6th Biennial Conference of the American Society of Health Economists (ASHEcon) – 2016
Selected papers

Effectiveness of Vaccination Recommendations versus Mandates: Evidence from the hepatitis A vaccine
Tuesday, June 14, 2016
Author(s): Emily Lawler
Discussant: Dr. Kerry Anne McGeary
Abstract
In the United States, immunization rates are persistently low for numerous vaccines, and recently there have been multiple outbreaks of vaccine-preventable diseases resulting from undervaccination. In response, a number of policies have been implemented in an attempt to achieve and maintain high population vaccination rates and reduce disease incidence. In this paper I provide novel evidence on the effectiveness of two vaccination policies – simple non-binding recommendations to vaccinate versus mandates requiring vaccination prior to childcare or kindergarten attendance– in the context of the only disease whose institutional features permit a credible examination of both: hepatitis A. Using a difference-in-differences strategy that allows me to take advantage of plausibly exogenous variation across states in the timing of the policy introductions, I find that recommendations significantly increased hepatitis A vaccination rates among young children by at least 20 percentage points, while mandates increased rates by another 8 percentage points. Together these policies explain approximately half of the change in vaccination rates over the sample period. These policies also significantly reduced population hepatitis A incidence, and similarly explain approximately half the change in disease incidence over the period of interest. These results are robust to the inclusion of both a number of controls for state vaccine- and healthcare-related policies, and state-specific linear time trends. I also demonstrate that these results are not present for other vaccines and diseases, which is strong evidence that my findings are not being driven by unobserved state policies that generally increased vaccination or decreased disease incidence.

This paper further provides evidence that the effects of the recommendations and the mandates differ along several important dimensions. First, my results indicate that the mandates are effective at inducing individuals to complete the vaccine series, while the recommendations only significantly increase the probability that individuals initiate the series. Second, when I allow policy effects to vary over time, I find that individuals who are induced to vaccinate by the mandate respond rapidly to the policy, whereas the recommendations have a more gradual effect that continues to increase for several years following implementation. Finally, for the mandates I find no significant heterogeneity in the effects of by ethnicity, mother’s education, or family income, although there is some evidence of a heterogeneous policy response for the recommendations. Overall, my results are informative about responses to vaccination recommendations versus mandates for young children, and suggest a range of policy options for addressing suboptimally low population vaccination rates.

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Group Incentives and the Take–Up of the Flu Vaccine
Monday, June 13, 2016
Author(s): Lenisa V Chang
Discussant: Lisa Schulkind
Abstract
The take-up of the flu vaccine has important benefits, especially among health care workers (HCW) who are in close contact with populations most vulnerable to the flu such as infants, the elderly, and those with chronic conditions and compromised health. Many health care organizations, especially hospitals, have mandated flu vaccination for their workers for years, and others have done so more recently as the flu vaccination rate is used as a publically reported quality measure of care. However, while the take-up of the flu shot by HCW has increased nationwide, it is less than the recommended 90% vaccination rate. Previous experimental work with students has found that financial incentives have increased the take-up of the flu shot (Bronchetti, Huffman, Magenheim, 2015). We study an incentive scheme aimed at residents in a Midwestern medical school that would pay $100 (as a gift card) to each individual resident if they collectively reached a 95% flu vaccination rate by the end of the early flu season on November 1st. While the vaccination target was met and the incentive distributed, we study whether the time to vaccination was shortened from the previous year, if there was a bunching at the deadline, and whether there were any differences compared to nurses, a similar group of workers who was not eligible for the gift card, but also benefitted from the availability of free flu shots and on site walk-in clinics at the hospital.

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The Effect of School-Immunization Exemption Policies on Enrollment Rates for Prekindergarten and Kindergarten
Tuesday, June 14, 2016:
Author(s): Emily Zier; W. David Bradford
Discussant: Lisa Schulkind
Abstract
There is no national immunization policy in the United States, and the strictness of regulations allowing vaccine exemption for school attendance varies greatly by state. Furthermore, despite substantial evidence on the safety and health benefits of immunization, there has been a recent upsurge in skepticism amongst parents regarding vaccine safety and efficacy for their children. In this paper, we analyze whether or not the strength of state vaccine exemption policies affect the enrollment rates for prekindergarten and kindergarten. Given the significant positive effects that pre-k and kindergarten have for a child’s future educational attainment, understanding negative unintended consequences from vaccination policy will be of interest to policy makers who seek to optimize public health and educational policy. We hypothesize that states with stricter exemption policies will have lower average enrollment in prekindergarten and kindergarten amongst children in the relevant age ranges. To test these hypotheses, we construct a long panel of data on state level enrollment rates, state characteristics and utilize a recently validated measure of state vaccination policy effectiveness.