Chao

Does Poor Health Induce Myopia? An Investigation of Mortality, Morbidity, Aging, and Time Preference

Time preference describes the ubiquitous phenomenon that individuals prefer to receive and to consume a reward sooner rather than later. The utility from consumption in the future is often “discounted” relative to the utility from consumption now of the same commodity bundle, ceteris paribus. Time preference drives futureoriented investment behavior, including savings for retirement, pursuit of healthy lifestyles, human capital investment for oneself and for one’s offsprings. Although theories in both evolutionary biology and economics predict that the individual’s health should be associated with the individual’s time preference, no prior study has been done to empirically support or refute such predictions. By collecting detailed measures of health, time preference, changes in health, and changes in time preference at two points in time, using both interviews and time preference trade-offs involving real monetary rewards on a sample of healthy and ailing adult and elderly individuals in black townships around Durban, South Africa, this study breaks new ground by being the first to analyze in detail the relationship between time preference and health, in an area of the world with high mortality and morbidity. The research question being addressed by this pilot project is policy relevant, as the study tries to determine the importance of health in economic development, not from the commonly asserted productivity-gain argument, but from a much broader investment-for-the-future argument. The pilot results will surely strengthen future funding proposals to examine the relationship between health and economic development.

Doshi

Impact of Prescription Copayments on Antidepressant Use and Adherence in Dual Eligibles: Implications for Medicare D

The Medicare Prescription Drug, Improvement and Modernization Act (MMA) established a new Medicare “Part D” that gives people access to a private Medicare prescription drug plan. The new law has particular relevance for the 6.4 million low-income Medicare beneficiaries also enrolled in Medicaid. These beneficiaries – often referred to as “dual eligibles” had their prescription coverage shifted from Medicaid to private Part D plans starting January 1, 2006. As a result, many dual eligibles face increases in their out-of-pocket costs under Part D since Medicaid co-payment requirements in many states fall below the levels that most face under Part D. In light of these changes, the relative lack of data on the impact of copayment requirements in this population is surprising given that these patients are much poorer and sicker than the privately insured population and hence may be more vulnerable to the intended and unintended effects of implementing even nominal cost sharing of a few dollars. This pilot study aims to examine the impact of copayment levels on antidepressant use and adherence in dual-eligibles with major depression. This study will take advantage of the variation in copayment requirements (i.e. $0.50 to $3) across the 50 states that existed in the pre-Part D period to inform the research question. Using the 2003 Medicaid Analytic Extract files merged with Medicare claims we will examine whether dual eligibles in states with higher copayments will have lower antidepressant use and adherence than those in states with lower or no copayments. Our long-term goal is to examine the impact of Part D on medication access, health outcomes, and expenditures among dual eligibles.

Elo

What Can We Learn from the 2000 Census of Population

The purpose of this study is to investigate race/ethnic differences in disability in the United States with an emphasis on immigrant populations and their U.S. born counterparts. The study utilizes the 5% PUMS sample from the 2000 Census of Population; the 2000 Census included a new set of questions on disability. The Census provides the most comprehensive information on race/ethnicity available in US data sources and the size of the 5% sample makes the Census the only data source that permits detailed analyses of health status among smaller race/ethnic subgroups in the United States. These data will be used to investigate race/ethnic differences in disability by age, place of birth, and length of stay in the United Sates, with and without controls for other individual and household-level characteristics. The results of the proposed analyses will advance our understanding of variations in health status among native-born and foreign-born Hispanics, NH-Whites, African-origin populations, and Asian Americans, including subpopulations within these broad race/ethnic groups.

Kohler, I

The Muslim Mortality Puzzle in Bulgaria

This research investigates mortality differentials in Eastern Europe, a region known for its excessively high adult mortality. It employs a unique longitudinal data set covering the entire population of Bulgaria from the census of 1992 until 1998. It focuses on differences in mortality between Muslims, a large and disadvantaged minority group, and non-Muslims. Virtually nothing is known about the health conditions of Muslims in Europe. Preliminary tabulations suggest that Muslims in Bulgaria have adult mortality levels that are below
the national average despite their severe social and economic disadvantages. Hypotheses are developed that attribute this puzzle, similar to the "Hispanic paradox" in the United States, to life-style factors and to social relations. The detailed information available on causes of death will be instrumental in distinguishing the factors involved. A dramatic economic downturn during the period under study will also help to identify factors affecting mortality. Non-parametric hazards models will be employed to test hypotheses. The research should help to identify reasons for the very high and rising mortality in Eastern Europe and to illuminate the health conditions of a large and growing minority population. More generally, it bears upon the relative explanatory power of materialist and social/behavioral approaches to the study of adult health and mortality.

Mitchell

The Efficiency and Characteristics of Investment Choices Offered by 401(k) Pension Plans

The proposed research seeks to investigate the adequacy and characteristics of investment choices offered by 401(k) plans. When constrained or inappropriate investment menus are offered to participants, they may experience decreases in returns as compared to a benchmark efficient portfolio. The goal, therefore, is to produce a working paper which measures the efficiency shortfall patterns in pension plan menu offerings, and to characterize these according to employee and plan characteristics. We do this so as to gain insight regarding the efficiency of investment menus offered in 401(k) plans, so that in future work we can further explore the investment efficiency of participants given the investment opportunities and the corresponding loss from participant investment choices which depart from the efficient ones.

Park

The Literacy Gap between Those with High Levels and Low Levels of Educational Attainment among Older Adults: A Comparative Study of 20 Countries

In the aging society, literacy skills among older adults become increasingly relevant for their economic and health outcomes, which makes it important to examine the levels and distributions of literacy skills among old population. In this pilot study, I compare the distributions of literacy skills among aged 56-65 in the U.S. and 19 other countries that participated in the International Adult Literacy Survey (IALS). I focus on the crossnational variation in the literacy gap between those with high levels and those with low levels of education. The large literacy gap between those with different levels of educational attainment implies significant disadvantages of people with low levels of educational attainment who also suffer from low levels of literacy skills. Cross-national comparisons may shed some light on why some countries are more successful in maintaining narrower literacy gaps among older adults. In particular, features of educational systems and between-country differences in opportunities of the participation in adult education and training are discussed as potential factors. In order to better identify sources of the cross-national variation, I also examine how the specific degree of literacy gap among older adults is compared to the gap among younger adults within countries. By examining how literacy inequality by educational attainment evolves with age, I aim to extend knowledge on social inequality associated with aging. Regression models predicting each of prose, document, and quantitative literacy scores by education, age, post-schooling experiences and other individual-level variables are estimated for each country, separately.

Turner

Understanding Barriers to Hypertension Control in the Elderly

This population-based study in primary care settings will evaluate the effect of attitudinal, subjective norms, and perceived behavioral control/structural factors on achieving sustained blood pressure (BP) control in hypertensive elderly patients aged >=70. We will also examine the impact of functional status/comorbidities as barriers to BP control. We hypothesize that patients with sustained uncontrolled hypertension (HTN) will: 1) place a higher priority on managing their other competing medical conditions; 2) have a poorer functional status; 3) have subjective norms that do not value HTN control; and 4) have more structural barriers to filling prescribed anti-hypertensive (anti-HTN) medications. We will randomly sample 100 individuals from each of two strata of all elderly HTN patients in affiliated urban primary care practices. We will conduct 30-minute telephone surveys of 200 patients to examine constructs within Ajzen's Theory of Planned Behavior. Survey items are primarily drawn from validated instruments. Analyses will be conducted in Stata using its svy features. Our dependent variable is sustained controlled HTN. We will examine multivariate models using generalized estimating equations and examine adjusted associations of the domains of interest both separately and together. This project will offer novel information on poorly understood patient-level barriers to HTN control in the elderly and will suggest targets for interventions to address uncontrolled HTN. The project has important relevance to reducing the most important risk factor for stroke and heart disease and offers an excellent basis for an NIH application.

Volpp

Financial Incentives for Weight Loss

Obesity is a major cause of premature aging and the second leading cause of preventable mortality in the United States, accounting for approximately 110,000 deaths per year. Financial incentives have been effective in modifying a number of health behaviors but they have not been applied to weight loss by low- SES obese veterans. We build on previous work showing the effectiveness of deposit contracts, in which subjects put their own money at risk if they do not lose weight, by adding a 1:1 match as well as a direct payment conditional on daily weight loss to make this approach more attractive to a low SES population. The proposed study, a 2-arm randomized control trial (RCT), would be tested with 24 patients at Philadelphia VA with BMIs between 30 and 40. Participants will receive for 16 weeks either weekly monitoring of their weights or the same monitoring plus a package of financial incentives if they lose weight at a rate proportional to a weight loss target of 16 lbs in 16 weeks consisting of: a.) daily payment of $3 and b.) return at the end of the month of the amount they deposited at the beginning of that month plus our 1:1 match. We will have 90% power to find a 15- pound difference in weight loss. The proposed intervention will serve as the basis for a larger-scale intervention study of incentives for weight loss and maintenance that has the potential to substantially reduce the health burden of obesity among Americans. Beyond assessing the effectiveness of the incentives on weight loss, we propose to use the difference in weight loss measured at 16 weeks to project the long-term cost-effectiveness if weight loss is sustained.

Watkins

Building and Maintaining Bibliographic Database for AIDS Research in Malawi

In Malawi, researchers studying AIDS have difficulty locating papers and reports that describe previous research. As a result, most research projects begin anew. We thus propose to build on the wide range of contacts that we have developed over nearly a decade of research in Malawi to create the Malawi AIDS Research Database (MARD) to be housed at the College of Medicine (COM) at the University of Malawi. This will include: 1) unpublished articles and reports that constitute the bulk of research on AIDS in Malawi; 2) links to published articles that are available without subscription on the Web; 3) published articles to which we have access through the PSC Demography library. Such a database will have intrinsic value for scholars in Malawi.