Counting the Dead: COVID-19 and Mortality in Quebec and British Columbia During the First Wave.

The first wave of the COVID-19 pandemic has led to excess mortality across the globe, and Canada has been no exception. Nonetheless, the pandemic experience has been very different across provinces, and the objective of this paper is to investigate these differences focusing on two extreme cases. We contrast the mortality experience of British Columbia with that of Québec to understand how large differences in mortality during the first wave of the pandemic emerged across these two provinces. We find that most of the differences can be found in excess mortality in institutions (nursing homes) and that travel restrictions, differences in how deaths are recorded, differences in the seasonality of the flu, or differences in how the pandemic spread across different economic segments of the population are unlikely explain these large differences. We document that the reported death toll from COVID-19 is about 30% larger than excess mortality in Quebec due to lower mortality from other causes of death, in particular malignant tumors, heart disease, and respiratory problems. We do not find evidence of an income gradient (measured by postal code level income) in relative excess death for the first wave.

La première vague de la pandémie de la COVID-19 a entraîné une surmortalité dans plusieurs pays à travers le monde, incluant le Canada. Par contre, l'ampleur fut bien différente à travers les provinces canadiennes et l'objectif de cette analyse est d'étudier ces différences en se concentrant sur deux provinces spécifiques. Pour ce faire, nous comparons la mortalité de la Colombie-Britannique avec celle du Québec pour tenter de comprendre les grandes différences observées entre ces deux provinces durant la première vague de la pandémie. On constate qu'une grande partie de la surmortalité différentielle est observée chez les personnes vivant en institutions de santé (maisons de soins). De plus, on remarque aussi que les restrictions concernant les déplacements internationaux, les processus d'enregistrement des décès, l'évolution de la grippe saisonnière ou les différences dans la façon dont la pandémie s'est propagée à travers les groupes sociaux-économiques de la population sont peu susceptibles d'expliquer ces grandes différences. Notre analyse montre que le nombre de décès attribués à la COVID-19 est d'environ 30% plus élevé que la surmortalité observée au Québec durant la première vague. Cet écart est, en partie, attribuable à une mortalité plus faible de d'autres causes de décès, en particulier les tumeurs malignes, les maladies cardiaques et les problèmes respiratoires durant la même période. Finalement, nous n'avons pas été en mesure de calculer un gradient de revenu (mesuré par le revenu au niveau du code postal) pour les décès excédentaires survenus lors de la première vague.Mots clés: excès de mortalité, COVID-19, institutions de santé, cause de décès.

Accounting for the Rise of Health Spending and Longevity.

We estimate a stochastic life-cycle model of endogenous health spending, asset accumulation and retirement to investigate the causes behind the increase in health spending and longevity in the U.S. over the period 1965-2005. Accounting for changes over time in taxes, transfers, Social Security, income, health insurance, smoking and obesity, and technological progress, we estimate that technological progress is responsible for half of the increase in life expectancy over the period. Substantial growth in health spending over the period is largely the result of growth in economic resources and the generosity of health insurance, with a modest role for medical technological progress. The growth in spending does not come from changes in a single source, but sources jointly interacted to increase spending: complementarity effects explain up to 26.3% of the increase in health spending. Overall, for those born in 1940, the combined changes in resources and health insurance that occurred over the period are valued at 35.7% of lifetime consumption.

The effect of college education on health and mortality: Evidence from Canada.

We investigate the returns to college attendance in Canada in terms of health and mortality reduction. To do so, we first use a dynamic health microsimulation model to document how interventions that incentivize college attendance among high school graduates may impact their health trajectory, health care consumption, and life expectancy. We find large returns both in terms of evity (4.1 years additional years at age 51), reduction in the prevalence of various health conditions (10-15 percentage points reduction in diabetes and 5 percentage points for stroke), and health care consumption (27.3% reduction in lifetime hospital stays, 19.7 for specialists). We find that education impacts mortality mostly by delaying the incidence of health conditions as well as providing a survival advantage conditional on having diseases. Second, we provide quasi-experimental evidence on the impact of college attendance on long-term health outcomes by exploiting the Canadian Veteran's Rehabilitation Act, a program targeted towards returning WW-II veterans and which incentivized college attendance. The impact on mortality is found to be larger than those estimated from the health microsimulation model (hazard ratio of 0.216 compared with 0.6 in the simulation model), which suggests substantial returns to college education in terms of healthy life extension which we estimate to be approximately one million canadian dollars.

Understanding Joint Retirement.

Evidence from different sources shows that spouses' retirement decisions are correlated. Retirement policies affecting individuals in couples are therefore also likely to affect behavior of their spouses. It is therefore important to account for joint features in modeling retirement. This paper studies a structural collective model of labor supply and retirement of both partners in a couple with interdependent preferences, imperfect knowledge of preferences of the spouse, and subjective expectations about the future. We propose a novel method to estimate preferences and the intra-household bargaining process, which relies on stated preferences data collected in the Health and Retirement Study. Respondents were asked to choose between hypothetical retirement trajectories describing the retirement ages and replacement rates of both spouses from three perspectives: considering their own preferences only, the preferences of their spouse only, or the most likely decision for the household. With these data, all model parameters are identified and potential sources of joint retirement can be disentangled. Our results suggest that males misperceive their wives' preferences, overestimating their disutility of work. Our estimates correct for this. We find strong positive correlations between preferences for joint leisure (leisure complementarity) of the two partners. Counterfactual simulations with stylized retirement paths suggest that the leisure complementarities explain a substantial part of joint retirement, much more than correlation in unobserved heterogeneity or potential wage rates.

Early Impact of the COVID-19 Pandemic on Household Finances in Quebec.

The coronavirus disease 2019 (COVID-19) pandemic surged in early March 2020, with unemployment reaching historic levels in April 2020. This study paints an early portrait of the pandemic's impact on the finances of households in Quebec, one of the hardest-hit provinces in terms of COVID-19 cases as well as unemployment levels. The article also provides an understanding of how government emergency benefit programs may have helped households get by during the early period of the pandemic. Finally, we draw on expectations data collected in a survey of 3,009 respondents living in Quebec to illustrate what households can expect for the rest of 2020.

La pandémie de maladie à coronavirus 2019 (COVID­19) a fait son apparition au début de mars 2020, le chômage ayant atteint des niveaux sans précédent en avril 2020. Les auteurs tracent un premier portrait des répercussions de la pandémie sur la situation financière des ménages du Québec, l'une des provinces les plus durement touchées par la COVID­19 quant au nombre de cas et au taux de chômage. Ils tentent également d'expliquer en quoi les programmes gouvernementaux de prestations d'urgence ont pu aider les ménages à surmonter leurs difficultés au cours de la phase initiale de la pandémie. Enfin, les auteurs s'appuient sur les données relatives aux attentes qu'ils tirent de leur sondage pour illustrer ce à quoi les ménages peuvent s'attendre pour le reste de 2020.

The economic benefits of reducing cardiovascular disease mortality in Quebec, Canada.

OBJECTIVES: We assess how different scenarios of cardiovascular disease (CVD) prevention, aimed at meeting targets set by the World Health Organization (WHO) for 2025), may impact healthcare spending in Quebec, Canada over the 2050 horizon. METHODS: We provide long-term forecasts of healthcare use and costs at the Quebec population level using a novel dynamic microsimulation model. Using both survey and administrative data, we simulate the evolution of the Quebec population's health status until death, through a series of dynamic transitions that accounts for social and demographic characteristics associated with CVD risk factors. RESULTS: A 25% reduction in CVD mortality between 2012 and 2025 achieved through decreased incidence could contain the pace of healthcare cost growth towards 2050 by nearly 7 percentage points for consultations with a physician, and by almost 9 percentage points for hospitalizations. Over the 2012-2050 period, the present value of cost savings is projected to amount to C$13.1 billion in 2012 dollars. The years of life saved due to improved life expectancy could be worth another C$38.2 billion. Addressing CVD mortality directly instead would bring about higher healthcare costs, but would generate more value in terms of years of life saved, at C$69.6 billion. CONCLUSIONS: Potential savings associated with plausible reductions in CVD, aimed at reaching a World Health Organization target over a 12-year period, are sizeable and may help address challenges associated with an aging population.

Distribution of lifetime nursing home use and of out-of-pocket spending.

Reliable estimates of the lifetime risk of using a nursing home and the associated out-of-pocket costs are important for the saving decisions by individuals and families, and for the purchase of long-term care insurance. We used data on up to 18 y of nursing home use and out-of-pocket costs drawn from the Health and Retirement Study, a longitudinal household survey representative of the older US population. We accumulated the use and spending by individuals over many years, and we developed and used an individual-level matching method to account for use before and after the observation period. In addition, for forecasting, we estimated a dynamic parametric model of nursing home use and spending. We found that 56% of persons aged 57-61 will stay at least one night in a nursing home during their lifetimes, but only 32% of the cohort will pay anything out of pocket. Averaged over all persons, total out-of-pocket expenditures looking forward from age 57 were approximately $7,300, discounted at 3% per year. However, the 95th percentile of spending was almost $47,000. We conclude that the percentage of people ever staying in nursing homes is substantially higher than previous estimates, at least partly due to an increase in nursing home episodes of short duration. Average lifetime out-of-pocket costs may be affordable, but some people will incur much higher costs.

End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported.

Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.

Individual survival curves comparing subjective and observed mortality risks.

We compare individual survival curves constructed from objective (actual mortality) and elicited subjective information (probability of survival to a given target age). We develop a methodology to estimate jointly subjective and objective individual survival curves accounting for rounding on subjective reports of perceived survival. We make use of the long follow-up period in the Health and Retirement Study and the high quality of mortality data to estimate individual survival curves that feature both observed and unobserved heterogeneity. This allows us to compare objective and subjective estimates of remaining life expectancy for various groups and compare welfare effects of objective and subjective mortality risk using the life cycle model of consumption. We find that subjective and objective hazards are not the same. The median welfare loss from misperceptions of mortality risk when annuities are not available is 7% of current wealth at age 65 whereas more than 25% of respondents have losses larger than 60% of wealth. When annuities are available and exogenously given, the welfare loss is substantially lower.

Optimal Financial Knowledge and Wealth Inequality.

We show that financial knowledge is a key determinant of wealth inequality in a stochastic lifecycle model with endogenous financial knowledge accumulation, where financial knowledge enables individuals to better allocate lifetime resources in a world of uncertainty and imperfect insurance. Moreover, because of how the U.S. social insurance system works, better-educated individuals have most to gain from investing in financial knowledge. Our parsimonious specification generates substantial wealth inequality relative to a one-asset saving model and one where returns on wealth depend on portfolio composition alone. We estimate that 30-40 percent of retirement wealth inequality is accounted for by financial knowledge.

The economic consequences of obesity and overweight among adults in Quebec.

OBJECTIVES: This article presents the first study of the economic consequences of obesity and overweight in the Canadian province of Quebec. The article examines three types of direct costs: hospitalizations, medical visits and drug consumption; and one type of indirect cost: productivity loss due to disability. METHODS: The National Population Health Survey, conducted in all Canadian provinces by Statistics Canada between 1994 and 2011, provides self-reported longitudinal data for body mass index and the frequency of health care utilization and disability. RESULTS: When we compared obese adults in Quebec to those with a normal weight at the beginning of the follow-up period, we observed that the former had significantly more frequent visits to the physician, more frequent hospital stays and higher consumption of drugs between 1994 and 2011. We estimated the annual cost of the excess health care utilization and excess disability at more than CAD $2.9 billion in 2011. CONCLUSION: The results confirm that, similar to what had been found elsewhere in Canada and abroad, there are important economic consequences associated with overweight and obesity in Quebec.

The Effect of Job Loss on Health: Evidence from Biomarkers.

We estimate the effect of job loss on objective measures of physiological dysregulation using biomarker measures collected by the Health and Retirement Study in 2006 and 2008 and longitudinal self-reports of work status. We distinguishing between mass or individual layoffs, and business closures. Workers who are laid off from their job have lower biomarker measures of health, whereas workers laid off in the context of a business closure do not. Estimates matching respondents wave-by-wave on self-reported health conditions and subjective job loss expectations prior to job loss, suggest strong effects of layoffs on biomarkers, in particular for glycosylated hemoglobin (HbA1c). A Layoff could increase annual mortality rates by 10.3%, consistent with other evidence of the effect of mass layoffs on mortality.

Disease incidence and mortality among older Americans and Europeans.

Recent research has shown a widening gap in life expectancy at age 50 between the United States and Europe as well as large differences in the prevalence of diseases at older ages. Little is known about the processes determining international differences in the prevalence of chronic diseases. Higher prevalence of disease could result from either higher incidence or longer disease-specific survival. This article uses comparable longitudinal data from 2004 and 2006 for populations aged 50 to 79 from the United States and from a selected group of European countries to examine age-specific differences in prevalence and incidence of heart disease, stroke, lung disease, diabetes, hypertension, and cancer as well as mortality associated with each disease. Not surprisingly, we find that Americans have higher disease prevalence. For heart disease, diabetes, and cancer, incidence is lower in Europe when we control for sociodemographic and health behavior differences in risk, and these differences explain much of the prevalence gap at older ages. On the other hand, incidence is higher in Europe for lung disease and not different between Europe and the United States for hypertension and stroke. Our findings do not suggest a survival advantage conditional on disease in Europe compared with the United States. Therefore, the origin of the higher disease prevalence at older ages in the United States is to be found in higher prevalence earlier in the life course and, for some conditions, higher incidence between ages 50 and 79.

Substantial health and economic returns from delayed aging may warrant a new focus for medical research.

Recent scientific advances suggest that slowing the aging process (senescence) is now a realistic goal. Yet most medical research remains focused on combating individual diseases. Using the Future Elderly Model--a microsimulation of the future health and spending of older Americans--we compared optimistic "disease specific" scenarios with a hypothetical "delayed aging" scenario in terms of the scenarios' impact on longevity, disability, and major entitlement program costs. Delayed aging could increase life expectancy by an additional 2.2 years, most of which would be spent in good health. The economic value of delayed aging is estimated to be $7.1 trillion over fifty years. In contrast, addressing heart disease and cancer separately would yield diminishing improvements in health and longevity by 2060--mainly due to competing risks. Delayed aging would greatly increase entitlement outlays, especially for Social Security. However, these changes could be offset by increasing the Medicare eligibility age and the normal retirement age for Social Security. Overall, greater investment in research to delay aging appears to be a highly efficient way to forestall disease, extend healthy life, and improve public health.

A health production model with endogenous retirement.

We formulate a stylized structural model of health, wealth accumulation and retirement decisions building on the human capital framework of health and derive analytic solutions for the time paths of consumption, health, health investment, savings and retirement. We argue that the literature has been unnecessarily restrictive in assuming that health is always at the 'optimal' health level. Exploring the properties of corner solutions, we find that advances in population health decrease the retirement age, whereas at the same time, individuals retire when their health has deteriorated. This potentially explains why retirees point to deteriorating health as an important reason for early retirement, whereas retirement ages have continued to fall in the developed world, despite continued improvements in population health and mortality. In our model, workers with higher human capital invest more in health and, because they stay healthier, retire later than those with lower human capital whose health deteriorates faster.

The value of medical and pharmaceutical interventions for reducing obesity.

This paper attempts to quantify the social, private, and public-finance values of reducing obesity through pharmaceutical and medical interventions. We find that the total social value of bariatric surgery is large for treated patients, with incremental social cost-effectiveness ratios typically under $10,000 per life-year saved. On the other hand, pharmaceutical interventions against obesity yield much less social value with incremental social cost-effectiveness ratios around $50,000. Our approach accounts for: competing risks to life expectancy; health care costs; and a variety of non-medical economic consequences (pensions, disability insurance, taxes, and earnings), which account for 20% of the total social cost of these treatments. On balance, bariatric surgery generates substantial private value for those treated, in the form of health and other economic consequences. The net public fiscal effects are modest, primarily because the size of the population eligible for treatment is small. The net social effect is large once improvements in life expectancy are taken into account.

The Displacement Effect of Public Pensions on the Accumulation of Financial Assets.

The generosity of public pensions may depress private savings and provide incentives to retire early. While there is plenty of evidence supporting the latter effect, there remains considerable controversy whether public pensions crowd out private savings. This paper uses international micro-datasets collected over recent years to investigate whether public pensions displace private savings. The identification strategy relies not only on cross-country differences in generosity but also on differences in the progressivity or non-linearity of pension formulas across countries. We estimate that an extra dollar of pension wealth depresses accumulated financial assets around the time of retirement by 22 cents. An extra ten thousand dollars in public pension wealth reduces the average retirement age by roughly one month which implies an elasticity of retirement years with respect to pension wealth of -0.15.

Differences in health between Americans and Western Europeans: Effects on longevity and public finance.

In 1975, 50-year-old Americans could expect to live slightly longer than most of their Western European counterparts. By 2005, American life expectancy had fallen behind that of most Western European countries. We find that this growing longevity gap is primarily due to real declines in the health of near-elderly Americans, relative to their Western European peers. We use a microsimulation approach to project what US longevity would look like, if US health trends approximated those in Western Europe. The model implies that differences in health can explain most of the growing gap in remaining life expectancy. In addition, we quantify the public finance consequences of this deterioration in health. The model predicts that gradually moving American cohorts to the health status enjoyed by Western Europeans could save up to $1.1 trillion in discounted total health expenditures from 2004 to 2050.

An Analysis of the Labor Markets for Anesthesiology.

The roughly 40,000 anesthesiologists (ANs) and anesthesiology residents and 39,000 licensed certified registered nurse anesthetists (CRNAs) and student CRNAs in the United States provide most anesthesiology services. Shortages in this critical area of health care can lead to problems in the provision of health services. The authors' surveys of ANs, CRNAs, and anesthesiology directors included questions about employer types, work hours, earnings, types of anesthesia provision, and technology adoption and preferences. They found a great deal of heterogeneity in work arrangements, clear urban/rural differences in the labor markets for anesthesiology, and even more-pronounced regional differences. In addition to the survey, demand-based and econometric analyses were conducted. The authors conclude that shortage of ANs and CRNAs is highly likely at the national level, with the survey approach providing hints of such a shortage and the economic analysis providing stronger confirmation. Finally, the authors examine the evolution of AN and CRNA labor markets up to 2020 under various scenarios.