Elsevier

Journal of Health Economics

Volume 39, January 2015, Pages 147-158
Journal of Health Economics

Inequity in long-term care use and unmet need: Two sides of the same coin

https://doi.org/10.1016/j.jhealeco.2014.11.004Get rights and content

Abstract

We investigate the determinants of several LTC services and unmet need using data from a representative sample of the non-institutionalised disabled population in Spain in 2008. We measure the level of horizontal inequity and compare results using self-reported versus a more objective indicator of unmet needs. Evidence suggests that after controlling for a wide set of need variables, there is not an equitable distribution of use and unmet need of LTC services in Spain; formal services are concentrated among the better-off, while intensive informal care is concentrated among the worst-off. The distribution of unmet needs for LTC services depends on the service considered and on whether we focus on subjective or objective measures. In 2008, only individuals with the highest dependency level had universal coverage. Our results show that inequities in most LTC services and unmet needs among this group either remain or even increase for formal services.

Introduction

A large body of literature describes the existence of inequity in health care use in most (if not all) developed countries (Van Doorslaer et al., 2004; Bago d’Uva and Jones, 2009, Devaux and de Looper, 2012). However, there is no evidence on the level of horizontal inequity in the access to long-term care (LTC) services, i.e., the range of services needed by persons who are dependent on help with basic activities of the daily living (OECD, 2005) or the level of unmet needs reported by potential users of these services.

It is well known that there are large differences in the current LTC organisation and spending among European countries. For example, while half of the EU-27 countries spent less than 1% of their GDP on LTC in 2007, Sweden and the Netherlands spent around 3.5% of their GDP (Economic Policy Committee, 2009). Although the baseline is very different between countries and the evolution of the health status of their populations is uncertain, the demographic evolution of European countries in the forthcoming decades is expected to pose significant pressure on public budgets regarding pension benefits, health care and LTC costs (DG ECFIN, 2006, Economic Policy Committee, 2009). The evolution of LTC expenditures will be conditioned by several distinct factors: demographics (percentage of the population over 65), institutions (organisation of the LTC system, trade-off between formal and informal care and support for the latter type of care) and health (Spillman, 2004, European Commission, 2007, Lafortune et al., 2007, Manton et al., 2007, Manton, 2008, De Meijer et al., 2011, Jiménez-Martín and Vilaplana Prieto, 2012). Therefore, ageing of the population will not only challenge the organisation of health care systems but also imply a redefinition of LTC systems in the years to come. In this regard, identifying how access to LTC services is distributed across socioeconomic groups among the subsample of the population with a health impairment is crucial. Moreover, it is likely that barriers are not distributed equally among socioeconomic groups, so people with high levels of education and financial safety experience a lower level of entry barriers than those with low levels of education and income. This could be due, among other reasons, to an inequitable geographic distribution of LTC services, to differences in the treatment of patients on the basis of socioeconomic status, or to the existence of differences in the demand of health and social care services among patients with different levels of income and education (Hurley and Grignon, 2006).

We investigate inequity in the access of various LTC services using a rich Spanish dataset representative of the non-institutionalised disabled Spanish population. At the time of conducting the survey, Spain was characterised by very low LTC expenditures, with a strong component of private financing. We first analyse equity in the use of a series of LTC services. We find that individuals at the higher end of the income distribution utilise a relatively larger share of formal services (provided by a professional). In particular, high levels of pro-rich inequity are found for the use of community care services and some home care services of all disabled individuals, which may be related to the existence of barriers to access for poorer individuals in terms of both availability of the service (e.g., waiting lists) and costs associated to these services (Hernández-Quevedo and Jiménez Rubio, 2011). The use of intensive informal care services appears to be disproportionately concentrated within the worse-off, with families acting as safety nets.

However, inequity regarding LTC use may not be due only to an inequitable treatment of the rich/poor, but also to differences in preferences. If people with higher incomes and better education levels have a stronger preference for the use of certain LTC services, then similar LTC consumption patterns could result (Koolman, 2007). In addition, a given amount of use does not guarantee that all health needs are satisfied. Hence, we investigate unmet need for LTC services using two alternative definitions. Measuring whether needs for long-term care are met is difficult because it has multiple dimensions, both subjective and objective, and depends in part on individual preferences and perceptions (Kemper et al., 2008). In fact, we can distinguish between normative need (defined by experts or professionals using professional standards), a person's or group's felt need (based on their own belief of need) and technical need (when existing provision is made more effective or a new kind of provision is developed) (Vlachantoni et al., 2011).

Therefore, the definition of unmet need depends on the concept of need considered. Together with self-reported measures of unmet needs for the use of several LTC services included in the survey, we consider an alternative indicator, which captures whether an individual who has at least one daily living activity (ADL) affected does not receive any care. While both self-reported and ADL-related unmet need variables have been used in several studies (Allin et al., 2010, Kemper et al., 2008, Shea et al., 2003, Tennstedt et al., 1994), this is the first study to our knowledge that compares results for both types of unmet needs measures. The empirical analysis indicates significant differences depending on the type of care considered and between the two types of indicators of unmet needs. This suggests the importance of considering complementary indicators of unmet needs whenever possible for enriching the analysis and not unduly limiting the nature and dimensions considered in this complex concept. Our results show that the more objective measure considered in the analysis has a larger level of pro-poor inequity compared to self-reported measures, suggesting some level of self-reporting bias on the basis of the socioeconomic position.

Spain provides an interesting context to study inequity in LTC. In 2006, a new Dependency Act was approved in Spain, which recognised the universal right of the dependent population to receive services. The implementation of the new system was designed to be progressive, and at the time of our analysis, only the population with the highest level of dependency were included. We investigate if inequity in access and unmet need is reduced once we look at the subgroup of the population with universal coverage. Our results are not very encouraging as they show that beneficiaries of LTC services (major dependents) seem to experience (relatively higher) pro-rich inequity in the use of formal services.

Our findings will be particularly useful to countries such as Italy, Poland or Hungary, which, like Spain, have not yet implemented fully comprehensive national LTC programmes and which rely heavily on informal care (Saltman et al., 2006). To our knowledge, this is the first attempt to evaluate the level of income related inequity in the access to LTC (rather than health care), that is, whether disabled individuals with the same level of need that require these services experience a difference in the level of utilisation or unmet needs related to their socioeconomic status.

In the next section we describe the Spanish LTC system. Section 3 describes the data and method used. In Section 4, we discuss the results on the determinants of use and unmet need in LTC and the inequity in the use of several LTC services and unmet need. The last section discusses the main policy implications and concludes.

Section snippets

Institutional background

The Spanish National Health Service is universal in coverage, funded from taxes and predominantly operates within the public sector, with health competences totally devolved to regions since 2002 (García-Armesto et al., 2010). Health expenditure in Spain reached US$ 3027 purchasing power parity (PPP) per capita and 9.54% of gross domestic product (GDP) in 2010. Most health expenditure (73.6%) is derived from public sources (mainly from taxation) (OECD Health Data, 2012).

By contrast, at the turn

Data

We base our analysis in the Spanish Disability and Dependency Survey for 2008 (SDDS) conducted by the Spanish National Statistics Institute. This is a representative survey of the non-institutionalised disabled population living within a household in Spain. 96,000 households with 260,000 individuals were selected between November 2007 and February 2008. 22,795 persons with disabilities were identified and interviewed in-depth. An individual aged at least six is considered to be disabled by SDDS

Determinants of long-term care-use

We first regress the different measures of long-term care use on the need and non-need variables used to compute all the CHIs by using a linear probability model. Estimated coefficients as well as the corresponding statistical significance are shown in Table A.II in the Appendix.9 Overall the estimated coefficients for the health variables show the

Discussion and conclusions

The egalitarian objective defined as “equal access for equal need” is part of the policy agenda for most European countries. This implies that, for the same level of need, there should not be differences in the access to health care services by socioeconomic conditions, race or sex. In particular, horizontal equity in the access to health care services has been defined by the World Health Organisation as an instrument to achieve health improvement, as well as the reduction of inequalities in

Acknowledgements

Data used in this study has been provided by the Spanish National Statistics Institute. The data collectors have no responsibility over the analysis and interpretations presented in this study. The authors are thankful to David Epstein for his help in the initial preparation of the data, and to Pieter Bakx, Manuel García-Goñi, Ángel López-Nicolás, Anna Maresso, Marisol Rodríguez, Laura Vallejo Torres, María Victoria Zunzunegui, participants at the SESPAS-SEE Congress 2011, the XXXIII Jornadas

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