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This paper uses data from 802,777 veterans assigned to 7,548 primary care providers (PCPs) within the Veterans Health Administration (VHA) to examine variations in the efficacy of primary care providers (PCPs), their consequences for health outcomes, and their determinants. Leveraging quasi-random assignment of veterans to PCPs, we measure PCP effectiveness along three dimensions: the probability their patients have subsequent hospitalizations for ambulatory care sensitive conditions (ACSC), subsequent hospitalizations or emergency department (ED) visits for mental health conditions, or hospitalizations/ED visits for circulatory conditions. We find a significant range in these measures across PCPs. For example, a one standard deviation improvement in our measure of mental health effectiveness predicts a 0.21 percentage point (3.8%) lower risk of patient death over the next three years and 4.4% lower total costs. We also find that patients whose physicians are better according to one dimension also have better outcomes in terms of the other dimensions we consider. Finally, we find that more effective PCPs do more with less: Their patients have fewer primary care visits, referrals to specialists, lab panels or imaging tests. Effective PCPs are slightly more likely to comply with guidelines for mental health screenings, and slightly less likely to comply with guidelines for physical health screenings, but these differences in screening propensities are negligible in magnitude.

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We leverage spatial variation in the severity of the Great Recession across the United States to examine its impact on mortality and to explore implications for the welfare consequences of recessions. We estimate that an increase in the unemployment rate of the magnitude of the Great Recession reduces the average, annual age-adjusted mortality rate by 2.3 percent, with effects persisting for at least 10 years. Mortality reductions appear across causes of death and are concentrated in the half of the population with a high school degree or less. We estimate similar percentage reductions in mortality at all ages, with declines in elderly mortality thus responsible for about three-quarters of the total mortality reduction. Recession-induced mortality declines are driven primarily by external effects of reduced aggregate economic activity on mortality, and recession-induced reductions in air pollution appear to be a quantitatively important mechanism. Incorporating our estimates of pro-cyclical mortality into a standard macroeconomics framework substantially reduces the welfare costs of recessions, particularly for people with less education, and at older ages where they may even be welfare-improving.