Uterus at a Price:
Disability Insurance and Hysterectomy
Elliott Fan
Hsienming Lien
Ching-To Albert Ma
October 2013
National Taiwan University, National ChengChi University, and Boston University
2
Motivations
• Health insurance implies moral hazard, excessive
treatment
• What about treatment that means removal of an organ?
• Disability insurance in Taiwan---incentives for organ
removal
• Cash payment to women who lose the ability to conceive
before age 45
3
Disability insurance
• Three social programs:
1. Government Employees Insurance, GEI
workers in public sector, school teachers
2. Labor Insurance, LI
workers in the private sector
3. Farmers’ Insurance, FI
farmers
• Women under age 45, undergoing a hysterectomy (surgical
removal of uterus，子宮切除術) or an oophorectomy
(surgical removal of both ovaries ，卵巢切除術)
• Disability benefit = 6 months of insured salary for GEI, 5.5
months for LI and FI
4
Several facts
• Each year about 25000 women have hysterectomy in
Taiwan.
• NHI records show that one out of five women have
hysterectomy in her life in Taiwan.
• Each year about 6000 labor enrollees have hysterectomy,
with NT130-140k per case. In total, LI paid NT 1 billion for
disability benefits each year.
• There is no clear associations between the number of
hysterectomy and the economic conditions
5
立委要求放寬勞保給付標準 (2013/11/20)
• 立法院衛環委員會今天審查勞委會預算，立委尤美女提案指
出，勞保失能給付標準中「生殖器遺存顯著障害」認定，女
性切除子宮與卵巢「未滿45歲，原有生殖能力因傷病割除.....
致不能生育者」，但對男性生殖障害並無年齡限制，勞團多
年前即認為性別歧視，且年過45歲仍生育者亦不少，建議勞
委會刪除年齡規定，否則將刪勞保預算。
• 但立委江慧貞認為，實務上的確有不少勞工因為生活過不去，
或者因為已經生了很多孩子，不打算再生，就將子宮切除領
給付，因此年齡限制反而是保護女性，避免有人真的為了給
付而切除子宮。但她也說，反而很多女性45歲以後仍生育，
45歲的門檻應延後，但不能不訂界線。
6
子宮切除勞保給付 擬放寬(2013/11/20)
• 勞保現行規定45歲以下切除子宮才能領失能給付，等於
認定年過45歲就沒有生育需要，但醫師立委蘇清泉認為，
婦女生育年齡普遍延後，且女性停經年齡約49歲以後，
因此主張延後至50歲。勞委會統計，目前失能給付每5
件失能給付就有1件是切除子宮；是否放寬規定降低門
檻，勞委會表示「可評估」，將與醫療等專業單位研議，
但不宜刪除年齡規定。
7
切除子宮 大都是醫生建議(2013/11/20)
• 女性勞工為領失能給付切除子宮？勞保局表示，切除子宮案件的
確佔失能給付1/5以上，比率不低，但是近年案件已逐年降低，而
且大都是醫生建議，原因是醫生認為無論是子宮或卵巢肌瘤復發
率很高，直接切除可以一勞永逸，「又可領給付」。
• 勞保局統計，自97年以來近五年失能件數約每年2.9-3.3萬件，其
中「喪失生育能力」案件從97年7萬多件降到101年的6萬多件，件
數逐年降低，但比率都約20%-22%，亦即約佔1/5 。
• 立委指證很多女性勞工為了領失能給付而切除子宮，勞保局總經
理羅五湖表示，實務上因為切除子宮而領給付者，大都是醫生建
議切除，不會因為想領給付而切除。但是他說，很多醫生會向勞
工說，子宮或卵巢肌瘤容易復發，大都會建議直接切除，加上
「又可領失能給付」，因此案件佔失能給付大宗。
10
Disability insurance
• Three social programs:
1. Government Employees Insurance, GEI
workers in public sector, school teachers
2. Labor Insurance, LI
workers in the private sector
3. Farmers’ Insurance, FI
farmers
• Women under age 45, undergoing a hysterectomy (surgical
removal of uterus，子宮切除術) or an oophorectomy
(surgical removal of both ovaries ，卵巢切除術)
• Disability benefit = 6 months of insured salary for GEI, 5.5
months for LI and FI
11
Uninsured group (control)
•
Women not covered by the above three social programs
•
Mostly unemployed women
12
Hazard by quarter
Total and partial hysterectomies
Labor
3
2
1
0
0
1
2
3
hazard (of 1,000)
4
4
Public
-20
-10
0
10
quarters from age 45
20
-20
-10
20
3
2
1
0
0
1
2
3
hazard (of 1,000)
4
Uninsured
4
Farmer
0
10
quarters from age 45
-20
-10
0
10
quarters from age 45
20
-20
-10
0
10
quarters from age 45
20
13
Hazard by quarter
Total and partial hysterectomies
1
2
3
4
Hysterectomy
-20
-10
0
quarters from age 45
Public
Farmer
10
Labor
Uninsured
20
14
Summary
• Treatment groups: occurrences and hazard of
hysterectomy increase as 45th birthday approaches, then
sharp drop
• Control group: no such pattern
• For partial oophorectomy or myomectomy (surgical
removal of uterine myomas) (both ineligible), no such
pattern
15
Hazard by quarter
Partial oophorectomies
.75
.5
0
.25
0
.25
.5
.75
hazard (of 1,000)
1
Labor
1
Public
-20
-10
0
10
quarters from age 45
20
-20
-10
20
.75
.5
0
.25
0
.25
.5
.75
hazard (of 1,000)
1
Uninsured
1
Farmer
0
10
quarters from age 45
-20
-10
0
10
quarters from age 45
20
-20
-10
0
10
quarters from age 45
20
16
Hazard by quarter
Myomectomies
1
.5
0
0
.5
1
hazard (of 1,000)
1.5
Labor
1.5
Public
-20
-10
0
10
quarters from age 45
20
-20
-10
20
1
.5
0
0
.5
1
hazard (of 1,000)
1.5
Uninsured
1.5
Farmer
0
10
quarters from age 45
-20
-10
0
10
quarters from age 45
20
-20
-10
0
10
quarters from age 45
20
17
Research questions
1. How many “induced” hysterectomies due to disability
insurances?
2. Any health impact?
18
Institutional background
• Taiwan social insurance programs
• Disability benefits
• Surgeries
19
Taiwan social insurance programs
• Mandatory major social insurance programs, through
employment
• Comprehensive benefits
• GEI: disability, life insurance, dependents' funeral
allowance, pension, parental leave
• LI: all GEI benefits, plus unemployment benefit
• FI: less generous than GEI, no pension or parental leave
公教保險
給付項目
育嬰留職停薪
眷屬喪葬
殘廢給付
養老給付
死亡給付
勞工保險
給付項目
21
Government employee insurance
• Eligibility
– Public workers
– Teachers (private and public schools)
• Number of enrollees: about 600,000
• Premium
– Insured salary, about 60-70% of full wage, but capped at
NTD52,000
– premium rate: 8.25% of insured salary
– contribution: 35% (employees) 65% (employers)
– employee premium: 8.25%*35%*insured salary
22
Labor insurance (I)
• Eligibility
– Employees in private sector or private schools (15--65 years old
and in firms with more than 5 employees)
– Employees in small companies or self employed---through trade
unions
• Number of enrollees: about 8,000,000
• Premium
– Insured salary based on full wage, but capped at NTD42,000
– premium rate: 9% (1% for unemployment insurance)
– contribution: 20% (employees), 70% (employers), 10%
(government)
– employee premium: 9%*20%*insured salary
23
Labor Insurance (II)
• Labor Law: firms with 5 or more employees to purchase LI for
workers; workers in small businesses may be uninsured
• Trade unions allow these left-out workers (e.g. taxi drivers,
lawyers, fishermen) to participate in LI
• Lax requirements for joining labor insurance through trade
unions
24
Farmer insurance
• Eligibility
– Farmers (members of farmer’s associations)
• Number of enrollees
– about 1,500,000
• Premium
–
–
–
–
The insured salary is fixed at NTD10,200
premium rate: 6.8% (1% for unemployed insurance)
contribution: 30% (employees), 70% (government)
employee premium: 6.8%*30%*insured salary
25
Disability benefits (I)
• Eligibility of reproduction impairment
– Women younger than 45 years old
– Sterility due to (1) total or partial removal of uterus; (2)
removal of both ovaries; or (3) radiation therapy
• Accordingly, women who have one of the following
surgeries before age 45 are eligible:
(1) Hysterectomy (partial or total removal of uterus)
(2) Total oophorectomy (surgical removal of both ovaries)
26
Disability benefits (II)
• Disability benefit of reproduction impairment
– GEI: 6 months of insured salary
– FI and LI: 5.5 months of insured salary.
• GEI and LI more generous than FI
• FI’s insured salary at NT10,200; benefit fixed at NT51,000
• High-income LI enrollees have less benefits than GEI
enrollees; LI insured salary capped at NT42,000.
27
Surgeries (covered by National Health Insurance)
• Hysterectomy
– Partial: surgical removal of uterus except cervix
– Total: surgical removal of uterus and cervix
– Both qualify for disability benefit
• Oophorectomy
– Removal of both ovaries
– Qualify for disability benefit
– Number of total oophorectomies small, as illustrated by the
following graphs
Occurrences by quarter (restricted sample)
28
Total oophorectomies
Labor
30
20
10
0
0
2
4
6
occurrences
8
40
10
Public
-20
-10
0
10
quarters from age 45
20
-20
20
30
20
10
0
0
5
10
occurrences
15
40
Uninsured
20
Farmer
-10
0
10
quarters from age 45
-20
-10
0
10
quarters from age 45
20
-20
-10
0
10
quarters from age 45
20
29
Surgeries for comparison
• Two reproductive-system related treatments that don’t
qualify for disability benefits:
(1) Myomectomy (surgical removal of one or more uterine
myomas，切除子宮肌瘤手術)
(2) Partial oophorectomy (surgical removal of only one
ovary，部分切除卵巢手術)
A simple (two-period) model
• Let u be the utility of receiving treatment, assuming
u~F(u)
• Let p be the price for treatment. For simplicity, p is the
same in two periods.
• Now at the second period (t=2)
– Obtain treatment if 𝑢 − 𝑝, last period straight forward
decision
– Value for period t=2 is
u
 ( u  p ) f ( u )du  V (z )
• Let  be discount factor
• In period 1 : let the draw f utility be u
– If common receive treatment for payoff is u  p
– If not, then period 2 applies. In which case for payoff is
V (z )
• For at t=1, receive treatment if
or u  p  V (z )  p
u  p  V (z )
Reservation period :
Incidence rate :
Now suppose that in period 1, then a bonus if treatment is
received then :
or
u     V ( z ) , B  0 is bonus
u    B  V (z )
This means a drop is the reservation utility at t=1
Reservation period :
Incidence rate :
t=1
t=1
t=2
t=2
Multiple periods
reservation utility
t
reservation utility
t
Bonus B
Without bonus
Incidence of treatment
Incidence of treatment
t
Bonus B
Without bonus
38
Data
• National Health Insurance (NHI): complete medical
records of all Taiwanese from 1997 to 2011 (15 years)
• Registry of beneficiaries (ID files): date of birth,
gender, insurance type at the start of each year
• Inpatient admissions (DD files): admission and
discharge dates, diagnoses, expenses of each
admission (copayment, drugs, bed, examinations
(itemized), surgeries (itemized), etc.)
• Physician and hospital identifiers for every surgery
• Limited information about demographic characteristics
39
Sampling issues (I)
Broad sample for this study:
• Women aged between 40 and 49 in the sample period,
covering 5 years before and after 45
• That is, women born between 1947 and 1970
• Enrolled in NHI every year during the sample period
(very few not enrolled)
40
Sampling issues (I)
years in sample
data record experience in
incentive change
left-censored
1
no
.
.
.
.
45
59
left-censored
5
no
1953
44
58
left-censored
6
yes
.
.
.
.
.
.
1956
41
55
left-censored
9
yes
1957
40
54
Balanced
10
yes
1958
39
53
Balanced
10
yes
1959
38
52
Balanced
10
yes
1960
37
51
Balanced
10
yes
1961
36
50
Balanced
10
yes
1962
35
49
Balanced
10
yes
1963
34
48
right-censored
9
yes
.
.
.
.
.
.
1966
31
45
right-censored
6
yes
1967
30
44
right-censored
5
no
.
.
.
.
.
.
1971
26
40
right-censored
1
no
Cohorts
Age at 1997
Age at 2011
1948
49
63
.
.
1952
41
Sampling issues (II)
Restricted sample for this study:
• Furthermore, drop women who have ever changed social
insurance programs between ages 40 and 49
• Eliminate selection bias between insurance programs
• Restricted sample about 69% of broad sample
• Results based on the restricted sample; results of broad
sample in robustness checks
42
Broad vs restricted samples, four surgeries
(by insurance type)
Broad sample
Restricted sample
(1) Freq.
%
(2) Freq.
%
(2)/(1)
Government
14,379
5.49
12,191
6.77
0.85
Labor
103,184
39.37
70,185
38.96
0.68
Farmer
16,192
6.18
13,119
7.28
0.81
Labor union
70,302
26.82
50,583
28.08
0.72
Uninsured
58,024
22.14
34,067
18.91
0.59
total
262,081
100.00
180,145
100.00
0.69
43
Broad vs restricted samples
(by surgery)
Broad sample
Restricted sample
(1) Freq.
%
(2) Freq.
%
(2)/(1)
Hysterectomies
184,679
70.47
126,455
70.20
0.68
Myomectomies
45,336
17.30
31,518
17.50
0.70
Total oophorectomies
4,987
1.90
3,373
1.87
0.68
Partial oophorectomies
27,079
10.33
18,799
10.44
0.69
total
262,081
100.00
180,145
100.00
0.69
44
Sampling issues (III)
• Left , right censoring unimportant if unrelated to
hysterectomy incidence
• Each censoring type depends only on age, so censoring
unlikely to be important
• Main results based on the unbalanced sample
• Balanced sample results in the robustness check
45
Sample statistics
• Show mainly the characteristics of surgery providers
• Separate into two subsamples
– Age 40-44
– Age 45-49
46
Summary statistics for women having hysterectomy (restricted sample)
Ages 40 to 44
Ages 45 to 49
Public
Labor
Farmer
Uninsured
Public
Labor
Farmer
Uninsured
Age
43.04
42.86
42.83
42.68
47.46
47.40
47.44
47.40
Bed days
5.31
5.34
5.40
5.61
5.49
5.64
5.51
5.86
49174.20
48482.47
49319.09
49380.32
50443.23
50333.23
49877.82
50301.32
Hospital beds<300
0.20
0.24
0.29
0.27
0.19
0.22
0.28
0.25
Hospital beds>=300, <500
0.13
0.17
0.20
0.19
0.14
0.16
0.19
0.17
Hospital beds>=1000
0.67
0.59
0.51
0.55
0.67
0.62
0.52
0.57
Public hospital
0.40
0.24
0.17
0.26
0.42
0.26
0.17
0.28
Private non-profit hospital
0.47
0.55
0.57
0.52
0.46
0.55
0.58
0.51
Private for-profit hospital
0.13
0.21
0.26
0.23
0.13
0.18
0.25
0.21
Major teaching hospital
0.60
0.51
0.40
0.47
0.61
0.55
0.40
0.50
Minor teaching hospital
0.29
0.35
0.42
0.37
0.30
0.33
0.43
0.35
Community hospital
0.10
0.13
0.17
0.15
0.09
0.12
0.17
0.14
Clinic
0.00
0.01
0.01
0.01
0.00
0.00
0.01
0.01
Medical expense
47
Difference-in-Difference
• Estimate D-in-D model at the cohort level
• Cohort defined by an individual’s birth year and birth
quarter
• In each estimation, treatment group (those women
insured by a social program); control group (the
uninsured)
• Each woman has a clock zeroed at 45th birthday
• Time variable q, standardized quarter, number of
quarters to 45th birthday
• q=-19,-18,…,-1,0,1,…,20
48
D-in-D model
• The specification is
hazardc,q   
20
d
q 19
q
q
   treatment 
20

q 19
q
(d q  treatment )  c ,q   c ,q
• ℎ𝑎𝑧𝑎𝑟𝑑𝑐,𝑞 : the ratio of women who underwent
hysterectomy in quarter q to those who had no such
prior experience
• 𝑑𝑞 : dummy indicating standardized quarter q
• 𝑡𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡 : treatment dummy
• X: hospital types, inpatient costs, and birth-quarter
cohort fixed effects
49
Preliminary examinations
• Omitted quarter is q= -20
• 𝛽𝑞 : Mean difference in hysterectomy hazard between
quarter q and the omitted quarter
• 𝛾𝑞 : Captures extra difference between the same two
quarters given the mean difference between control and
treatment groups
• If disability insurance does not alter the hysterectomy
hazard, effect should be all zero
• Robust errors, clustering by groups formed by (birth
quarter cohort) x (insurance type)
• Compare the results with and without controls
50
D-in-D results for hysterectomy
(restricted sample)
Quarters from
age 45
-11
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
2
Restricted sample
Public
0.286*
(0.154)
0.482***
(0.159)
0.630***
(0.186)
0.332**
(0.163)
0.632***
(0.165)
0.605***
(0.156)
0.835***
(0.194)
0.729***
(0.202)
1.016***
(0.194)
1.072***
(0.201)
2.252***
(0.214)
-0.182
(0.146)
-0.0579
(0.174)
0.0451
(0.179)
Labor
0.165
(0.116)
0.292**
(0.120)
0.454***
(0.124)
0.264**
(0.125)
0.246**
(0.109)
0.629***
(0.121)
0.845***
(0.119)
0.486***
(0.127)
0.844***
(0.131)
1.018***
(0.137)
2.157***
(0.160)
-0.559***
(0.115)
-0.265**
(0.133)
-0.136
(0.136)
Broad sample
Farmer
0.0649
(0.203)
0.00845
(0.196)
0.169
(0.194)
-0.269
(0.189)
0.0892
(0.198)
0.300
(0.222)
0.257
(0.198)
0.115
(0.206)
0.108
(0.193)
0.201
(0.201)
0.476*
(0.248)
-0.395**
(0.168)
-0.403**
(0.190)
-0.124
(0.215)
Public
0.329**
(0.155)
0.483***
(0.165)
0.639***
(0.169)
0.411**
(0.161)
0.671***
(0.167)
0.429***
(0.154)
0.683***
(0.190)
0.849***
(0.190)
1.016***
(0.180)
1.174***
(0.191)
2.191***
(0.216)
0.00500
(0.133)
0.133
(0.162)
0.227
(0.160)
Labor
0.158
(0.109)
0.257**
(0.119)
0.374***
(0.116)
0.236*
(0.126)
0.282**
(0.114)
0.498***
(0.123)
0.751***
(0.122)
0.522***
(0.112)
0.786***
(0.123)
0.879***
(0.123)
2.051***
(0.163)
-0.442***
(0.105)
-0.173
(0.110)
-0.0778
(0.122)
Farmer
-0.00993
(0.186)
-0.0134
(0.189)
0.170
(0.172)
-0.266
(0.181)
0.0782
(0.170)
0.0924
(0.185)
0.217
(0.180)
0.136
(0.181)
0.100
(0.167)
0.250
(0.177)
0.230
(0.221)
-0.334**
(0.137)
-0.225
(0.157)
-0.0289
(0.195)
51
D-in-D results for hysterectomy
-.5
0
.5
1
1.5
2
(restricted sample)
-20
-10
0
quarters from age 45
Public
Farmer
10
Labor
20
52
Summary
1. Spike in the hazard of hysterectomy before age 45
evident for GEI and LI groups, but less so for FI
2. Significant, positive effects before 45th birthday, and
significant, negative after; consistent with prediction
3. Restricted and broad samples similar results
4. Covariates (hospital types, inpatient cost, and birth
cohorts) only change estimates slightly
53
Robustness check
• Broad sample versus restricted sample
Comparing the D-in-D results for broad and restricted
samples (Government)
-.5
0
.5
1
1.5
2
Public
-20
-10
0
quarters from age 45
Broad sample
10
Restricted sample
20
54
Comparing the D-in-D results for broad and restricted
samples (Labor)
-.5
0
.5
1
1.5
2
Labor
-20
-10
0
quarters from age 45
Broad sample
10
Restricted sample
20
55
Comparing the D-in-D results for broad and restricted
samples (Farmer)
-.5
0
.5
1
1.5
2
Farmer
-20
-10
0
quarters from age 45
Broad sample
10
Restricted sample
20
56
57
Robustness check
• Partial oophorectomies and myomectomies: neither
qualifies for disability benefit
58
D-in-D results for partial oophorectomy
(restricted sample)
Quarters from
age 45
-11
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
2
Restricted sample
Public
-0.0884
(0.0984)
0.0241
(0.110)
0.0543
(0.118)
0.0430
(0.117)
0.0721
(0.121)
0.0946
(0.119)
-0.0500
(0.115)
0.0495
(0.100)
0.0989
(0.107)
-0.0333
(0.0994)
0.0711
(0.108)
0.0290
(0.129)
0.0120
(0.109)
0.0230
(0.109)
Labor
-0.0756
(0.0535)
-0.00387
(0.0517)
-0.0498
(0.0576)
-0.00492
(0.0543)
-0.0968*
(0.0563)
-0.0226
(0.0604)
-0.0420
(0.0588)
-0.0349
(0.0532)
-0.0188
(0.0511)
-0.0678
(0.0549)
-0.0784
(0.0546)
-0.0777
(0.0592)
-0.0855
(0.0578)
-0.0841
(0.0608)
Broad sample
Farmer
-0.00926
(0.0873)
-0.0709
(0.0912)
-0.0551
(0.0915)
0.00554
(0.0802)
-0.000385
(0.0907)
0.106
(0.0990)
0.0728
(0.0990)
0.0424
(0.0975)
-0.0547
(0.0809)
0.0293
(0.0979)
-0.0394
(0.0908)
-0.0285
(0.0888)
-0.0889
(0.0882)
-0.0455
(0.0916)
Public
-0.00495
(0.0842)
0.0700
(0.0931)
0.0450
(0.0905)
0.0457
(0.102)
0.129
(0.102)
0.148
(0.101)
-0.0405
(0.0934)
0.0691
(0.0860)
0.169*
(0.0892)
0.0358
(0.0879)
0.130
(0.0974)
0.0586
(0.108)
0.0687
(0.0981)
0.119
(0.101)
Labor
-0.0334
(0.0445)
0.0103
(0.0456)
-0.00327
(0.0430)
-0.0220
(0.0471)
-0.0431
(0.0457)
0.0402
(0.0499)
-0.0233
(0.0515)
-0.0126
(0.0447)
0.0298
(0.0434)
-0.00283
(0.0470)
-0.00333
(0.0484)
-0.0298
(0.0500)
-0.0685
(0.0484)
-0.0397
(0.0479)
Farmer
-0.0610
(0.0821)
-0.102
(0.0966)
-0.0257
(0.0915)
-0.114
(0.0904)
-0.0683
(0.0908)
0.0790
(0.0950)
-0.0380
(0.0993)
-0.0633
(0.0897)
-0.0695
(0.0887)
0.0192
(0.0873)
0.0267
(0.0895)
-0.00710
(0.106)
-0.120
(0.0904)
-0.0541
(0.0943)
59
D-in-D results for partial oophorectomy
-.5
-.25
0
.25
.5
.75
1
(restricted sample)
-20
-10
0
quarters from age 45
Public
Farmer
10
Labor
20
60
D-in-D results for myomectomy
(restricted sample)
Quarters from
age 45
-11
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
2
Restricted sample
Public
-0.0553
(0.150)
-0.0793
(0.134)
-0.180
(0.124)
-0.190
(0.117)
0.0394
(0.134)
-0.196
(0.121)
-0.0859
(0.125)
-0.0745
(0.130)
-0.0453
(0.131)
-0.0820
(0.136)
0.000769
(0.127)
-0.133
(0.122)
-0.229*
(0.128)
0.00863
(0.124)
Labor
0.00957
(0.0756)
-0.0414
(0.0701)
-0.0177
(0.0671)
-0.0216
(0.0635)
-0.0394
(0.0637)
-0.00788
(0.0658)
-0.0295
(0.0670)
-0.0552
(0.0647)
-0.0810
(0.0664)
-0.0880
(0.0667)
-0.00517
(0.0674)
-0.0437
(0.0638)
-0.0500
(0.0610)
0.0355
(0.0623)
Broad sample
Farmer
-0.0582
(0.134)
-0.234**
(0.110)
-0.151
(0.114)
-0.00347
(0.136)
-0.123
(0.119)
-0.0859
(0.116)
-0.0900
(0.126)
-0.160
(0.123)
-0.0801
(0.124)
-0.182
(0.127)
-0.0212
(0.126)
-0.176
(0.115)
-0.195*
(0.112)
-0.118
(0.106)
Public
-0.0390
(0.133)
-0.0401
(0.121)
-0.0821
(0.117)
-0.0896
(0.109)
0.0369
(0.116)
-0.147
(0.113)
0.00612
(0.116)
-0.0103
(0.115)
-0.00301
(0.114)
-0.0207
(0.125)
0.0361
(0.117)
-0.0923
(0.105)
-0.110
(0.124)
0.0669
(0.114)
Labor
0.0461
(0.0635)
0.0469
(0.0644)
0.0821
(0.0560)
0.00516
(0.0575)
0.00552
(0.0583)
0.0235
(0.0603)
0.0503
(0.0572)
0.0340
(0.0522)
-0.00582
(0.0590)
-0.0115
(0.0593)
0.0206
(0.0600)
-0.0406
(0.0525)
0.00219
(0.0551)
0.0762
(0.0538)
Farmer
0.0111
(0.125)
-0.164
(0.106)
-0.0855
(0.102)
0.0245
(0.124)
-0.0954
(0.105)
-0.0874
(0.108)
-0.107
(0.112)
-0.0797
(0.110)
-0.0241
(0.106)
-0.137
(0.107)
-0.0698
(0.112)
-0.176*
(0.102)
-0.120
(0.105)
-0.0653
(0.105)
61
D-in-D results for myomectomy
-.5
-.25
0
.25
.5
.75
1
(restricted sample)
-20
-10
0
quarters from age 45
Public
Farmer
10
Labor
20
62
Robustness check
• Only balanced panel
63
D-in-D results for hysterectomies
(balanced panel)
Quarters from
age 45
-11
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
2
Restricted sample
Public
-0.177
(0.276)
0.440
(0.306)
0.725*
(0.401)
0.0441
(0.293)
0.621**
(0.307)
0.547*
(0.312)
0.578
(0.406)
0.501
(0.314)
0.942**
(0.374)
1.300***
(0.449)
2.416***
(0.370)
-0.459**
(0.197)
-0.436
(0.298)
0.0215
(0.349)
Labor
0.112
(0.207)
0.542**
(0.263)
0.671**
(0.262)
0.410
(0.245)
0.351*
(0.200)
0.759***
(0.240)
0.943***
(0.245)
0.511**
(0.235)
0.985***
(0.212)
0.979***
(0.287)
2.356***
(0.319)
-0.645***
(0.169)
-0.180
(0.244)
0.118
(0.248)
Broad sample
Farmer
-0.354
(0.332)
-0.0436
(0.339)
-0.0688
(0.302)
-0.196
(0.313)
0.356
(0.349)
-0.0363
(0.355)
0.166
(0.322)
0.412
(0.304)
0.0719
(0.273)
-0.168
(0.330)
0.342
(0.423)
-0.452*
(0.257)
-0.619*
(0.335)
-0.0651
(0.299)
Public
0.0173
(0.236)
0.405
(0.300)
0.689**
(0.340)
0.242
(0.298)
0.684**
(0.327)
0.252
(0.326)
0.276
(0.367)
0.847***
(0.256)
1.022***
(0.331)
1.389***
(0.363)
2.072***
(0.360)
-0.0969
(0.192)
-0.260
(0.283)
0.146
(0.287)
Labor
0.0974
(0.190)
0.326
(0.218)
0.472**
(0.219)
0.278
(0.242)
0.372
(0.233)
0.390*
(0.222)
0.697***
(0.234)
0.608***
(0.168)
0.775***
(0.198)
0.647***
(0.225)
2.042***
(0.294)
-0.551***
(0.160)
-0.221
(0.185)
-0.00641
(0.174)
Farmer
-0.280
(0.328)
0.0271
(0.287)
-0.00549
(0.267)
-0.0369
(0.330)
0.252
(0.313)
-0.349
(0.288)
0.0823
(0.304)
0.519**
(0.218)
0.0675
(0.227)
-0.142
(0.268)
-0.0123
(0.370)
-0.396**
(0.178)
-0.513**
(0.238)
-0.0736
(0.293)
64
D-in-D results for hysterectomies
-.5
0
.5
1
1.5
2
(balanced panel)
-20
-10
0
quarters from age 45
Public
Farmer
10
Labor
20
65
Examining the accumulated hazards
• For each insurance group, we graph the accumulated
hazards (AH) of having a hysterectomy across the
standardized quarter from q=-19 to q=20.
• Key hypothesis: If the provisions of disability insurance
induce more treatment (not just changing the time of
treatment), the accumulated hazard curves of GEI and LI
groups should converge to that of the uninsured group.
66
Accumulated hazards of having a hysterectomy
0
20
40
60
Hysterectomy
-20
-10
0
Quarters to Age 45
Public
Farmer
10
Labor
Uninsured
20
67
Future works
• Incorporate the financial incentives
• Sort out the mechanisms causing the increase of
incidence rate
– Patients
– Doctors
• The health impact
68
69
70
Appendix:
Frequency distributions based on the broad sample
Hazard by quarter (broad sample)
71
Total and partial hysterectomies
Labor
3
2
1
0
0
1
2
3
hazard (of 1,000)
4
4
Public
-20
-10
0
10
quarters from age 45
20
-20
-10
20
3
2
1
0
0
1
2
3
hazard (of 1,000)
4
Uninsured
4
Farmer
0
10
quarters from age 45
-20
-10
0
10
quarters from age 45
20
-20
-10
0
10
quarters from age 45
20
Hazard by quarter (broad sample)
72
Total and partial hysterectomies
1
2
3
4
5
Hysterectomy
-20
-10
0
quarters from age 45
Public
Farmer
10
Labor
Uninsured
20
Hazard by quarter (broad sample)
73
Partial oophorectomy
.75
.5
0
.25
0
.25
.5
.75
hazard (of 1,000)
1
Labor
1
Public
-20
-10
0
10
quarters from age 45
20
-20
-10
20
.75
.5
0
.25
0
.25
.5
.75
hazard (of 1,000)
1
Uninsured
1
Farmer
0
10
quarters from age 45
-20
-10
0
10
quarters from age 45
20
-20
-10
0
10
quarters from age 45
20
Hazard by quarter (broad sample)
74
Partial oophorectomy
.2
.4
.6
.8
Partial oophorectomy
-20
-10
0
quarters from age 45
Public
Farmer
10
Labor
Uninsured
20
Hazard by quarter (broad sample)
75
Myomectomy
1
.5
0
0
.5
1
hazard (of 1,000)
1.5
Labor
1.5
Public
-20
-10
0
10
quarters from age 45
20
-20
-10
20
1
.5
0
0
.5
1
hazard (of 1,000)
1.5
Uninsured
1.5
Farmer
0
10
quarters from age 45
-20
-10
0
10
quarters from age 45
20
-20
-10
0
10
quarters from age 45
20
Hazard by quarter (broad sample)
76
Myomectomy
.2
.4
.6
.8
1
Myomectomy
-20
-10
0
quarters from age 45
Public
Farmer
10
Labor
Uninsured
20