Ana I. Balsa

Statistical discrimination in health care

This paper considers the role of statistical discrimination as a potential explanation for racial and ethnic disparities in health care. The underlying problem is that a physician may have a harder time understanding a symptom report from minority patients. If so, even if there are no objective differences between Whites and minorities, and even if the physician has no discriminatory motives, minority patients will benefit less from treatment, and may rationally demand less care. After comparing these and other predictions to the published literature, we conclude that statistical discrimination is a potential source of racial/ethnic disparities, and worthy of research.

Longitudinal Analysis of Changes in Illicit Drug Use and Health Services Utilization

OBJECTIVE To analyze the relationships between illicit drug use and three types of health services utilization: emergency room utilization, hospitalization, and medical attention required due to injury(s). DATA Waves 1 and 2 (11,253 males and 13,059 females) from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). STUDY DESIGN We derive benchmark estimates by employing standard cross-sectional data models to pooled waves of NESARC data. To control for potential bias due to time-invariant unobserved individual heterogeneity, we reestimate the relationships with fixed-effects models. PRINCIPAL FINDINGS The cross-sectional data models suggest that illicit drug use is positively and significantly related to health services utilization in almost all specifications. Conversely, the only significant (p<.05) relationships in the fixed-effects models are the odds of receiving medical attention for an injury and the number of injuries requiring medical attention for men, and the number of times hospitalized for men and women. CONCLUSIONS Failing to control for time-invariant individual heterogeneity could lead to biased coefficients when estimating the effects of illicit drug use on health services utilization. Moreover, it is important to distinguish between types of drug user (casual versus heavy) and estimate gender-specific models.

From Pubs to Scrubs: Alcohol Misuse and Health Care Use

OBJECTIVE To analyze the relationships between alcohol misuse and two types of acute health care use-hospital admissions and emergency room (ER) episodes. DATA SOURCES/STUDY SETTING The first (2001/2002) and second (2004/2005) waves of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC). STUDY DESIGN Longitudinal study using a group of adults (18-60 years in Wave 1, N=23,079). Gender-stratified regression analysis adjusted for a range of covariates associated with health care use. First-difference methods corrected for potential omitted variable bias. DATA COLLECTION The target population of the NESARC was the civilian noninstitutionalized population aged 18 and older residing in the United States and the District of Columbia. The survey response rate was 81 percent in Wave 1 (N=43,093) and 65 percent in Wave 2 (N=34,653). PRINCIPAL FINDINGS Frequent drinking to intoxication was positively associated with hospital admissions for both men and women and increased the likelihood of using ER services for women. Alcohol dependence and/or abuse was related to higher use of ER services for both genders and increased hospitalizations for men. CONCLUSIONS These findings provide updated and nationally representative estimates of the relationships between alcohol misuse and health care use, and they underscore the potential implications of alcohol misuse on health care expenditures.

Alcohol use and the labor market in Uruguay

This paper is one of only a few studies to examine potential labor market consequences of heavy or abusive drinking in Latin America and the first to focus on Uruguay. We analyzed data from a Uruguayan household survey conducted in 2006 using propensity score matching methods and controlling for a number of socio-demographic, family, regional, behavioral health, and labor market characteristics. As expected, we found a positive association between heavy drinking and absenteeism, particularly for female employees. Counter to the findings for developed countries, our results revealed a positive relationship between heavy drinking and labor force participation or employment. This result was mostly driven by men and weakened when considering more severe measures of abusive drinking. Possible explanations for these findings are that employment leads to greater alcohol use through an income effect, that the Uruguayan labor market rewards heavy drinking, or that labor market characteristics typical of less developed countries, such as elevated safety risks or job instability, lead to problem drinking. Future research with panel data should explore these possible mechanisms.

Parental Problem-drinking and Adult Children’s Labor Market Outcomes

Current estimates of the societal costs of alcoholism do not consider the impact of parental drinking on children. This paper analyzes the consequences of parental problem-drinking on childrens labor market outcomes in adulthood. Using the NLSY79, I show that having a problem-drinking parent is associated with longer periods out of the labor force, lengthier unemployment, and lower wages, in particular for male respondents. Increased probabilities of experiencing health problems and abusing alcohol are speculative forces behind these effects. While causality cannot be determined due to imprecise IV estimates, the paper calls for further investigation of the intergeneration costs of problem-drinking.

Relative Deprivation and Risky Behaviors

Relative deprivation has been associated with lower social and job satisfaction as well as adverse health outcomes. Using Add Health data, we examine whether a student’s relative socioeconomic status (SES) has a direct effect on substance use. We advance the existing literature by addressing selection and simultaneity bias and by focusing on a reference group likely to exert the most influence on the respondents. We find that relative deprivation is positively associated with alcohol consumption, drinking to intoxication, and smoking for adolescent males, but not for females. Alternative variable definitions and robustness checks confirm these findings.

Exposures to Particulate Matter from the Eruptions of the Puyehue Volcano and Birth Outcomes in Montevideo, Uruguay.

Background: The ashes and dust resulting from the 2011 eruptions of the Puyehue volcano in Chile more than doubled monthly averages of PM10 concentrations in Montevideo, Uruguay. Few studies have taken advantage of natural experiments to assess the relationship between ambient air pollutant concentrations and birth outcomes. Objectives: In this study we explored the effect of particulate matter with diameter of ≤ 10 μm (PM10) on perinatal outcomes in Uruguay, a middle-income country in South America with levels of PM10 that in general do not exceed the recommended thresholds. The analyzed outcomes are preterm birth, term birth weight, and term low birth weight. Methods: We took advantage of the sharp variation in PM10 concentrations due to the Puyehue eruptions to estimate the associations between mother’s exposure to PM10 in each trimester of pregnancy and perinatal outcomes. We use birth registries for 2010–2013 and control for covariates, including maternal and pregnancy characteristics, weather, co-pollutants, and calendar quarter and hospital indicators. Results: A 10-μg/m3 increase in exposure to PM10 during the third trimester was associated with a higher likelihood of a preterm birth [odds ratio (OR) = 1.10; 95% CI: 1.03, 1.19]. The association was robust to different model specifications, and increased with categorical exposure levels (OR for third-trimester PM10 ≥ 70 vs. < 30 μg/m3 = 5.24; 95% CI: 3.40, 8.08). Exposures were not consistently associated with birth weight or low birth weight among term births, though second-trimester exposures were associated with higher birth weight, contrary to expectations. Conclusions: Taking advantage of a natural experiment, we found evidence that exposure to high levels of PM10 during the third trimester of pregnancy may have increased preterm births among women in Montevideo, Uruguay. Citation: Balsa AI, Caffera M, Bloomfield J. 2016. Exposures to particulate matter from the eruptions of the Puyehue Volcano and birth outcomes in Montevideo, Uruguay. Environ Health Perspect 124:1816–1822; http://dx.doi.org/10.1289/EHP235

Lessons From Participation in a Web-Based Substance Use Preventive Program in Uruguay

We analyzed individual and program characteristics associated with participation in an Information and Communication Technologies (ICT)-based substance use preventive intervention in Uruguay, South America. The intervention was directed at ninth- and tenth-grade students in 10 private schools in Montevideo. Participation in the program was non-mandatory and effective participation rates were low. We found that individual characteristics, such as prior heavy engagement with alcohol and opportunity costs of time, were associated with the decision to participate. We also found that sending the participants periodic reminders via e-mail and short message service (SMS) text messages had a positive impact on participation. The lessons from this intervention suggest that participation in non-mandatory Web-based programs aimed at preventing substance use among adolescents could be substantially improved with a more structured, mandatory, and longer intervention.

The Impact of Parental Drinking on Children’s Use of Health Care

While a significant body of literature documents the health problems of children caused by and/or associated with parental alcohol misuse, little research has been conducted on the relationship between parental problem drinking and childrens use of health care. We should expect to see an increase in childrens health care if alcohol-misusing parents were responsive to their childrens higher physical and mental health needs. Contrarily, it would decrease (conditional on health status) if alcohol-misusing parents were irresponsive to those needs. Analyzing a nationally representative sample of parents and children, we find a positive and significant association between parental high intensity drinking and pediatric visits for their children. We also find evidence linking parental drinking to more emergency room use. These findings suggest that the impact of parental drinking on child well-being should be considered when assessing the full costs of alcohol misuse.

Horizontal Inequity in Access to Health Care in Four South American Cities

This paper analyzes and compares socioeconomic inequalities in the use of healthcare services by the elderly in four South-American cities: Buenos Aires (Argentina), Santiago (Chile), Montevideo (Uruguay) and San Pablo (Brazil). We use data from SABE, a survey on Health, Well-being and Aging administered in several Latin American cities in 2000. After having accounted for socioeconomic inequalities in healthcare needs, we find socioeconomic inequities favoring the rich in the use of preventive services (mammograms, pap tests, breast examinations, and prostate exams) in all of the studied cities. We also find inequities in the likelihood of having a medical visit in Santiago and Montevideo, and in some measures of quality of access in Santiago, Sao Paulo, and Buenos Aires. Santiago depicts the highest inequities in medical visits and Uruguay the worse indicators in mammograms and pap scans tests. For all cities, inequities in preventive services at least double inequities in other services. We do not find evidence of a trade-off between levels of access and equity in access to healthcare services. The decomposition of healthcare inequalities suggests that inequities within each health system (public or private) are more important than between systems.