Working papers

Shocks to Hospital Occupancy and Mortality: Evidence from the 2009 H1N1 Pandemic 

(joint with Emilio Gutierrez) - forthcoming, Management Science

Abstract: Existing literature suggests that hospital occupancy matters for quality of care as measured by various patient outcomes. However, estimating the causal effect of increased hospital busyness on in-hospital mortality remains an elusive task due to statistical power challenges and the difficulty in separating shocks to occupancy from changes in patient composition. Using data from a large public hospital system in Mexico, we estimate the impact of congestion on in-hospital mortality by exploiting the shock in hospitalizations induced by the 2009 H1N1 pandemic, instrumenting hospital admissions due to acute respiratory infections (ARIs) with measures of ARI cases at nearby healthcare facilities as a proxy for the size of the local outbreak. Our instrumental variables estimates show that a one percent increase in ARI admissions in 2009 led to a 0.25% increase in non-ARI in-hospital mortality. We show that these effects are non-linear in the size of the local outbreak, consistent with the existence of tipping points. We further show that effects are concentrated at hospitals with limited infrastructure, suggesting that supply-side policies that improve patient assignment across hospitals and strategically increase hospital capacity could mitigate some of the negative impacts. We discuss managerial implications, suggesting that up to 25-30% of our estimated deaths at small and non-ICU hospitals could have been averted by reallocating patients to reduce congestion. 

Local Water Quality, Diarrheal Disease, and the Unintended Consequences of Soda Taxes 

(joint with Emilio Gutierrez) - forthcoming, World Bank Economic Review

Abstract: Could taxing sugar-sweetened beverages in areas where clean water is unavailable lead to increases in diarrheal disease? An excise tax introduced in Mexico in 2014 led to a significant 6.6% increase in gastrointestinal disease rates in areas lacking safe drinking water throughout the first year of the tax, with evidence of a diminishing impact in the second year. Suggestive evidence of a differential increase in the consumption of bottled water by households without access to safe water two years post-tax provides a potential explanation for this declining pattern. The costs implied by these results are small, particularly compared to tax revenues and the potential public health benefits. However, these findings inform the need for accompanying soda taxes with policy interventions that guarantee safe drinking water for vulnerable populations. 

Trade-Offs Between Access and Quality in Healthcare: Evidence from Retail Clinics in Mexico - R&R, Journal of Public Economics 

Abstract: Private-market innovations may be a cost-effective solution to healthcare provision challenges. I exploit the expansion of retail clinics at private pharmacies in Mexico to analyze changes in provider choices and prescription quality. I find that the first entry in the local market leads to a 6-9% decline in public healthcare use. I also find large shifts toward stronger antibiotics in private-market sales. Hence, retail clinics shuffled patients away from existing providers toward doctors with stronger incentives to over-prescribe. These results illustrate how market solutions to congested public services may affect consumers due to agents' incentives that trade-off quality for access.  

Increasing Retirement Savings through Access Points and Persuasive Messages: Evidence from Mexico 

(joint with Mariano Bosch) - R&R, Journal of Human Resources

Abstract: We study transaction costs for making deposits within the privatized pension system in Mexico. We analyze an expansion of access channels for additional (voluntary) contributions at 7-Eleven stores, followed by a media campaign providing information on this policy and persuasive messages to save. We estimate a differential 6-9% increase in the volume of transactions post-policy in municipalities with 7-Eleven relative to those without. However, due to smaller deposits compared to pre-policy sizes, we find modest effects on the flow of savings. Contribution size was not just smaller for marginal savers, but also decreased significantly for some inframarginal savers.  

Electoral Repercussions of a Pandemic: Evidence from the 2009 H1N1 Outbreak 

(joint with Emilio Gutierrez and Jaakko Meriläinen) - under review 

Abstract: In the aftermath of a large negative shock, such as an epidemic, retrospective voters evaluate the policy-makers' response and either punish or reward them in elections. A prominent concern during the on-going coronavirus pandemic has been whether politicians who are worried about re-election have incentives to impose stringent mitigation measures that may carry high economic costs.  On the other hand, voters might also react to the shock itself, no matter what the government does. To understand the effect of epidemic outbreaks on voting, we revisit the 2009 H1N1 outbreak in Mexico. Leveraging detailed administrative data and a difference-in-differences approach, we document a strong, negative relationship between the magnitude of the local epidemic outbreak and the governing party vote share in the 2009 congressional election. Although the average effect is small, the magnitudes may be decisive in close elections. The electoral punishment depended on the magnitude of the peak of the epidemic curve but not on its timing, and it occurred independently of the remedial actions taken by the government. Furthermore, we find persistent effects in the 2012 election. Our results indicate that voters are aware of epidemics, responding to them at the ballot box. The findings indirectly suggest that mitigation policies may be politically valuable even if they are costly for the economy.

Information and Behavioral Responses during a Pandemic: Evidence from Delays in Covid-19 Death Reports 

(joint with Emilio Gutierrez and Tiago Tavares; Covid Economics Working Paper)

Abstract: Information may be an important policy tool for managing epidemics. Focusing on Covid-19 in Mexico, we randomize an informational treatment in an online survey showing a higher or lower death toll by leveraging delays in death reports, and estimate its effects on individuals' beliefs and behavior. We find that reporting a lower death count -- when delays are not accounted for -- leads to a lower perceived risk of contagion and a lower intention to comply with social distancing. An equilibrium model incorporating the endogenous behavioral response documented by our intervention illustrates the implied differences for the evolution of the epidemic.

Delays in Death Reports and their Implications for Tracking the Evolution of COVID-19 

(joint with Emilio Gutierrez and Tiago Tavares; Covid Economics Working Paper)  

Abstract: Understanding the determinants and implications of delays in reporting COVID-19 deaths is important for managing the epidemic. Contrasting England and Mexico, we document that reporting delays in Mexico are larger on average, exhibit higher geographic heterogeneity, and are more responsive to the total number of occurred deaths in a given location-date. We then estimate simple SIR models for each country to illustrate the implications of not accounting for reporting delays. Our results highlight the fact that low and middle-income countries are likely to face additional challenges during the pandemic due to lower quality of real-time information.  

Over-the-Counter Access Regulations: Evidence from an Antibiotics Law in Mexico

Abstract: Regulations restricting over-the-counter (OTC) access to drugs are important policy tools for mitigating self-medication and encouraging doctor visits. However, they may have unintended consequences when access to affordable healthcare is lacking. This paper estimates the effect of a law restricting OTC sales of antibiotics in Mexico on public hospital admission rates. I find a temporary but significant decline of around 40% in admission rates due to infections. This effect is driven by viral infections, adult patients, and patients from higher education municipalities. OTC regulations may inadvertently increase the socioeconomic health gradient unless accompanied by policies that expand affordable healthcare. 


The Effect of a Cash Transfer Program for the Elderly in Mexico City on Co-Residing Children’s School Enrollment. World Bank Economic Review, 2017. (joint with Emilio Gutierrez and Laura Juarez) link

Select work in progress

Gasoline Pipeline Leaks, Health and Crime (joint with Emilio Gutierrez and Fernanda Marquez-Padilla)

Allocation of Government Resources and Service Provision: Evidence from the Quality of Healthcare

Climate Change and Tourism: Evidence from Algae Outbreaks

Utility Disconnection Policies and Health Outcomes (joint with William Violette)