Dissertation Title： "The Health Impacts of Public Programs for the Poor in Brazil and the United States"This dissertation examines the health impacts of large public programs for the poor in Brazil and the United States.
Paper 1 evaluates the impact of Brazil’s conditional cash transfer program, Bolsa Família, on infant mortality. Bolsa Família was created in 2003 and implemented nationwide in 2004. I use vital statistics data to calculate municipality-level infant mortality rates from 1998-2008 and take advantage of variation in levels of program coverage over time between and within municipalities to identify the impact of Bolsa Família on infant mortality rates. Bolsa Família is found to have significantly reduced infant mortality rates, with a greater impact during the post-neonatal period. There is a differential impact of Bolsa Família by baseline infant mortality rates. In particular, the magnitude of the program’s impact on infant mortality rates and post-neonatal mortality rates is greater in municipalities with higher baseline infant mortality rates, suggesting that Bolsa Família may have a greater impact on municipalities with poor health conditions and may help reduce long-standing health inequalities. Furthermore, there are significant interaction effects with a large, national health program.
Paper 2 utilizes primary data collected in 2010 to examine the impact of Bolsa Família on children's health care utilization and health outcomes. Detailed household surveys were conducted with randomly selected Bolsa Família beneficiaries and non-beneficiaries in an urban slum in the northeast of Brazil. A total of 567 families (with 1,266 children) were interviewed. Propensity-score methods were used to control for differences between beneficiary and non-beneficiary children to estimate program impacts on health care utilization and health outcomes. Bolsa Família was found to increase the odds of children’s visits to the health post for growth monitoring, vaccinations, and checkups and the number of visits for growth monitoring and checkups. There were positive spillover effects on older siblings (ages 7-17) no longer required to meet the health conditionalities. The program increased their odds for growth monitoring and checkups and improved psychosocial health. Bolsa Família has had a positive impact on health care utilization, especially for services related to the health conditionalites, and on psychosocial health. It did not appear to impact illnesses or physical health. To have a greater impact on health, the program should examine the quality of health care services being offered, consider broadening the scope of services linked to the health conditionalities, and coordinate with other social programs.
Paper 3 examines the impact of Medicaid coverage of tobacco dependence treatments on quit attempts and smoking among low-income Americans. Smoking is the leading preventable cause of morbidity and mortality in the United States, and it accounts for significant productivity losses and Medicaid expenditures. Medicaid recipients have a higher rate of smoking, and their ability to successfully quit may be limited due to the cost of tobacco dependence treatments. Since the mid-1990s, Medicaid programs have offered varying levels of coverage of tobacco dependence treatments. This study utilizes BRFSS data from 1998-2009 to estimate the impact of coverage of tobacco dependence treatments on quit attempts and smoking. Medicaid coverage of tobacco dependence treatments is found to significantly increase the probability of quit attempts among low-income women, and this effect is greatest among pregnant women. Coverage of tobacco dependence treatments also has a significant impact on the probability of being a current smoker among low-income women.