Working papers

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.  

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

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

Abstract: We ask whether taxing sugar-sweetened beverages in areas where clean water is unavailable may increase diarrheal disease. Exploiting a tax in Mexico, we find a significant 6.6% increase in gastrointestinal disease rates throughout the first year of the tax, with evidence of a declining impact in the second year. We document avoidance behavior by affected households through differential consumption of bottled beverages two years post-tax. The costs implied by our results are small. However, our findings inform the need for accompanying soda taxes with interventions that guarantee safe drinking water for vulnerable populations. 

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 how reducing transaction costs for deposits affects savings, and whether non-branded advertising matters for these effects. Focusing on retirement savings in the privatized pension system in Mexico, we analyze two policies: an expansion of access channels for additional contributions at 7-Eleven stores, and the subsequent media campaign providing information on this expansion and persuasive messages to save.  We find that access alone has small and weak effects, but including the campaign leads to a 10-12% increase in savings behavior. However, due to declines in the average contribution size, we find null effects on the total amount saved

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

(joint with Emilio Gutierrez) - R&R, Management Science

Abstract: What is the effect of increased hospital occupancy on in-hospital mortality? Using data from public hospitals in Mexico, we exploit the shock in hospitalizations induced by the 2009 H1N1 pandemic, instrumenting hospital admissions due to acute respiratory infections (ARIs) with measures of ARIs at nearby healthcare facilities. We estimate that a one standard deviation increase in ARI admissions leads to a 38% increase in non-ARI in-hospital mortality. We show that these effects are non-linear in the size of the local outbreak, and are concentrated in hospitals with limited infrastructure. We discuss policy implications for the current pandemic.

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

(joint with Emilio Gutierrez and Jaakko Meriläinen) - resubmitted, PNAS

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) - under review

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)