Sick and depressed? The causal impact of a diabetes diagnosis on depression.

BACKGROUND: There is sparse evidence on the impact of health information on mental health as well as on the mechanisms governing this relationship. We estimate the causal impact of health information on mental health via the effect of a diabetes diagnosis on depression. METHODS: We employ a fuzzy regression discontinuity design (RDD) exploiting the exogenous cut-off value of a biomarker used to diagnose type-2 diabetes (glycated haemoglobin, HbA1c) and information on psycometrically validated measures of diagnosed clinical depression drawn from rich administrative longitudinal individual-level data from a large municipality in Spain. This approach allows estimating the causal impact of a type-2 diabetes diagnosis on clinica ldepression. RESULTS: We find that overall a type-2 diabetes diagnosis increases the probability of becoming depressed, however this effect appears to be driven mostly by women, and in particular those who are relatively younger and obese. Results also appear to differ by changes in lifestyle induced by the diabetes diagnosis: while women who did not lose weight are more likely to develop depression, men who did lose weight present a reduced probability of being depressed. Results are robust to alternative parametric and non-parametric specifications and placebo tests. CONCLUSIONS: The study provides novel empirical evidence on the causal impact of health information on mental health, shedding light on gender-based differences in such effects and potential mechanisms through changes in lifestyle behaviours.

Health System Decentralization: Creating as Many Problems Than It Solves? Comment on "The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis".

This comment draws on the study by Rotulo et al about the effects of fiscal decentralization on access, utilization and availability of healthcare resources across Italian regions. We start by discussing the recent trends in health system decentralization worldwide, and then reflect on the rationale and main benefits and the key complexities and challenges of this much debated reform. We address these issues with reference to the recent experience of Italy as well as that of other comparable highly decentralized countries, most notably Spain, paying particular attention to their similarities and contrasts. We conclude that decentralization of health services poses complex challenges and trade-offs which may require careful design of equalisation mechanisms, framework regulation and efficient coordination mechanisms by central and sub central governments.

Waiting times in healthcare: equal treatment for equal need?

BACKGROUND: In many universal health systems, waiting times act as a non-monetary rationing mechanism, one that should be based on clinical need rather than the ability to pay. However, there is growing evidence that among patients with similar levels of need, waiting times often differ according to socioeconomic status. The mechanisms underlying inequality in access remain unclear. METHODS: Using data for Spain, we study whether waiting times for primary and specialist care depend on patients' socioeconomic status (SES). Additionally, we make use of the continuous nature of our data to explore whether the SES-related differences in waiting times found for specialist consultations vary among different points of the waiting time distribution. RESULTS: Our results reveal the presence of a SES gradient in waiting times for specialist services explained on the basis of education, employment status and income. In addition, for primary care, we found evidence of a slightly more moderate SES gradient mostly based on employment status. Furthermore, although quantile regression estimates indicated the presence of a SES gradient within the distribution of waiting times for specialist visits, the SES differences attenuated in the context of longer waiting times in the public sector but did not disappear. CONCLUSION: Our findings suggest the principle of equal treatment for equal need, assumed to be inherent to national health systems such as the Spanish system, is not applied in practice. Determining the mechanism(s) underlying this selective barrier to healthcare is of crucial importance for policymakers, especially in the current COVID-19 health and economic crises, which could exacerbate these inequalities as increasing numbers of treatments are having to be postponed.

Does health information affect lifestyle behaviours? The impact of a diabetes diagnosis.

Despite an increasing interest in the effect of health information on health-behaviours, evidence on the causal impact of a diagnosis on lifestyle factors is still mixed and does not often account for long-term effects. We explore the role of health information in individual health-related decisions by identifying the causal impact of a type-2 diabetes diagnosis on body mass index (BMI) and lifestyle behaviours. We employ a fuzzy regression discontinuity design (RDD) exploiting the exogenous cut-off value in the diagnosis of type-2 diabetes provided by a biomarker (glycated haemoglobin) drawn from unique administrative longitudinal data from Spain. We find that following a type-2 diabetes diagnosis individuals appear to reduce their weight in the short-term. Differently from previous studies, we also provide evidence of statistically significant long-term impacts of a type-2 diabetes diagnosis on BMI up to three years from the diagnosis. We do not find perceivable effects of a type-2 diabetes diagnosis on quitting smoking or drinking. Overall, health information appears to have a sustained causal impact on weight reduction, a key lifestyle and risk factor among individuals with type-2 diabetes.

Freedom of choice and health services' performance: Evidence from a national health system.

Public policies fostering the freedom of choice of provider in the healthcare sector are increasingly common in many countries and regions, where policymakers wish to empower patients and improve health service performance. However, in the literature there is not clear consensus about the impact of expanded patient choice on healthcare quality yet. This study investigates whether increasing patients' freedom of choice influences health system outcomes in terms of various non-clinical aspects of care, a dimension often overlooked by researchers in this field. Our study considers a "natural experiment" that took place within the Spanish National Health System in 2009 under which citizens of the Community (region) of Madrid were allowed to freely choose among any GP and/or specialist in their region. The empirical analysis was conducted by using Spanish microdata for the period 2002-2016 and used synthetic control estimation techniques. The key findings show the reform had a strong and long-lasting impact, reducing average waiting times and increasing patients' satisfaction with the specialist attention received. We did not detect any statistically significant impact of the reform on the other responsiveness domains analysed. Our analysis shows that freedom of choice policies could improve health system performance if they are combined with appropriate economic incentives for health providers.

Effect of the COVID-19 pandemic on depression in older adults: A panel data analysis.

BACKGROUND: This paper investigates the impact of the COVID-19 pandemic on depression in the older population, an especially vulnerable group for which to date there is limited empirical research. METHODS: We employ a panel data consisting of seven waves of the English Longitudinal Study of Ageing (2010-2020). The breadth and depth of the data considered enabled us to control for individual fixed effects, to adjust for pre-pandemic trends in depression levels and to perform a heterogeneity analysis, depending on the intensity of the lockdown measures implemented and relevant socioeconomic characteristics. RESULTS: We find that, following the COVID-19 pandemic, study participants reported a statistically significant increase in the depressive symptoms by around 0.7 over 8 points as measured by the Centre for Epidemiologic Studies Depression (CES-D) index. The estimated coefficients were larger in November than in July, for individuals who lost their job, retired and women. Interestingly, we observed that mental health has worsened substantially relative to the pre-pandemic period across all income groups of the older population, suggesting a limited role of income as a protective mechanism for mental health. CONCLUSIONS: Our findings provide compelling evidence that depression levels amongst older adults have worsened considerably following the COVID-19 pandemic, and that factors other than income, such as social interactions, may be highly relevant for well-being in later life.

How do policy levers shape the quality of a national health system?

Poor quality of care may have a detrimental effect on access and take-up and can become a serious barrier to the universality of health services. This consideration is of particular interest in view of the fact that health systems in many countries must address a growing public-sector deficit and respond to increasing pressures due to COVID-19 and aging population, among other factors. In line with a rapidly emerging literature, we focus on patient satisfaction as a proxy for quality of health care. Drawing on rich longitudinal and cross-sectional data for Spain and multilevel estimation techniques, we show that in addition to individual level differences, policy levers (such as public health spending and the patient-doctor ratio, in particular) exert a considerable influence on the quality of a health care system. Our results suggest that policymakers seeking to enhance the quality of care should be cautious when compromising the level of health resources, and in particular, health personnel, as a response to economic downturns in a sector that traditionally had insufficient human resources in many countries, which have become even more evident in the light of the current health crisis. Additionally, we provide evidence that the increasing reliance on the private health sector may be indicative of inefficiencies in the public system and/or the existence of features of private insurance which are deemed important by patients.

The Challenge of Sustaining Long-term Care in Aging Societies: Lessons From Japan and Spain Comment on "Financing Long-term Care: Lessons From Japan".

This article compares the provision of long-term care (LTC) in Japan and Spain, two countries with similar demographic structures but which address the provision of LTCs in very different ways. Both countries provide universal LTC. However, Japan has developed a generous benefit package of formal services for dependents to alleviate the care burden on the family, but provides no cash benefits. In Spain, on the other hand, cash allowances are the norm rather than the exception in the practical implementation of LTC services. After discussing the necessary delineation of LTC in response to future sociodemographic challenges, we discuss LTC system characteristics and the recent cost containment reforms implemented in Japan and Spain. Finally, we consider the lessons that may be drawn from each country's experience and the reforms that must be undertaken in order ensure the sustainability of LTC provision in other countries with incipient or more developed LTC systems. In addition, since Japan and Spain are both faced with challenging demographic projections, it is important for each country to learn from the other's initiatives and reforms.

Limiting health-care access to undocumented immigrants: A wise option?

The number of undocumented migrants in high-income countries has increased in recent decades, imposing considerable political, fiscal, and social pressures on governments. This has fostered discussions on whether and to what extent undocumented migrants should get access to public programs and public benefits. Looking at the 2012 Spanish health reform, this is the first paper to document the impacts of a restriction on access to the health-care system for undocumented migrants on health-care utilization, health-care system perceptions, and self-reported health in a high-income country. We show that such restrictions may significantly reduce planned care for undocumented migrants and result in sharp fall in positive opinions about the health-care services still left available to them. We also exploit the heterogeneity in implementing the policy across regions and report stronger effects in regions that enforced the national ban more fully. Furthermore, in the first 3 years since the implementation of the reform, we find suggestive evidence of a worsening in self-assessed health. This study is relevant for policymakers in the developed world, especially in countries that have recently implemented initiatives aimed at reducing the health-care coverage for targeted groups, such as the United Kingdom and the United States.

Catastrophic risk associated with out-of-pocket payments for long term care in Spain.

OBJECTIVES: This study analyses the financial burden associated with the introduction of copayment for long-term care (LTC) in Spain in 2012 for dependent individuals. MATERIAL AND METHODS: We analyse and identify households for which the dependency-related out-of-pocket payment exceeds the defined catastrophic threshold (incidence), and the gap between the copayment and the threshold for the catastrophic copayment (intensity), for the full population sample and for subsamples based on the level of long-term care dependency and on regional characteristics (regional income and political ideology of party ruling the region). RESULTS: The results obtained show there is a higher risk of impoverishment due to copayment among relatively well-off dependents, although the financial burden falls more heavily on less well-off households. Our findings also reveal interesting regional patterns of inequity in financing and access to long-term care services, which appear to be explained by an uneven development of LTC services (monetary transfers versus formal services) and varying levels of copayment across regions. CONCLUSIONS: The new copayment for long-term care dependency in Spain is an important factor of catastrophic risk, and more attention should be addressed to policies aimed at improving the progressivity of out-of-pocket payments for LTC services within and between regions. In addition, formal services should be prioritised in all regions in order to guarantee equal access for equal need.

[What does the decision to opt for private health insurance reveal about public provision?] / ¿Qué revela sobre el sistema público sanitario la contratación de un seguro de salud privado?

OBJECTIVE: This study examines individuals' choice of private health insurance in Spain. Private health insurance choices reveal the attributes of health care most highly valued by the population, and the perceived responsiveness of the public system in delivering those preferences. METHOD: The paper exploits the 2004, 2009 and 2014 waves of the national Health Barometer survey, examining the health insurance choice separately for the general population and a small but influential sector of elite public-sector employees who can opt out from the public health system (civil servants). RESULTS: Public healthcare is a highly regarded provider in terms of technology and doctor training, even by those who chose private health insurance, but falls short in terms of amenities such as comfort and speed of attendance. These findings confirm well-known strengths and criticisms of the public system. However, the study also finds that citizens are concerned about the performance of the public sector in key domains of health system responsiveness, such as personal contact and information and these concerns also influence their decision to opt for private provision. Finally, civil servants, even the minority who opted for public provision, tend to have a lower opinion of the public health service than non-civil servants, especially in terms of personal contact, information, primary care and specialist care. CONCLUSIONS: These perceptions and concerns of the public about the performance of the public health service will be of interest for policy makers and should be investigated further.

Decentralization of health care systems and health outcomes: Evidence from a natural experiment.

While many countries worldwide are shifting responsibilities for their health systems to local levels of government, there is to date insufficient evidence about the potential impact of these policy reforms. We estimate the impact of decentralization of the health services on infant and neonatal mortality using a natural experiment: the devolution of health care decision making powers to Spanish regions. The devolution was implemented gradually and asymmetrically over a twenty-year period (1981-2002). The order in which the regions were decentralized was driven by political factors and hence can be considered exogenous to health outcomes. In addition, we exploit the dynamic effect of decentralization of health services and allow for heterogeneous effects by the two main types of decentralization implemented across regions: full decentralization (political and fiscal powers) versus political decentralization only. Our difference in differences results based on a panel dataset for the 50 Spanish provinces over the period 1980 to 2010 show that the lasting benefit of decentralization accrues only to regions which enjoy almost full fiscal and political powers and which are also among the richest regions.

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

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.

Income inequalities in unhealthy life styles in England and Spain.

Health inequalities in developed societies are persistent. Arguably, the rising inequalities in unhealthy lifestyles might underpin these inequality patterns, yet supportive empirical evidence is scarce. We examine the patterns of inequality in unhealthy lifestyles in England and Spain, two countries that exhibit rising obesity levels with a high prevalence of smoking and alcohol use. This study is unique in that it draws from health survey data spanning over a period in which major contextual and policy changes have taken place. We document persistent income-related inequalities in obesity and smoking; both unhealthy lifestyles appear to be disproportionately concentrated among the relatively poor in recent decades. In contrast, alcohol use appears to be concentrated among richer individuals in both periods and countries examined.

[Inequity in the use of health and social care services for disabled individuals in Spain]. / Inequidad en la utilización de servicios sociosanitarios en España para las personas discapacitadas.

OBJECTIVES: The objective of "equal access for equal need" is part of the policy agenda of most European countries. Several studies have provided evidence of equity in the use of healthcare services by the adult population in Spain. However, less attention has been paid to equity in access to health and social care services among the disabled population. In this study, we present an analysis of the distribution of unmet need for a set of economic, health and social care services by the disabled population in Spain. METHODS: Horizontal inequity in unmet need for various socioeconomic services was measured by using data from the EDAD2008 survey conducted in the disabled population in Spain and methods based on the Concentration Index. RESULTS: In Spain the distribution of unmet need among disabled individuals is not equitable. The greatest proportion of unmet needs is concentrated among individuals at the bottom of the income distribution. In addition, the level of horizontal inequity differs depending on the individual's gender and age, together with the specific service analyzed and the reasons giving rise to this unmet need. CONCLUSIONS: Socioeconomic status is important in access to health and social care services by the disabled. These results will allow policymakers to design policies aimed at reducing barriers to health and social care services among the disabled population in Spain.

The impact of fiscal decentralization on infant mortality rates: evidence from OECD countries.

This study re-examines the hypothesis that shifts towards more decentralization would be accompanied by improvements in population health on a panel of 20 OECD countries over a thirty year period (1970-2001). Decentralization is proxied using a conventional indicator of revenue decentralization and a new measure of fiscal decentralization that reflects better than previous measures the existence of autonomy in the decision-making authority of lower tiers of government, a crucial issue in the decentralization process. The results show a considerable and positive effect of fiscal decentralization on infant mortality only if a substantial degree of autonomy in the sources of revenue is devolved to local governments. The proportion of health care expenditure on GDP and, in particular, education, were found to have a larger contribution to the reduction of infant mortality in the sample of OECD countries analysed over the period of study.

Inequalities in the use of health services between immigrants and the native population in Spain: what is driving the differences?

In Spain, a growing body of literature has drawn attention to analysing the differences in health and health resource utilisation of immigrants relative to the autochthonous population. The results of these studies generally find substantial variations in health-related patterns between both population groups. In this study, we use the Oaxaca-Blinder decomposition technique to explore to what extent disparities in the probability of using medical care use can be attributed to differences in the determinants of use due to, e.g. a different demographic structure of the immigrant collective, rather than to a different effect of health care use determinants by nationality, holding all other factors equal. Our findings show that unexplained factors associated to immigrant status determine to a great extent disparities in the probability of using hospital, specialist and emergency services of immigrants relative to Spaniards, while individual characteristics, in particular self-reported health and chronic conditions, are much more important in explaining the differences in the probability of using general practitioner services between immigrants and Spaniards.

Explaining the demand for pharmaceuticals in Spain: are there differences in drug consumption between foreigners and the Spanish population?

OBJECTIVE: The aim of this study is to examine the factors driving the demand for drugs in Spain, focusing on the existence of disparities in pharmaceutical consumption between the Spanish and the foreign population. METHODS: Our analysis is based on a multilevel multinomial probit model that compares three consumption options (no consumption, prescribed consumption and self-medicated consumption) on the five most consumed drugs in Spain. Data is taken from the adult sample of the 2006 Spanish National Health Survey, including 29,478 individuals over 15 years old. RESULTS: Overall, the findings show a lower consumption of medicines by some immigrants categories relative to Spaniards. In addition, the results indicate that the consumption of medicines is mainly related to variables associated to the specific cost sharing structure in Spain, such as health limitations and retirement status. Other variables found to explain the demand for drugs were: private health insurance, age, sex, alcohol and cigarette consumption and drug class. CONCLUSION: Further understanding of the reasons for the observed differences in drug consumption on the basis of country of birth would allow the health system to design more effective health policies aimed at ensuring equality of access to health resources to all population groups.

[Differences in self-medication in the adult population in Spain according to country of origin]. / Diferencias en la automedicación en la población adulta española según el país de origen.

OBJECTIVES: To explore the factors determining self-medication among the Spanish adult population, paying special attention to differences in pharmaceutical consumption patterns between the immigrant and autochthonous populations in Spain. METHODS: Logistic regression models were used to evaluate the effect of several demographic, socioeconomic, lifestyle, and health-related variables on self-medication. Data were drawn from the adult sample of the 2006 Spanish National Health Survey, which included 29,478 individuals over 15 years old. RESULTS: The results show that individuals at higher risk of self-medication were young, with a positive perception of health and no chronic diseases, frequent consumers of alcohol, widowers, holders of a private medical insurance policy not contracted through the civil servants' mutual funds, residents in the Autonomous Communities of Madrid or Valencia, and individuals born in Central or Eastern Europe. CONCLUSIONS: Identifying the profile of self-medicated drug users in Spain may help health authorities to target high risk individuals in order to comply with European Union public health goals.

[Socioeconomic differences in health between the Spanish and immigrant population: evidence from the National Health Survey]. / Las diferencias socioeconómicas en salud entre la población española y extranjera en España: evidencia de la Encuesta Nacional de Salud.

OBJECTIVE: Reducing inequalities in health is one of the main objectives in any healthcare system. Several studies have analyzed inequalities in health in the Spanish population. However, the empirical evidence for the immigrant population is still insufficient. This study aim to quantify socioeconomic inequalities in health in the immigrant population living in Spain, in comparison with the national population. METHODS: To measure socioeconomic inequalities in health, we used a methodology based on the Concentration Index with data from the 2003 and 2006 Spanish National Health Surveys. RESULTS: According to the results there were socioeconomic inequalities in health for the health variables considered favoring high-income individuals. However, inequalities were lower for the immigrant subgroup than for the national population, although the magnitude of inequalities considerably increased between 2003 and 2006 for the immigrant population. CONCLUSIONS: This study shows the importance of socioeconomic position in explaining differences in health both in the national and in the immigrant population and provides evidence that could be used to design appropriate strategies to reduce inequalities in health in the immigrant collective in Spain.