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Chris Sampson’s journal round-up for 18th May 2020

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Socioeconomic factors and happiness: evidence from self-reported mental health data. Empirical Economics [RePEc] Published 7th March 2019

Empirical Economics is not a journal that I regularly visit, but this paper from the most recent issue caught my eye. I think it’s also the first paper I’ve ever read by authors from the US Navy. Apparently, happiness economics is still cool, because this paper has little to do with happiness and yet is couched entirely in those terms. It’s about mental health, which, if you ask me, is a far more important outcome than happiness.

The authors analyse data from the Behavioral Risk Factor Surveillance System (BRFSS), which is a large health survey in the US. This analysis includes data from 23 years’ worth of cross-sections since 1993, with around 6.9 million responses. In some respects, the study is an extension of a previous study, including many more waves of data. The analysis is quite straightforward, with a linear regression including lots of explanatory variables for the main outcome of interest, which is the self-reported number of days in the last 30 days that the respondent’s mental health was “not good”.

The main contribution of the paper is not in understanding the socioeconomic correlates of mental health, for which a huge body of evidence already exists, but rather in understanding how these might have changed over time in the US. Overall, self-reported mental health has worsened over time, though this is very likely to be at least partly explained by changes in reporting behaviour. The study tentatively identifies a few trends emerging from this vast data set. The two findings that are most interesting to me, because they confirm all my prior beliefs, relate to economic precarity and women’s role burden.

Debt, unemployment, and relationship separation are all indicators of an uncertain future, shouldered by the precariat, that dominate as correlates of self-reported mental health. The authors don’t explain how their impact has changed over time, if at all. All else equal, women tend to report more days in poor mental health than men. Rather than including absolute income in their analyses, the authors focus on income relative to the average for the individual’s demographic cohort. As you might expect, a lower relative income is associated with more days with poor mental health. Notably, the impact is greater for women. And other variables linked to social comparison, such as body weight, affect women more than men and have worsened for women over time. The impact of children has also changed over time. Back in 1993, kids were bad for men’s mental health and even worse for women’s. But by 2015 they had a positive impact for men and essentially no impact for women. This hints at changing household roles.

This study doesn’t uncover anything groundbreaking or prove anything about the determinants of good mental health. But, by looking at a large dataset over a long period of time, it provides numerous clues for future research.

When are pharmaceuticals priced fairly? An alternative risk-sharing model for pharmaceutical pricing. Health Care Analysis [PhilPapers] [PubMed] Published 30th March 2020

The title of this paper poses a challenging question. To answer it, the authors set out to describe the stakeholders involved in setting pharmaceutical prices, what might constitute fairness, and how we might establish a framework for setting prices fairly.

There are two objectives specified in the setting of prices: 1) financial accessibility to drugs for people who need them, and 2) viability for the pharmaceutical industry. Based on this, the starting point for the authors is to define fairness in two corresponding ways: accessible pricing and justifiable pricing. Accessible pricing allows everyone who needs a drug to access it. This is framed as a kind of Rawlsian social justice argument. Justifiable pricing is about prices corresponding to the value of a drug and the cost of bringing it to market, and the authors discuss ideas from business ethics and the role of firms. Acknowledging that a given price for a given drug may or may not achieve either accessbility or justification, the four possible scenarios that arise are discussed and related to examples. For instance, prices for generic drugs are likely to be accessible and justifiable, while the recent example of EpiPen price hikes achieve neither accessibility nor justification.

The authors go on to map out the stakeholders, including i) the public, ii) third party payers, iii) pharmaceutical companies, and iv) company stockholders, acknowledging the difficulty in identifying prices that satisfy all four. For example, the authors highlight the role of prices as signals to stockholders, which does not relate to the value of drugs but does ensure the viability of companies and support future R&D.

In short, the authors recommend a more collaborative approach to setting prices, which they give the grandiose title ‘enlightened risk sharing’. They contrast this with a kind of ‘englightened capitalism’ based on sales maximisation and wishful thinking. What this englightened risk sharing would look like is not entirely clear. The authors seem to suggest that it is essentially what we already have going on in the UK, with formal agreements between industry and government that limit the profits that companies can make overall, while also discounting individual drug prices through appraisal processes.

I buy the argument that companies have a duty to behave with some morality in this context. There’s no place for neoliberal interpretations of social (ir)responsibility here; if only Friedman had been skint and in need of an EpiPen. Some form of value-based pricing is a reasonable starting point. But the authors’ interpretation of accessible pricing starts to fall down when we unpick the definition of ‘need’, which isn’t adequately explored in this paper. If ‘need’ is quantified in relation to cost-effective care, which it surely should be, then we end up with a circular argument with need as a function of prices and prices a function of need.

Accountability for an unhealthy lifestyle. The European Journal of Health Economics [PubMed] [RePEc] Published 2nd May 2020

A large part of health care expenditure is on chronic conditions that are at least partially related to individuals’ choices and behaviours. The author of this paper explains that health is stated to be – in various important places – a human right. Rights are normally coupled with responsibilities. The author’s contention is that no such responsibility exists for health care, but it should (or, at least, could). That responsibility would come in the form of accountability for self-inflicted health care costs.

The author’s definition of self-harm includes any behaviour or lifestyle adopted with knowledge of negative consequences for health. Some examples are outlined with reference to real-world policies, such as liver transplant availability for people who can’t stay sober. It’s hard to tell, but I think these are presented as positive examples. There is a meandering discussion of accountability and things that might undermine it, such as mental health. The author suggests that a ‘responsibility grading system’ could be created and achnowledges that inequities might arise from the (mis)allocation of responsibility. But the discussion isn’t anchored in any medical ethics or philosophical literature and it’s difficult to decipher any clear arguments.

I’m not sure what the purpose of this paper is. If it is an argument in favour of creating legal responsibilities for self-care, it is very weak and I am strongly opposed. As I write this blog post on my tablet, late in the evening, of sound mind, slouching on the sofa, having just eaten an ice cream that I didn’t need, I wonder what I could do that wouldn’t constitute self-harm. But my most fundamental concern is that the author’s arguments hinge on the ‘right’ being understood as a right to health, rather than to health care. I’d say that’s simply wrong. The right to health relates to health that is attainable, and that attainability, insofar as it pertains to public administration, is determined by health care. It doesn’t take much thought to realise that there is a responsibility related to the public provision of services; we are all duty bound (or even coerced) to work and pay taxes. Regardless, it doesn’t follow that a responsibility arising from a right to health must be measurable in terms of health. Do I have a duty to practise my timestables because I had the right to a basic education?

Alternatively, this paper might simply be highlighting that there is no legal basis for the allocation of responsibility to people who have the right to health (care). Fine. But the reasons for such a legal responsibility not existing seem obvious to me, and the author doesn’t do enough to acknowledge these reasons.


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