Cristina Elisa Orso

Home Sweet Home? Public Financing and Inequalities in the Use of Home Care Services in Europe†

Income-related inequalities in health care access have been found in several European countries but little is known about the extent of inequalities in the provision of Long Term Care services (LTC). This paper fills this gap: it addresses equity issues related to the provision of home care services across three macro-areas in Europe which are highly heterogeneous in terms of the degree of public financing of LTC and the strength and the social value of family ties. Using cross-country comparative micro-data from SHARE (Survey of Health, Ageing and Retirement in Europe) survey, we estimate and decompose an Erreygers concentration index of the use of both paid domestic help (�unskilled� care) and personal nursing care (�skilled� care), measuring the contribution of income, needs and non-needs factors to overall inequality. We base the decomposition on a bivariate probit model which takes into account the reciprocal interaction between formal and informal home care use. We find evidence of high horizontal inequity in the use of unskilled home care in areas where public financing of LTC is relatively low (Southern Europe) while moderate inequalities emerges in areas where public-private mix of financing is more balanced (Continental Europe). At the same time, we do not detect inequity in Northern Europe characterized by high public spending on universal services equitable for all, including LTC public coverage. In all areas, informal care has been found to be a substitute for paid unskilled care among the poor and this contributes to further skewing the distribution of the use of formal care services towards the rich.

Eligibility and Inclusiveness of Long-Term Care Institutional Frameworks in Europe: A Cross-Country Comparison

Although economic literature has recently started to concentrate on the design, the scope and the regulations of main public programmes of Long-Term-Care in Europe, no analysis have, so far, compared different systems in terms of their degree of inclusiveness with respect to vulnerable elderly�s health status. Focusing on several European countries, this paper investigate how LTC regulations assess vulnerability, as well as how they define a minimum level of objective-dependency that would entitle individuals to receive public benefits (in-kind or in-cash) for home-based care. Our contribution is threefold. We provide detailed information on assessment and eligibility frameworks for eleven LTC programmes in Europe. We show that substantial heterogeneities exist both at the extensive margin (the health-outcomes that are included in the vulnerability-assessment) and at the intensive margin (the minimum vulnerability threshold that defines benefit eligibility) of the assessment strategies. Building on this information, we compare LTC programmes in terms of their degree of inclusiveness, i.e., we investigate the extent to which each programme is able to cover a standard population of elderly individuals facing functional and cognitive limitations. The comparison is performed following both a directly- and an indirectly- adjusted strategy using SHARE data.

Country Profiles of Eligibility Legislations in Europe

In this chapter, we detail the main LTC legislations in Austria, Belgium, the Czech Republic, England, France, Germany, Italy and Spain. Each country profile includes up-to-date legislative information, details on the assessment of need procedures, the eligibility rules and the in-kind or in-cash benefits for the eligible population. The chapters for Belgium and Italy are organised at the regional level, given the high degree of heterogeneity of the local LTC programmes.

Life-Course Health and Inequality

In Chap. 5, we address the “health equity” issue related to the access to formal home care services across a set of European countries. We make use of the individual-level eligibility index developed in Chap. 4, and relate it to the most relevant “covariates”. The novelty of this chapter is that, by using the SHARE and the ELSA data, we can analyse the effect of adverse health shocks occurring during individuals’ lives as captured by a cumulative measure of health deterioration. The purpose of the analysis is to compare individuals with similar socio-economic backgrounds and similar health histories, by distinguishing those who may face the need for LTC as a result of a health shock: this is the “demand side” of the programme. However, depending on the LTC regulation to which these individuals are exposed, they will have different probabilities of access to care and different coverage, i.e., there is also a “supply side”. We describe how different LTC systems cope with the “cumulative health disadvantage”.

A Comparative Analysis of LTC Systems in Terms of Inclusiveness

In Chap. 4, using micro-data from SHARE (the Survey of Health Ageing and Retirement in Europe) and ELSA (the English Longitudinal Study on Ageing), we estimate the potential coverage of each specific LTC programme, disentangling the differences between countries’ coverage rates in terms of population and regulation effects. More precisely, by applying each regulation on the standard population of SHARE and ELSA, we generate a set of comparable “directly adjusted” eligibility rates (i.e., the share of the standard population that would be covered by each programme). Furthermore, we perform a pair-wise comparison of programmes’ inclusiveness through a counterfactual analysis (indirect adjustment), i.e., simulating the adoption of a region’s regulation on another region’s population.

The Concept of Vulnerability: Clinical Versus Policy Perspectives

In Chap. 2, we address the substantial differences existing among the Western European LTC legislations (namely, Austria, Belgium, the Czech Republic, England, France, Germany, Italy and Spain), both between and within countries, on defining the target population in need of long-term care (LTC). Although the majority of programmes cover functional (mostly Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [iADL]) and cognitive limitations, the assessment process appears in most countries as a patchwork of different rules and practices. These differences can give rise also to differential measurement criteria: the health outcomes may attract different weights within an assessment scale; some limitations are given more importance than others in determining eligibility; and there are legislations that characterize some deficit as necessary and/or sufficient for eligibility.

31. Eligibility regulations and formal home-care utilisation among the vulnerable older people in SHARE Wave 5

▸ Eligibility matters and differs across countries ▸ Potential failures of Long-term Care (LTC) systems arise when objective vulnerable elders are left out of home-care programmes, or when formal care is provided to healthy individuals ▸ Education plays a crucial role in determining the access to formal home-care for eligible individuals ▸ Diabetes, cancer, Parkinson, fractures partially explain why non-vulnerable individuals receive home-care