uterus at a price: disability insurance and hysterectomy elliott fan hsienming lien ching -to...

Uterus at a Price: Disability Insurance and Hysterectomy

Elliott FanHsienming Lien

Ching-To Albert Ma

October 2013

National Taiwan University, National ChengChi University, and Boston University

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

2

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

3

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

4

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。

5

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。

6

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。

7

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

10

Uninsured group (control)

• Women not covered by the above three social programs

• Mostly unemployed women

11

Hazard by quarter Total and partial hysterectomies

12

01

23

4ha

zard

(of 1

,000

)

-20 -10 0 10 20quarters from age 45

Public

01

23

4ha

zard

(of 1

,000

)


Labor

01

23

4ha

zard

(of 1

,000

)


Farmer

01

23

4ha

zard

(of 1

,000

)


Uninsured

Hazard by quarter Total and partial hysterectomies

13

12

34

Haz

ard

(of 1

,000

)


Public LaborFarmer Uninsured

Hysterectomy

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

14

Hazard by quarterPartial oophorectomies

15

0.2

5.5

.75

1ha

zard

(of 1

,000

)


Public

0.2

5.5

.75

1ha

zard

(of 1

,000

)


Labor

0.2

5.5

.75

1ha

zard

(of 1

,000

)


Farmer

0.2

5.5

.75

1ha

zard

(of 1

,000

)


Uninsured

Hazard by quarterMyomectomies

16

0.5

11.

5ha

zard

(of 1

,000

)


Public

0.5

11.

5ha

zard

(of 1

,000

)


Labor

0.5

11.

5ha

zard

(of 1

,000

)


Farmer

0.5

11.

5ha

zard

(of 1

,000

)


Uninsured

17

1. How many “induced” hysterectomies due to disability insurances?

2. Any health impact?

Research questions

18

• Taiwan social insurance programs

• Disability benefits

• Surgeries

Institutional background

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

19

育嬰留職停薪殘廢給付

眷屬喪葬養老給付

死亡給付

勞工保險給付項目

公教保險給付項目

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

21

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

22

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

23

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

24

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)

25

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.

26

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

27

Occurrences by quarter (restricted sample)Total oophorectomies

28

02

46

810

occu

rren

ces


Public

010

2030

40oc

curr

ence

s


Labor

05

1015

20oc

curr

ence

s


Farmer

010

2030

40oc

curr

ence

s


Uninsured

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 )

29

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 , last period straight forward decision– Value for period t=2 is

( ) ( ) ( )

uu p f udu V z

• Let be discount factor• In period 1 : let the draw f utility be u

– If common receive treatment for payoff is – If not, then period 2 applies. In which case for payoff is

• For at t=1, receive treatment if or

u p

( )V z

( )u p V z ( )u p V z p

Reservation period :

Incidence rate :

Now suppose that in period 1, then a bonus if treatment is

received then :

or

This means a drop is the reservation utility at t=1

( ) , 0 is bonusu V z B

( )u B V z

Reservation period :

Incidence rate : t=1 t=2

t=1 t=2

Multiple periods

t

reservation utility

t

reservation utility

Bonus B Without bonus

Incidence of treatment

t

Incidence of treatment

Bonus B Without bonus

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

38

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)

39

Sampling issues (I)40

Cohorts Age at 1997 Age at 2011 years in sample data record experience in incentive change

1948 49 63 left-censored 1 no

. . . . . .

1952 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






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

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

41

Broad vs restricted samples, four surgeries(by insurance type)

42

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

Broad vs restricted samples(by surgery)

43


(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

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

44

Sample statistics• Show mainly the characteristics of surgery providers• Separate into two subsamples

– Age 40-44– Age 45-49

45

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

Medical expense 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

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

47

D-in-D model• The specification is

• : the ratio of women who underwent hysterectomy in quarter q to those who had no such prior experience

• : dummy indicating standardized quarter q

• : treatment dummy

• X: hospital types, inpatient costs, and birth-quarter cohort fixed effects

48

20 20

, , ,19 19

( )

c q q q q q c q c qq q

hazard d treatment d treatment

Preliminary examinations

• Omitted quarter is q= -20

• : Mean difference in hysterectomy hazard between quarter q and the omitted quarter

• : 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

49

Quarters from age 45 Restricted sample Broad sample

Public Labor Farmer Public Labor Farmer-11 0.286* 0.165 0.0649 0.329** 0.158 -0.00993

(0.154) (0.116) (0.203) (0.155) (0.109) (0.186)-10 0.482*** 0.292** 0.00845 0.483*** 0.257** -0.0134

(0.159) (0.120) (0.196) (0.165) (0.119) (0.189)-9 0.630*** 0.454*** 0.169 0.639*** 0.374*** 0.170

(0.186) (0.124) (0.194) (0.169) (0.116) (0.172)-8 0.332** 0.264** -0.269 0.411** 0.236* -0.266

(0.163) (0.125) (0.189) (0.161) (0.126) (0.181)-7 0.632*** 0.246** 0.0892 0.671*** 0.282** 0.0782

(0.165) (0.109) (0.198) (0.167) (0.114) (0.170)-6 0.605*** 0.629*** 0.300 0.429*** 0.498*** 0.0924

(0.156) (0.121) (0.222) (0.154) (0.123) (0.185)-5 0.835*** 0.845*** 0.257 0.683*** 0.751*** 0.217

(0.194) (0.119) (0.198) (0.190) (0.122) (0.180)-4 0.729*** 0.486*** 0.115 0.849*** 0.522*** 0.136

(0.202) (0.127) (0.206) (0.190) (0.112) (0.181)-3 1.016*** 0.844*** 0.108 1.016*** 0.786*** 0.100

(0.194) (0.131) (0.193) (0.180) (0.123) (0.167)-2 1.072*** 1.018*** 0.201 1.174*** 0.879*** 0.250

(0.201) (0.137) (0.201) (0.191) (0.123) (0.177)-1 2.252*** 2.157*** 0.476* 2.191*** 2.051*** 0.230

(0.214) (0.160) (0.248) (0.216) (0.163) (0.221)0 -0.182 -0.559*** -0.395** 0.00500 -0.442*** -0.334**

(0.146) (0.115) (0.168) (0.133) (0.105) (0.137)1 -0.0579 -0.265** -0.403** 0.133 -0.173 -0.225

(0.174) (0.133) (0.190) (0.162) (0.110) (0.157)2 0.0451 -0.136 -0.124 0.227 -0.0778 -0.0289

(0.179) (0.136) (0.215) (0.160) (0.122) (0.195)

50

D-in-D results for hysterectomy(restricted sample)

D-in-D results for hysterectomy(restricted sample)

51

-.50

.51

1.5

2H

azar

d re

lativ

e to

uni

nsur

ed w

omen


Public LaborFarmer

Summary1. 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

52

Robustness check• Broad sample versus restricted sample

53

Comparing the D-in-D results for broad and restricted samples (Government)

54

-.50

.51

1.5

2H

azar

d re

lativ

e to

uni

nsur

ed w

omen



Public

Comparing the D-in-D results for broad and restricted samples (Labor)

55

-.50

.51

1.5

2H

azar

d re

lativ

e to

uni

nsur

ed w

omen



Labor

Comparing the D-in-D results for broad and restricted samples (Farmer)

56

-.50

.51

1.5

2H

azar

d re

lativ

e to

uni

nsur

ed w

omen



Farmer

Robustness check• Partial oophorectomies and myomectomies: neither

qualifies for disability benefit

57


Public Labor Farmer Public Labor Farmer-11 -0.0884 -0.0756 -0.00926 -0.00495 -0.0334 -0.0610

(0.0984) (0.0535) (0.0873) (0.0842) (0.0445) (0.0821)-10 0.0241 -0.00387 -0.0709 0.0700 0.0103 -0.102

(0.110) (0.0517) (0.0912) (0.0931) (0.0456) (0.0966)-9 0.0543 -0.0498 -0.0551 0.0450 -0.00327 -0.0257

(0.118) (0.0576) (0.0915) (0.0905) (0.0430) (0.0915)-8 0.0430 -0.00492 0.00554 0.0457 -0.0220 -0.114

(0.117) (0.0543) (0.0802) (0.102) (0.0471) (0.0904)-7 0.0721 -0.0968* -0.000385 0.129 -0.0431 -0.0683

(0.121) (0.0563) (0.0907) (0.102) (0.0457) (0.0908)-6 0.0946 -0.0226 0.106 0.148 0.0402 0.0790

(0.119) (0.0604) (0.0990) (0.101) (0.0499) (0.0950)-5 -0.0500 -0.0420 0.0728 -0.0405 -0.0233 -0.0380

(0.115) (0.0588) (0.0990) (0.0934) (0.0515) (0.0993)-4 0.0495 -0.0349 0.0424 0.0691 -0.0126 -0.0633

(0.100) (0.0532) (0.0975) (0.0860) (0.0447) (0.0897)-3 0.0989 -0.0188 -0.0547 0.169* 0.0298 -0.0695

(0.107) (0.0511) (0.0809) (0.0892) (0.0434) (0.0887)-2 -0.0333 -0.0678 0.0293 0.0358 -0.00283 0.0192

(0.0994) (0.0549) (0.0979) (0.0879) (0.0470) (0.0873)-1 0.0711 -0.0784 -0.0394 0.130 -0.00333 0.0267

(0.108) (0.0546) (0.0908) (0.0974) (0.0484) (0.0895)0 0.0290 -0.0777 -0.0285 0.0586 -0.0298 -0.00710

(0.129) (0.0592) (0.0888) (0.108) (0.0500) (0.106)1 0.0120 -0.0855 -0.0889 0.0687 -0.0685 -0.120

(0.109) (0.0578) (0.0882) (0.0981) (0.0484) (0.0904)2 0.0230 -0.0841 -0.0455 0.119 -0.0397 -0.0541

(0.109) (0.0608) (0.0916) (0.101) (0.0479) (0.0943)

58

D-in-D results for partial oophorectomy(restricted sample)

59

D-in-D results for partial oophorectomy(restricted sample)

-.5-.2

50

.25

.5.7

51

Haz

ard

rela

tive

to u

nins

ured

wom

en


Public LaborFarmer


Public Labor Farmer Public Labor Farmer-11 -0.0553 0.00957 -0.0582 -0.0390 0.0461 0.0111

(0.150) (0.0756) (0.134) (0.133) (0.0635) (0.125)-10 -0.0793 -0.0414 -0.234** -0.0401 0.0469 -0.164

(0.134) (0.0701) (0.110) (0.121) (0.0644) (0.106)-9 -0.180 -0.0177 -0.151 -0.0821 0.0821 -0.0855

(0.124) (0.0671) (0.114) (0.117) (0.0560) (0.102)-8 -0.190 -0.0216 -0.00347 -0.0896 0.00516 0.0245

(0.117) (0.0635) (0.136) (0.109) (0.0575) (0.124)-7 0.0394 -0.0394 -0.123 0.0369 0.00552 -0.0954

(0.134) (0.0637) (0.119) (0.116) (0.0583) (0.105)-6 -0.196 -0.00788 -0.0859 -0.147 0.0235 -0.0874

(0.121) (0.0658) (0.116) (0.113) (0.0603) (0.108)-5 -0.0859 -0.0295 -0.0900 0.00612 0.0503 -0.107

(0.125) (0.0670) (0.126) (0.116) (0.0572) (0.112)-4 -0.0745 -0.0552 -0.160 -0.0103 0.0340 -0.0797

(0.130) (0.0647) (0.123) (0.115) (0.0522) (0.110)-3 -0.0453 -0.0810 -0.0801 -0.00301 -0.00582 -0.0241

(0.131) (0.0664) (0.124) (0.114) (0.0590) (0.106)-2 -0.0820 -0.0880 -0.182 -0.0207 -0.0115 -0.137

(0.136) (0.0667) (0.127) (0.125) (0.0593) (0.107)-1 0.000769 -0.00517 -0.0212 0.0361 0.0206 -0.0698

(0.127) (0.0674) (0.126) (0.117) (0.0600) (0.112)0 -0.133 -0.0437 -0.176 -0.0923 -0.0406 -0.176*

(0.122) (0.0638) (0.115) (0.105) (0.0525) (0.102)1 -0.229* -0.0500 -0.195* -0.110 0.00219 -0.120

(0.128) (0.0610) (0.112) (0.124) (0.0551) (0.105)2 0.00863 0.0355 -0.118 0.0669 0.0762 -0.0653

(0.124) (0.0623) (0.106) (0.114) (0.0538) (0.105)

60

D-in-D results for myomectomy(restricted sample)

D-in-D results for myomectomy(restricted sample)

61

-.5-.2

50

.25

.5.7

51

Haz

ard

rela

tive

to u

nins

ured

wom

en


Public LaborFarmer

Robustness check• Only balanced panel

62


Public Labor Farmer Public Labor Farmer-11 -0.177 0.112 -0.354 0.0173 0.0974 -0.280

(0.276) (0.207) (0.332) (0.236) (0.190) (0.328)-10 0.440 0.542** -0.0436 0.405 0.326 0.0271

(0.306) (0.263) (0.339) (0.300) (0.218) (0.287)-9 0.725* 0.671** -0.0688 0.689** 0.472** -0.00549

(0.401) (0.262) (0.302) (0.340) (0.219) (0.267)-8 0.0441 0.410 -0.196 0.242 0.278 -0.0369

(0.293) (0.245) (0.313) (0.298) (0.242) (0.330)-7 0.621** 0.351* 0.356 0.684** 0.372 0.252

(0.307) (0.200) (0.349) (0.327) (0.233) (0.313)-6 0.547* 0.759*** -0.0363 0.252 0.390* -0.349

(0.312) (0.240) (0.355) (0.326) (0.222) (0.288)-5 0.578 0.943*** 0.166 0.276 0.697*** 0.0823

(0.406) (0.245) (0.322) (0.367) (0.234) (0.304)-4 0.501 0.511** 0.412 0.847*** 0.608*** 0.519**

(0.314) (0.235) (0.304) (0.256) (0.168) (0.218)-3 0.942** 0.985*** 0.0719 1.022*** 0.775*** 0.0675

(0.374) (0.212) (0.273) (0.331) (0.198) (0.227)-2 1.300*** 0.979*** -0.168 1.389*** 0.647*** -0.142

(0.449) (0.287) (0.330) (0.363) (0.225) (0.268)-1 2.416*** 2.356*** 0.342 2.072*** 2.042*** -0.0123

(0.370) (0.319) (0.423) (0.360) (0.294) (0.370)0 -0.459** -0.645*** -0.452* -0.0969 -0.551*** -0.396**

(0.197) (0.169) (0.257) (0.192) (0.160) (0.178)1 -0.436 -0.180 -0.619* -0.260 -0.221 -0.513**

(0.298) (0.244) (0.335) (0.283) (0.185) (0.238)2 0.0215 0.118 -0.0651 0.146 -0.00641 -0.0736

(0.349) (0.248) (0.299) (0.287) (0.174) (0.293)

63

D-in-D results for hysterectomies(balanced panel)

64

D-in-D results for hysterectomies(balanced panel)

-.50

.51

1.5

2H

azar

d re

lativ

e to

uni

nsur

ed w

omen


Public LaborFarmer

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.

65

Accumulated hazards of having a hysterectomy66

020

4060

accu

mul

ated

haz

ard

(of 1

,000

)

-20 -10 0 10 20Quarters to Age 45


Hysterectomy

Future works• Incorporate the financial incentives• Sort out the mechanisms causing the increase of

incidence rate– Patients – Doctors

• The health impact

67

Appendix:Frequency distributions based on the broad sample

70

Hazard by quarter (broad sample) Total and partial hysterectomies

71

01

23

4ha

zard

(of 1

,000

)


Public

01

23

4ha

zard

(of 1

,000

)


Labor

01

23

4ha

zard

(of 1

,000

)


Farmer

01

23

4ha

zard

(of 1

,000

)


Uninsured

Hazard by quarter (broad sample) Total and partial hysterectomies

72

12

34

5 H

azar

d (o

f 1,0

00)



Hysterectomy

Hazard by quarter (broad sample) Partial oophorectomy

73

0.2

5.5

.75

1ha

zard

(of 1

,000

)


Public

0.2

5.5

.75

1ha

zard

(of 1

,000

)


Labor

0.2

5.5

.75

1ha

zard

(of 1

,000

)


Farmer

0.2

5.5

.75

1ha

zard

(of 1

,000

)


Uninsured

Hazard by quarter (broad sample) Partial oophorectomy

74

.2.4

.6.8

Haz

ard

(of 1

,000

)



Partial oophorectomy

Hazard by quarter (broad sample) Myomectomy

75

0.5

11.

5ha

zard

(of 1

,000

)


Public

0.5

11.

5ha

zard

(of 1

,000

)


Labor

0.5

11.

5ha

zard

(of 1

,000

)


Farmer

0.5

11.

5ha

zard

(of 1

,000

)


Uninsured

Hazard by quarter (broad sample) Myomectomy

76

.2.4

.6.8

1 H

azar

d (o

f 1,0

00)



Myomectomy

uterus at a price: disability insurance and hysterectomy elliott fan hsienming lien ching -to...

Documents

diability insurance

total salary

government employees

number of women

women eligible

months of insured salary

li workers

number of hysterectomy