Do Public Caregiving Subsidies and Supports affect the Provision of Care and Transfers?

We study whether caregiving and intergenerational transfer decisions are sensitive to changes in economic incentives following the inception of a new unconditional and universal system of allowances and supports, after the introduction of the 2006 Promotion of Personal Autonomy and Care for Dependent Persons Act (SAAD in Spanish), and the ensuing effects of its austerity cuts after 2012. We find that whilst the introduction of a caregiving allowance (of a maximum value of €530 in 2011) increased the supply of informal caregiving by 20-22 percentual points (pp), the inception of a companion system of publicly subsidised homecare supports did not modify the supply of care. Consistent with an exchange motive for intergenerational transfers, we estimate an average 17 pp (8.2-8.7pp) increase (decrease) in downstream (upstream) transfers among those receiving caregiving allowances. Our estimates resulting from the reduction in the allowances and supports after the austerity cuts in 2012 are consistent with our main estimates, and suggest stronguer effects among lower-income families.

Fatal Underfunding? Explaining COVID-19 Mortality in Spanish Nursing Homes.

The COVID-19 pandemic has exerted a disproportionate effect on older European populations living in nursing homes. This article discusses the 'fatal underfunding hypothesis', and reports an exploratory empirical analysis of the regional variation in nursing home fatalities during the first wave of the COVID-19 pandemic in Spain, one of the European countries with the highest number of nursing home fatalities. We draw on descriptive and multivariate regression analysis to examine the association between fatalities and measures of nursing home organisation, capacity and coordination plans alongside other characteristics. We document a correlation between regional nursing home fatalities (as a share of excess deaths) and a number of proxies for underfunding including nursing home size, occupancy rate and lower staff to a resident ratio (proxying understaffing). Our preliminary estimates reveal a 0.44 percentual point reduction in the share of nursing home fatalities for each additional staff per place in a nursing home consistent with a fatal underfunding hypothesis.

Hiring subsidies for people with a disability: do they work?

This article evaluates the effectiveness of hiring subsidies targeted to people with disabilities. By exploiting the timing of implementation among different Spanish regions of a subsidy scheme implemented in Spain during the period 1990-2014, we employed a difference-in-differences approach to estimate the impact of the scheme on the probability of disability insurance (DI) beneficiaries of transiting to employment and on the propensity of individuals of entering the DI program. Our results show that the introduction of the subsidy scheme is in general ineffective at incentivizing transitions to employment, and in some cases it is associated with an increased propensity of transiting to DI. Furthermore, we show that an employment protection component incorporated into the subsidy scheme, consisting in the obligation for the employer to maintain the subsidized worker in employment, is associated with less transitions to permanent employment, more transitions to temporary employment and more transitions to DI, suggesting that these type of employment protection measures can have undesired effects for people with disabilities.

Does long-term care subsidization reduce hospital admissions and utilization?

We use quasi-experimental evidence on the expansion of the public subsidization of long-term care to examine the causal effect of a change in caregiving affordability on the delivery of hospital care. More specifically, we examine a reform that both introduced a new caregiving allowance and expanded the availability of publicly funded home care services, on both hospital admissions (both on the internal and external margin) and length of stay. We find robust evidence of a reduction in both hospital admissions and utilization among both those receiving a caregiving allowance and, albeit less intensely, among beneficiaries of publicly funded home care, which amounts to 11% of total healthcare costs. These effects were stronger when regions had an operative regional health and social care coordination plan in place. Consistently, a subsequent reduction in the subsidy, five years after its implementation, is found to significantly attenuate such effects. We investigate a number of potential mechanisms, and show a number of falsification and robustness checks.

Interactions between Private Health and Long-term Care Insurance and the Effects of the Crisis: Evidence for Spain.

This paper analyzes the reasons for the scarce development of the private long-term care insurance market in Spain, and its relationship with health insurance. We are also interested in the effects the crisis has had both on the evolution of the demand for long-term care insurance and on the existence of regional disparities. We estimate bivariate probit models with endogenous variables using Spanish data from the Survey on Health and Retirement in Europe. Our results confirm that individuals wishing to purchase long-term care insurance are, in a sense, forced to subscribe a health insurance policy. In spite of this restriction in the supply of long-term care insurance contracts, we find its demand has grown in recent years, which we attribute to the budget cuts affecting the implementation of Spain's System of Autonomy and Attention to Dependent People. Regional differences in its implementation, as well as the varying effects the crisis has had across Spanish regions, lead to the existence of a crowding-in effect in the demand for long-term care insurance in those regions where co-payment is based on income and wealth, those that have a lower percentage of public long-term care beneficiaries, or those with a smaller share of cash benefits over total public benefits. Copyright © 2016 John Wiley & Sons, Ltd.

BAD TIMES, SLIMMER CHILDREN?

Although the majority of the literature has confirmed that recessions are beneficial for adults' health and babies' outcomes at delivery, this effect should not necessarily be the same for children. In this paper, we study the effect of business cycle conditions on infant underweight, overweight, and obesity. We exploit eight waves of repeated cross-sectional data (1987-2012) of the Spanish National Health Survey for children aged 2-15 and use the regional unemployment rate of the trimester of the interview as a proxy for the business cycle phase at the local level. We find that an increase in the unemployment rate is associated with lower obesity incidence, especially for children under 6 years old and over 12 years old. However, economic shocks also proof to have potentially negative consequences as they increase the prevalence of infant underweight for the same age groups. Moreover, we show that the possible mechanisms through which the cycle is impacting infant obesity is the nutritional composition of the children's diet, as well as, increases in the frequency of exercise. We provide some evidence that suggests that the impact of business cycle conditions on infant weight disorders have little objective health consequences in the short run. However, the potential long-term effects may become important as underweight during childhood is associated with worse outcomes later in life. Copyright © 2016 John Wiley & Sons, Ltd.

Informal care motivations and intergenerational transfers in European countries.

This work sets out to analyze the motivations adult children may have to provide informal care, considering the monetary transfers they receive from their parents. Traditional motivations, such as altruism and exchange, are matched against more recent social bond theories. Our findings indicate that informal caregivers receive less frequent and less generous transfers than non-caregivers; that is, caregivers are more prone to suppress their self-interested motivations in order to prioritize the well being of another person. Additionally, long-term public care benefits increase both the probability of receiving a transfer and its amount, with this effect being more intense for both the poorest and richest households. Our findings suggest that if long-term care benefits are intended to increase the recipients' welfare and represent a higher fraction of total income for the poorest households, the effectiveness of these long-term care policies may be diluted.

Unmet needs in formal care: kindling the spark for caregiving behavior.

This paper studies if a situation of formal care unmet needs is a strong motivation for the onset of caregiving behavior, and if becoming caregiving is a compelling argument for leaving current job (in the presence/absence of formal care unmet needs). We use data from the Eurobarometer 67.3 for 18 European countries and estimate a three simultaneous equations model taking into account the potential endogeneity of labor participation and formal care unmet needs and assuming non-zero correlation among the error terms of the three equations. Results show that individuals who anticipate that becoming caregiver can suppose an obstacle for continuing working feel more refractory and are more prone to avoid caregiving responsibilities. Knowing someone with an unmet needs problem increases the probability of becoming caregiver by +19.23 pp (with a maximum of +39.39 pp for difficult access unmet needs) and raises the probability of leaving employment by 5.77 pp. Having to possibility of receiving economic benefits for caregivers encourage more labor market exit as compared to payment of social security contributions during care leaves.

An empirical analysis of the multimarket contact theory in pharmaceutical markets.

Multimarket contact theory predicts that firms will optimally reduce prices in markets where collusive prices are sustainable and allocate the slack of the corresponding incentive compatibility to increase prices in markets where collusion is not sustainable. Binding price caps in collusive markets will have different effects over the multimarket contact mechanism depending on the severity of the cap. Setting a price cap close to the unregulated case will increase the size of the redistribution of market power whereas stronger regulation will even reduce prices in unregulated markets. Therefore, price regulations aiming at capping prices in a specific market will also affect markets that are not subject to specific mandatory price regulations. We find evidence of the theory predictions using information for nine OECD countries for pharmaceutical markets. Unregulated US markets are shown to respond to the redistribution effect; Canadian markets, known to be subject to soft price regulations, with respect to the former, are shown to be consistent with a stronger redistribution effect. EU markets and Japan are either consistent with the effect of a medium regulation or strong regulation. In this last case multimarket contact cannot explain prices, and these are expected to be lower compared to the unregulated benchmark.

The determinants of pricing in pharmaceuticals: are US prices really so high?

This paper studies price determination in pharmaceutical markets using data for 25 countries, 6 years, and a comprehensive list of products from the MIDAS IMS database. A key finding is that the USA has prices that are not significantly higher than those of countries with similar income levels, especially those that are 'lightly regulated'. More importantly, price differences to the US levels increase for 'branded', world top selling, or innovative products, and decrease, regardless of the level of regulation for mature or widely diffused molecules. Because prices for top selling molecules may be easier to perceive and recollect and more important for companies, they may bias the public discussion about international price differences.

La interacción del sistema social y el sanitario. Informe SESPAS 2012 / Interaction between the social and the health systems. SESPAS Report 2012

La Ley 39/2006, de 14 de diciembre, de Promoción de la Autonomía Personal y Atención a las Personas en situación de Dependencia, regula las condiciones básicas para la promoción de la autonomía personal y el cuidado de las personas en situación de dependencia mediante la creación del Sistema de Autonomía y Atención a la Dependencia (SAAD), y constituye una oportunidad excelente para avanzar en la construcción del espacio sociosanitario. El objetivo de la integración sociosanitaria es pasar de un marco fragmentado, en donde el individuo recibe y solicita las prestaciones a servicios sociales y sanitarias por separado, a un nuevo modelo de responsabilidad compartida. Desde los años 1980 se han desarrollado diversos proyectos de ámbito nacional o regional de cooperación sociosanitaria. Sin embargo, aunque se han realizado importantes esfuerzos en este sentido, y hay diversas experiencias de integración de servicios sanitarios en varias comunidades autónomas, sigue predominando la coordinación asistencial en el ámbito sanitario por encima de la integración (AU)

Act 39/2006, of 14th December, for the Promotion of Personal Autonomy and the Care of Dependent Individuals establishes the basic conditions for the promotion of personal autonomy and the care of the dependent through the creation of the System of Autonomy and Care of Dependent Individuals and constitutes an excellent opportunity to make progress in the development of a health care space.The aim of healthcare integration is to move from a fragmented framework, in which individuals apply for and receive health benefits and care benefits separately, to a new model of shared responsibility. Since the 1980s, several national and regional projects of healthcare cooperation have been developed. However, although substantial efforts have been made in some autonomous regions of Spain, healthcare coordination seems to predominate over integration in the health setting (AU)

The trade-off between formal and informal care in Spain.

Understanding the factors that determine the type and amount of formal care is important for predicting use in the future and developing long-term policy. In this context, we jointly analyze the provision of care at both the extensive (choice of care) and the intensive margin (number of hours of care received). In particular, we estimate and test, for the first time in this area of research, a sample selection model with the particularities that the first step is a multinomial logit model and the hours of care is an interval variable. Our results support the complementary and task-specific models which evidence has been found in other countries. Furthermore, we obtain evidence of substitution between formal and informal care for the male, young, married and unmarried subsamples. Regarding the hours of care, we find significant biases in predicted hours of care when sample selection is not taken into account. For the whole sample, the average bias is 2.77% for total hours and 3.23% for formal care hours. However, biases can be much larger (up to 10-15%), depending on the subsample and the type of care considered.

[Interaction between the social and the health systems. SESPAS Report 2012]. / La interacción del sistema social y el sanitario. Informe SESPAS 2012.

Act 39/2006, of 14th December, for the Promotion of Personal Autonomy and the Care of Dependent Individuals establishes the basic conditions for the promotion of personal autonomy and the care of the dependent through the creation of the System of Autonomy and Care of Dependent Individuals and constitutes an excellent opportunity to make progress in the development of a health care space. The aim of healthcare integration is to move from a fragmented framework, in which individuals apply for and receive health benefits and care benefits separately, to a new model of shared responsibility. Since the 1980s, several national and regional projects of healthcare cooperation have been developed. However, although substantial efforts have been made in some autonomous regions of Spain, healthcare coordination seems to predominate over integration in the health setting.

[Trade-off between formal and informal care in Europe]. / Trade-off entre cuidados formales e informales en Europa.

OBJECTIVE: To study the relationship between formal and informal care for the dependent population in a number of European countries. METHOD: Data from the Survey of Health, Aging and Retirement in Europe for 2004 were used and a bivariate probit model was estimated. Unlike other studies, the present analysis includes the institutional features of the various long-term care systems, in addition to the demographic, health and environmental characteristics of the individual receiving care. RESULTS: A significant correlation was found between the two options, which reveals that, conditional on receiving care, there was a preference for the combination of both types of care. The results show the importance of health status and living arrangements for defining the combination of formal and informal care. There were substantial differences in the likelihood of the two types of care among European countries. A notable finding was the importance of informal care in Spain in comparison with other countries. CONCLUSIONS: The probability of receiving formal or informal care is higher in countries where families have a legal obligation to look after dependent relatives and where institutionalization rates are higher. This finding should be considered in the design of long-term care policies. Therefore, to control growth of public expenditure and, at the same time, improve caregiver satisfaction, policies that combine distinct formal services should be promoted over the implementation of care allowances.

Trade-off entre cuidados formales e informales en Europa / Trade-off between formal and informal care in Europe

Objetivo: En este trabajo se estudia la relación entre cuidados personales formales e informales para la población dependiente en un conjunto de países europeos. Métodos: Se utilizan datos del Survey of Health, Ageing and Retirement in Europe (2004), y se estima un modelo probit bivariado. A diferencia de otros estudios, no sólo se tienen en cuenta características sociodemográficas, de salud y del entorno del receptor de los cuidados, sino que también se consideran las características institucionales de los sistemas de cuidados de largo plazo. Resultados: Se obtiene una correlación positiva y significativa entre ambas decisiones, es decir, condicional a recibir cuidados; hay una cierta preferencia por la combinación de ambos tipos de cuidados. Los resultados muestran la relevancia de las variables de salud y del régimen de convivencia a la hora de definir la combinación de cuidados formales e informales. Hay diferencias importantes en la probabilidad de utilización de ambos tipos de cuidados entre países europeos, y destaca la relevancia de los cuidados informales en España. Conclusiones: El diseño de políticas de cuidados de largo plazo debe tener en consideración que la probabilidad de recibir cuidados formales o informales aumenta más en los países donde hay obligación legal de atender a familiares dependientes o con una mayor tasa de institucionalización. Por tanto, la combinación de diferentes servicios formales, más que la implementación de prestaciones económicas para el cuidador, debiera considerarse como alternativa posible para controlar el gasto público y aumentar la satisfacción de los cuidadores (AU)

Objective: To study the relationship between formal and informal care for the dependent population in a number of European countries. Method: Data from the Survey of Health, Aging and Retirement in Europe for 2004 were used and a bivariate probit model was estimated. Unlike other studies, the present analysis includes the institutional features of the various long-term care systems, in addition to the demographic, health and environmental characteristics of the individual receiving care. Results: A significant correlation was found between the two options, which reveals that, conditional on receiving care, there was a preference for the combination of both types of care. The results show the importance of health status and living arrangements for defining the combination of formal and informal care. There were substantial differences in the likelihood of the two types of care among European countries. A notable finding was the importance of informal care in Spain in comparison with other countries. Conclusions: The probability of receiving formal or informal care is higher in countries where families have a legal obligation to look after dependent relatives and where institutionalization rates are higher. This finding should be considered in the design of long-term care policies. Therefore, to control growth of public expenditure and, at the same time, improve caregiver satisfaction, policies that combine distinct formal services should be promoted over the implementation of care allowances (AU)

Inmigración y demanda de seguros sanitarios / Immigration and the demand for private health insurance

Introducción: El aumento del flujo migratorio hacia España durante los últimos 10 años ha tenido repercusiones importantes en la provisión de servicios públicos clave. En este trabajo analizamos el efecto que ha tenido el aumento de la percepción de una mayor congestión sobre la demanda de seguros sanitarios privados. Métodos: Empleando datos recogidos en la Encuesta Nacional de Salud de los años 2001, 2003 y 2006, se plantean modelos dicotómicos de elección discreta para modelizar la demanda de doble cobertura sanitaria (seguro público y privado) y sobre la demanda de cobertura privada de funcionarios públicos. Resultados: Los resultados obtenidos apuntan a que tanto el porcentaje de inmigrantes como el incremento de la población resulta en una mayor demanda de seguros médicos privados (muestra de doble cobertura), principalmente en grupos de renta media-alta y con hijos, o en una mayor preferencia por un suministrador privado de atención sanitaria (en la muestra de funcionarios públicos). En ambos casos, esto ocurre para poder acceder con mayor prontitud a servicios especializados y de emergencias privadas. Obtenemos que el efecto marginal utilizando la variable del porcentaje de inmigrantes es mucho mayor en la muestra de funcionarios públicos (cerca de 0,20) que en la muestra de la Seguridad Social (0,05). Conclusiones: Pese a que los inmigrantes gozan, en media, de un mejor estado de salud que los españoles y utilizan menos los servicios sanitarios (a excepción de las urgencias), han supuesto un importante aumento de la demanda de atención sanitaria y, en particular, de seguros sanitarios privados (AU)

Introduction: The wave of immigration in Spain in the last 10 years has had major consequences in the provision of key public services. In the present study, we examined the effect of this population shock on the demand for private health insurance. Methods: Using data from the National Health Survey for 2001, 2003 and 2006, we estimated discrete choice models to analyze the demand for dual coverage (public and private insurance) and the demand for private coverage among civil servants. Results: The results suggest that both the percentage of immigrants and the increase in the population resulted in greater demand for private health insurance (social security sample), mainly in groups with a middle-to-high income and with children or with a greater choice of private healthcare provider (in the sample of civil servants). In both cases, private healthcare was sought to gain access to specialized and emergency services more rapidly. The marginal effect obtained by using the variable of the percentage of immigrants was much higher in the sample of civil servants (about 0.20) than in the social security sample (0.05). Conclusions: Although immigrants tend to enjoy better health and use health services (with the exception of emergencies) less frequently than Spaniards, this collective has led to a significant increase in the demand for healthcare and, especially, private health insurance (AU)

[Immigration and the demand for private health insurance]. / Inmigración y demanda de seguros sanitarios.

INTRODUCTION: The wave of immigration in Spain in the last 10 years has had major consequences in the provision of key public services. In the present study, we examined the effect of this population shock on the demand for private health insurance. METHODS: Using data from the National Health Survey for 2001, 2003 and 2006, we estimated discrete choice models to analyze the demand for dual coverage (public and private insurance) and the demand for private coverage among civil servants. RESULTS: The results suggest that both the percentage of immigrants and the increase in the population resulted in greater demand for private health insurance (social security sample), mainly in groups with a middle-to-high income and with children or with a greater choice of private healthcare provider (in the sample of civil servants). In both cases, private healthcare was sought to gain access to specialized and emergency services more rapidly. The marginal effect obtained by using the variable of the percentage of immigrants was much higher in the sample of civil servants (about 0.20) than in the social security sample (0.05). CONCLUSIONS: Although immigrants tend to enjoy better health and use health services (with the exception of emergencies) less frequently than Spaniards, this collective has led to a significant increase in the demand for healthcare and, especially, private health insurance.

A sequential model of older workers' labor force transitions after a health shock.

In this paper we estimate and validate a three-period sequential model of older workers' labor force transitions following a health/disability shock, using retrospective information from Spanish cross-section data. Central to the analysis are the effects of the various disabilities and their severity. We find that the probability of remaining employed decreases both with age and the severity of the shock. Moreover, we find strong interactions between age and severity for older workers and none for prime-age workers. Suffering any kind of disability reduces the probability of being employed immediately prior to retirement age, and in such cases it is severity which is the strongest indicator. With respect to demographics, we find that female gender, having a retired spouse or being married all reduce the probabilities of both remaining in employment and returning to work following a spell of inactivity; in turn, principal breadwinner status, education and skill levels increase this likelihood.

An empirical analysis of the demand for physician services across the European Union.

This paper presents parameter estimates for physician service equations using the "European Community Household Panel" for 12 countries covering the period 1994-1996. The focus is on two specific points: (1) the identification of behavioural similarities and differences in the demand for health services across the 12 countries; (2) the variability in demand for health services represented through a joint model for all countries. We found that there are significant differences among countries, although there are also similarities in the effect of variables such as health stock, labour situation or family structure. An important fraction of the variability in the demand for health services across countries could be explained by differences in age, income and the role of general practitioners as gatekeepers in the public health system. We found some evidence of induced demand in the decision to visit a specialist and in the number of such visits.