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Eligibility and inclusiveness of long-term-care institutional frameworks in Europe: a cross-country comparison

2014 Conference Presentation

(Inter)national systemsEquity EU

1 September 2014

Eligibility and inclusiveness of long-term-care institutional frameworks in Europe: a cross-country comparison

Ludovico- Ca' Foscari Carrino, University of Venice, Italy
Cristina Orso, University of Venice, Italy


Economic literature has recently started to concentrate on long-term-care (LTC) institutional frameworks, namely the design, the scope and the regulation of main public programs focused on assistance to disabled elderly population in European countries. Being able to effectively compare LTC systems can indeed prove highly useful to economists, social scientists and policy makers. Research in this field has to account for countries’ institutional differences, but existing studies have often to rely on classifications built on generic socio-economic characteristics that might not reflect the actual LTC policies. Some recent contributions on LTC regulations are the OECD publications (Colombo F. et al., 2011; Murakami, Colombo, 2013), the European Commission (Ageing Report 2012), the ENEPRI-ANCIEN reports (Kraus et al., 2010), Da Roit, Le Bihan (2007) and Pommer et al. (2007).

Existing analysis do not offer an overall view of the degree of inclusiveness that characterizes each European system and that is especially determined by eligibility conditions and assessment-ofneed processes, both regulated by law. Besides being different in financing models, degree of universalism and centralization, LTC systems differ in how they define and assess “disability conditions”, and therefore also in the definition of a minimum level of need that allows someone to be eligible to a program of care. The way in which eligibility conditions are designed and implemented represent an additional and primary “institutional feature” which depends on countries’ specific political and sociological approaches (leading to heterogeneity in degrees of inclusiveness). These features should not be neglected when studying individuals’ decisions related to LTC programs, as well as when monitoring programs’ performances per-se.

Our contribution to the literature is threefold. After providing a typology of existing European LTC systems (nature of the programs, choice of the care-provider, support to informal caregivers, etc.) we provide detailed information on eligibility and assessment-of-need processes in Europe, thus offering a complete ‘at a glance’ picture of how disability and dependence are defined and assessed in each main LTC programs. Our analysis goes deep in characterizing both the extensive margin (the dimensions of disability) and the intensive margin (the minimum threshold of dependency that gives access to a program). Secondly, building on these information, we generate an index that allows for comparability between countries’ systems: a measure of inclusiveness that takes into account both the extensive and the intensive margins of the need-assessment process and reflects the extent to which each program offers coverage to individuals who suffer from some limitations (we adopt the ADL and IADL taxonomies by Katz and Lawton-Brody, respectively).

Finally, we perform a micro-simulation on European elderly population (using data from the Survey of Health Ageing and Retirement). We assess the counterfactual consequences of the adoption of a unified European LTC regulation with a unique set of eligibility conditions, and show how it would affect each country’s potential demand of formal care (quota of eligible population) and its consequences on public expenditure on LTC.