Essays in Applied Health Economics

Abstract

Injuries and violence are a major public health issue and represent a threat to individual wellbeing, productivity, and societal development at large. In recent years, the public health approach to reduce violence and injury has become crucial in guiding research and public policy. Governmental and nongovernmental organizations are strengthening data collection and surveillance systems to promote research and inform policy making. Yet the idea that violence and injuries can be prevented through systematic monitoring and research is still a novel one. The three essays that comprise this dissertation make advancements in this direction focusing on the United States. The first two chapters focus on child safety, examining the issues of bullying and firearm violence at school. The third chapter expands on the topic of gun violence examining the impact of firearm legislation on the broader problem of suicide deaths. From a methodological point of view, this dissertation combines economic models with a public health approach employing both structural estimation techniques and a quasi-experimental approach. While quasi-experimental methods are effective in uncovering broad causal relationships between legislative changes and outcome measures, structural estimation methods are essential when interested in recovering deep preference parameters and performing counterfactual policy analysis. As such, this dissertation represents an example of multidisciplinary work combining Economics and Public Health, and highlights the importance of employing diverse methodologies to uncover crucial behavioral patterns and their policy implications. The first essay, titled Is School Bullying Contagious?, uses a nationwide cross-section of students to uncover peer effects in adolescent bullying behavior at school. Victimization at school has been linked to a number of adverse effects for child development and well-being, including depression, higher drop-out risk, and lower earnings during adulthood. While understanding social interactions in bullying behavior is essential to designing effective policies, previous empirical work has overlooked the impact of classmates’ behavior on the individual inclination for bullying. This essay estimates a structural model of bullying with social interactions where the individual bullying effort depends on the average effort among classmates. The model controls for individual and family characteristics, classmates’ characteristics, as well as classroom unobservable factors. The results present strong evidence of peer effects in a large number of bullying behaviors. Considering a median classroom of 20 students with five bullies, the introduction of a new bully would spawn two additional bullies due to peer influences. This suggests that social interactions can be targeted to reduce the prevalence of bullying. In particular, counter-factual policy experiments indicate that schools may achieve sizable reductions in the number of bullies by spreading them out over classrooms. The second essay, titled Gun Laws and School Safety, is joint with Summer Hawkins and Christopher Baum. Motivated by the documented link between school safety and psychological well-being, this essay examines the impact of state-level gun control on adolescent school safety. The analysis uses data on 926,639 adolescents from 45 states in the 1999-2015 Youth Risk Behavior Surveys. Students self-reported on weapon carrying at school, the number of times they had been threatened or injured with a weapon at school, the number of school days missed due to feeling unsafe, and weapon carrying at any location. For each state and year, 133 gun laws were combined into an index of gun control strength. Difference-in-differences logistic regressions were used to evaluate the impact of stricter gun laws on binary measures of school safety. Each regression controlled for individual and state characteristics, as well as year and state fixed effects. An interquartile-range (IQR) increase in the index (i.e. a 15-point increase corresponding to a strengthening of gun control) was associated with a 0.8 percentage point decrease in the probability of weapon threats at school (p=0.038) and a 1.2 percentage point decrease in the probability of missing school due to feeling unsafe (p=0.004). While we did not find a significant impact of gun laws on weapon carrying at school, an IQR increase in the index was associated with a 2-percentage point decrease in the probability of carrying weapons at any location (p=0.002). Our results suggest that the adoption of stricter state gun laws may improve school climate and subjective perceptions of safety. The third essay, joint with Summer Hawkins and Christopher Baum, is titled Gun Laws and Firearm Suicides. Between 2005 and 2015, suicide rates have been steadily increasing in the US, with firearm suicides representing over half of all suicides and the primary cause of firearm mortality. As such, firearm suicides represent an urgent policy matter and a prompt policy response is required. Using a 10-year-long panel of the 50 states, we investigated whether stricter gun laws may reduce firearm suicides, possibly by reducing firearm availability. As a reduction in firearm availability may simply result in a substitution towards alternative suicide methods, we further explored whether stricter gun laws are associated with an increase in non-firearm suicides. We analyzed 2005-2015 National Vital Statistics System mortality files from the 50 states, with 212,804 firearm suicides and 206,795 non-firearm suicides. We measured the strength of state-level gun control using an index that combines 133 different laws. We conducted difference-in-differences regression models to assess whether changes in the index were associated with changes in the number of firearm and non-firearm suicides. We found that implementing an additional gun law would result in a decrease in the number of firearm-related suicides by 2 to 4 percentage points. In addition, significant interactions between the gun score and demographic characteristics suggest that the effectiveness of stronger gun laws is the highest among individuals age 20 to 49, but seems to be null among black individuals. Although we found no overall association between a stricter gun law environment and non-firearm suicides, stricter gun laws seem to increase non-firearm suicides among white and black individuals, suggesting that additional policy actions are required to prevent suicides in these groups. Our findings are robust to controlling for demographic characteristics, state time-varying characteristics, state and year fixed effects, as well as state-specific time trends. We also provide graphical evidence that trends in suicide rates were not dependent on the level of strength of gun control, supporting the parallel trend assumption and a causal interpretation of our estimates.