Association of Cost Sharing With Mental Health Care Use, Involuntary Commitment, and Acute Care (with E. Schachar, A. Beekman, R. Janssen, and P. Jeurissen in: Jama Psychiatry 74.9 (2017): 932-939).
This difference-in-differences study compared changes in mental health care use by adults, who experienced an increase in cost sharing, with changes in youths, who did not experience the increase and thus formed a control group. The study examined all 2 780 558 treatment records opened from January 1, 2010, through December 31, 2012, by 110 organizations that provide specialist mental health care in the Netherlands. The number of regular mental health care records opened for adults decreased abruptly and persistently by 13.4% (95% CI, −16.0% to −10.8%; P < .001) per day when cost sharing was increased in 2012. The decrease was substantial and significant for severe and mild disorders and larger in low-income than in high-income neighborhoods. Simultaneously, in 2012, daily record openings increased for involuntary commitment by 96.8% (95% CI, 87.7%-105.9%; P < .001) and for acute mental health care by 25.1% (95% CI, 20.8%-29.4%; P < .001). In contrast to our findings for adults, the use of regular care among youths increased slightly and the use of involuntary commitment and acute care decreased slightly after the reform. Overall, the cost-sharing reform was associated with estimated savings of €13.4 million (US$15.1 million). However, for adults with psychotic disorder or bipolar disorder, the additional costs of involuntary commitment and acute mental health care exceeded savings by €25.5 million (US$28.8 million).
Press coverage (English): Reuters.
Press coverage (Dutch): Algemeen Dagblad, NOSMedisch Contact.

The Wear and Tear on Health: What Is the Role of Occupation?.pdf (with E. Van Doorslaer and H. Van Kippersluis. Forthcoming in Health Economics).
Abstract: Health is well known to show a clear gradient by occupation. While it may appear evident that occupation affects health, there are multiple sources of selection that preclude the strong association to be interpreted as exclusively deriving from a causal effect of occupation on health. Despite abundant literature documenting the association, quantification of the relative importance of selection into occupation and the effect of occupation on health is scarce. We link job characteristics to German panel data spanning 29 years to characterize occupations by their physical and psychosocial burden. Employing a dynamic model to control for factors that simultaneously affect health and selection into occupation, we find that selection into occupation accounts for at least 60 percent of the association between health and both physical strain and job control, while selection accounts for nearly 100 percent of the association between psychosocial workload and health. The residual effect of occupational characteristics such as physical strain and low job control is negative and increases with age. The effects of late-career exposure of one year to high physical strain and low job control are equivalent to the health deterioration from ageing 16 and 6 months, respectively.
Press coverage (in Dutch): de VolkskrantTrouwDe StandaardRadio 1 Nog Steeds WakkerTelegraaf. 

The Contribution of Occupation to Health Inequality (with E. Van Doorslaer and H. Van Kippersluis in: Research on economic inequality 21 (2013): 311-332).
Abstract: Health is distributed unequally by occupation. Workers on a lower rung of the occupational ladder report worse health, have a higher probability of disability and die earlier than workers higher up the occupational hierarchy. Using a theoretical framework that unveils some of the potential mechanisms underlying these disparities, three core insights emerge: (i) there is selection into occupation on the basis of initial wealth, education, and health, (ii) there will be behavioral responses to adverse working conditions, which can have compensating or reinforcing effects on health, and (iii) workplace conditions increase health inequalities if workers with initially low socioeconomic status choose harmful occupations and don’t offset detrimental health effects. We provide empirical illustrations of these insights using data for the Netherlands and assess the evidence available in the economics literature.

Non-refereed publications:

Reply to Wierdsma and Mulder (with A. Beekman and R. Janssen, in JAMA Psychiatry. Published online December 13, 2017).

Psychische klachten en de arbeidsmarkt (with M. Einerhand, in Economische en Statistische Berichten 102.4754 (2017).
Press coverage (in Dutch): Trouwde Volkskrant, Ministerie van SZW.

Eigen bijdragen: non nocere (with A. Beekman, 
E. Schachar, R. Janssen, and P. Jeurissen, in de psychiater 23.6 (2017)).

Op weg naar een duurzame ggz; een beleidsperspectief (with P. Jeurissen, R. Janssen, and M. Tanke, in Tijdschrift voor Psychiatrie 58.10 (2016): 683-687).

k in progress:

Strategisch gedrag en werkzekerheid in de uitzendsector: wat is de rol van het fasensysteem? (with M. den Hartog).


We concluderen dat bovenmatig veel arbeidsrelaties worden beëindigd als de maximumtermijn van het uitzendbeding is bereikt. Zo kunnen werkgevers voorkomen dat een werknemer meer werkzekerheid krijgt. De bovenmatige uitstroom, kort voordat het einde van het uitzendbeding is bereikt, betreft naar schatting 5.5% van de uitzendwerknemers die in een jaar zijn ingestroomd in uitzendwerk en die in totaal meer dan 52 weken uitzendwerk doen bij de instroomwerkgever. Dit komt voor bij beide uitzendsectoren (ABU en NBBU). Door langer dan 26 weken uit dienst te gaan begint de teller van het uitzendbeding bij dezelfde werkgever opnieuw te lopen. Zo kan de maximumtermijn van het uitzendbeding wetmatig overschreden worden. We onderzochten bij hoeveel uitzendkrachten de totale maximumtermijn van het uitzendbeding werd overschreden door de periodes van werk met uitzendbeding bij dezelfde werkgever voor en na een dergelijke pauze van tussen de 26 en 52 weken bij elkaar op te tellen. Een dergelijke “strategische herstart” vond plaats bij 4,510 van de 50,448 ABU-uitzendkrachten (8.9 procent) die in een jaar instroomden en langer dan 52 weken uitzendwerk deden. Daarnaast vond er bij 1,395 van deze 50,448 ABU-uitzendkrachten een strategische herstart plaats vanuit fase B, waardoor kon worden voorkomen dat een werknemer in fase C terecht kwam en feitelijk een arbeidsovereenkomst voor onbepaalde tijd zou krijgen. We onderzochten hoe vaak er sprake is van “structurele uitzendkrachten”: 62,339 uitzendkrachten (16.4 procent van alle 2011 instromers) verkeerden tussen 2011 en 2019 meer dan 3,5 jaar in fase A of B, met beperkte werkzekerheid dus. 23,165 (6.1 procent) van hen werkte meer dan 5,5 jaar in fase A of B.

This paper investigates whether less generous insurance coverage for mental health care impacts economic productivity through reduced mental health treatment. We evaluate a health insurance reform in the Netherlands and use exogenous variation in the out-of-pocket price of treatment continuation, which depended on the exact date on which a patient began a prior treatment record before the reform was announced. We construct a dataset that links at the individual level administrative data on the mental health care claims records of all residents of the Netherlands to administrative data on employment. Our results indicate that the reduction in moral hazard under less generous insurance came at the expense of reductions in employment for certain subpopulations. Therefore, a well-targeted Pigouvian subsidy in the form of a lower out-of-pocket price for mental health care can be welfare-improving. 
Late Tracking, Intergenerational Mobility, and Human Capital: The Impact of the Finnish Comprehensive School Reform  (with H. Van Kippersluis, M. Avendano, P. Martikainen, H. Vessari, and E. Van Doorslaer).
Abstract: This paper investigates whether delaying the age at which children are tracked into differing-ability classrooms can reduce socioeconomic disparities in mortality. We estimate the effect of the extension of the tracking age from 11 to 16 in Finland in the 1970s. Since the reform may have coincided with other factors influencing mortality, we use the fact that some regions were reformed later than others in a difference-in-differences setup which allows us to account for region and cohort effects. Rich administrative data allows us to observe the health outcomes of children who were born in the early 1960s for over fifty years, and to link them to the income of their parents while growing up. We find that late tracking reduces the disparities in mortality by parental income for men. However, the longevity gains of men from low-income families seem to have come at the cost of  increased mortality rates among men who grew up in high-income families.

When a Bad Control Variable Turns Good: Is the Effect of Parental Socioeconomic Status on Health Transmitted by Education?
Abstract: It is common practice in the economics literature as well as in other disciplines to include an intervening (bad) control variable—which itself is an outcome of the treatment variable—in an OLS regression model. I show that the estimators of direct and indirect treatment effects are asymptotically biased if the intervening control variable is correlated with the error term. The problem of endogenous intervening controls can be solved in the special case where (i) we have a valid instrumental variable for the bad control variable, and (ii) the local average treatment effect for compliers with the instrument is equal to the average treatment effect. Using these insights to revisit the relationship between parental socioeconomic status, schooling, and health in the UK, the bad controls method suggests that 23 percent of the total effect of parental socioeconomic status is transmitted by schooling. However, after eliminating the bad controls bias by instrumenting educational attainment by the 1947 and 1972 UK compulsory schooling reforms, the estimate of the indirect effect is close to zero and not significant. I conclude that caution is warranted when interpreting a regression coefficient if other covariates are themselves outcomes of that particular variable. Not only do intervening control variables block causal pathways—which is sometimes what we want—, but their inclusion also introduces asymptotic bias which produces results which lack a meaningful interpretation.

First-episode Psychosis, Health Care Use and Social Functioning (with A. Busch, N. Joyce, T. McGuire, and J. Shi).

Supply Effects of Cost Sharing for Mental Health Care (with E. Schachar).

Employer Incentives in Disability Insurance (with N. Maestas and D. Prinz).

Child Outcomes and Neighborhood Effects: Evidence from Random Housing Assignment in Amsterdam (with W. van Dijk).

Determinants of Child Wellbeing: Evidence from the Dutch Youth Health Care Registry (with C. van de Kraats).