Type

Dissertation Economics

Author

Hofmann, Sarah Maria

Examiner

Prof. Dr. Martin Karlsson

Download

https://10.17185/duepublico/84253

Abstract

An individual’s health over their lifetime is shaped by various factors, including access to healthcare, the quality of healthcare provided, as well as social and socioeconomic factors such as the physical and social environment, income, and education. The degree to which people adopt healthy lifestyles and take preventive measures can be considered another important determinant of health. This dissertation is composed of 4 empirical papers which each seek to explore the causal effects of a policy interventions or external shock in Germany on individuals’ health outcomes or relevant determinants of health.

The first paper examines the impact of local disease outbreaks on preventive health behavior, specifically vaccination rates. Using health insurance claims data, the study examines how regional measles outbreaks in Germany affect vaccination behaviors for children and adults. By exploiting temporal and geographic variation in outbreak. patterns, the paper identifies a causal relationship between local outbreaks and an increase in timely vaccinations among children, as well as catch-up vaccinations in adults. Notably, the effect is localized to the regions experi- encing outbreaks, and the behavioral changes are short-lived, suggesting that perceived disease risk – rather than a rational, long-term reassessment of the benefits of vaccination – drives the observed increase in preventive behavior.

The second and third papers focus on a recent education reform in Germany, known as

the G8 reform, which reduced the number of years in the upper secondary school track while maintaining the same curriculum. This reform, which intensified learning by compressing the number of instructional years, provides a unique opportunity to assess its unintended consequences on students’ mental and physical health. The second paper uses survey data. From the German Socio-Economic Panel Study (SOEP) to examine self-reported mental and physical health outcomes. The results reveal that the reform significantly decreased students’ mental health, particularly affecting vitality and emotional balance. However, it did not show a measurable impact on physical health.

The third paper extends this analysis by using healthcare claims data to investigate the incidence of diagnosed mental and physical health conditions among students. Contrary to the survey data findings, the analysis suggests that there is no significant increase in diagnosed mental disorders or stress-related physical conditions as a result of the reform. This apparent contradiction highlights the complexity of measuring health effects across different data sources and underscores the importance of using multiple methodologies to triangulate findings in policy evaluation research.

Finally, the fourth paper shifts focus to the healthcare system and explores the role primary care physicians as gatekeepers in the German healthcare system. In Germany, gatekeeping programs allow patients to access specialist services only upon referral from their primary care provider. Theoretically, such programs aim to improve coordination of care and control healthcare costs. Using healthcare claims data and a quasi-experimental approach, the paper examines whether participation in a physician-centered gatekeeping program leads to better health outcomes, higher quality of care, and changes in healthcare costs. Employing multiple identification strategies – including an instrumental variable approach and physician fixed effects. The

study finds that gatekeeping modestly improves care coordination and preventive care, while also leading to increased ambulatory costs. These findings contribute to the ongoing debate about the efficiency of gatekeeping programs in healthcare systems.