistake which ultimately led to his death, because he himself went on to Paris after calculating that Holmes would normally go on to Paris, failing to deduce that Holmes had deduced that he would deduce what Holmes would normally do and in this circumstance get off earlier.