Convidámos o Manuel Serrano-Alarcón, que terminou este ano o doutoramento em Global Public Health na Escola Nacional de Saúde Pública da Universidade Nova de Lisboa, a partilhar os trabalhos da sua tese. Fique a conhecer os resultados da investigação do Manuel.
Functional disability among middle-aged and elderly Europeans: socioeconomic patterning, burden and policies
The share of elderly population is increasing across all high-income countries. As long as such increase is not offset by improvements in the health status and functional disability of older adults, there will be grave consequences for healthcare and welfare systems. In this context, it is of extreme relevance to get to know what factors are associated with the process of ageing and disability and to study which policies can potentially reduce the burden of increasing disability and population ageing.
With these challenges in mind, the objective of my thesis was twofold: first, to determine what are the socioeconomic factors associated with the onset of functional disability and its associated burden for families and the healthcare system. Second, to evaluate the effectiveness of a set of policies that may prevent or mitigate the burden of functional disability either on individuals, families or in the countries’ healthcare systems. The thesis was defended in April 2021 in the NOVA National School of Public Health and it is formed by 4 chapters that I briefly summarize below.
Ageing under unequal circumstances
In the first chapter, I look at the socioeconomic determinants of functional disability using data from the Survey of Health Ageing and Retirement from three Southern European countries (i.e.: Italy, Portugal and Spain). These countries are characterised by severely aged societies, increasing income inequalities and low levels of long-term care (LTC) spending. We find that the process of functional disability is unequally distributed across the socioeconomic status of the individuals. Women and those with a lower socioeconomic status see their onset of disability at earlier ages.
We also show that the middle-aged and older adults in Portugal show a higher prevalence of functional disability as compared to Spain and Italy. At the same time, Portugal presents the lower levels of informal care use and LTC expenditure. This suggests the existence of potential unmet needs among the functionally disabled Portuguese population, as compared to Italy and Spain. Actually, the limited expansion of LTC in the three countries under analysis, indicates that there is room to ease the burden on families by the expansion of such systems.
Tobacco control policies and smoking among older adults
In the second chapter I study the effectiveness of a set of policies aimed to reduce the second risk factor for disability in Europe: smoking. Tobacco control policies have been implemented across Europe in the last years. Yet, studies on the effectiveness of such policies on the middle-aged and older population are scarce. We therefore studied the effect of tobacco control policies on smoking among the European older population during a period of strong tobacco control legislation (2004-2013). We found that tax increases and smoke-free policies are associated with a reduction in smoking probability, especially among those with lower socioeconomic status, as measured by education.
Hence, as long as smoking cessation at old ages can still bring significant health gains, these tobacco control policies can decrease inequalities in smoking-related diseases. Ultimately, tobacco control policies can also contribute to reduce the disability burden among the most disadvantaged families. Still, our results suggest that tobacco control policies were more effective in reducing smoking prevalence among middle-aged adults (i.e.: aged 50-65), than among older adults (i.e.: older than 65). This might be explained by older adults being largely formed by the so-called “hardcore” smokers, who may be less sensible to tobacco control policies. If this is the case, specific tobacco control policies should be designed for this increasing share of the population if we aim to continue to reduce smoking prevalence.
Long-term unemployment subsidies and middle-age disadvantaged workers’ health
In the third chapter I look at a social policy that, although its primary objective is not related with health, it can indirectly have significant health effects: unemployment subsidies. In particular, we studied the health effects of an unemployment subsidy targeted to disadvantaged middle-age long-term unemployed workers. In order to do so, we exploited a legislation change in Spain that rose the minimum age required to have access to this subsidy from 52 to 55.
Our results start by showing how the recipients of such subsidy were very disadvantaged in terms of education and the type of previous jobs. Men who were eligible to the subsidy reduced their hospitalizations due to injuries, fact that we explain by them having as an alternative source of income very physically demanding and precarious jobs. Also they showed a higher probability of being diagnosed with a mental health condition. Overall results show that restricting the access to this subsidy had detrimental physical and mental health effects, despite not being hardly effective in incentivizing formal employment. Long-term unemployment benefits emerge then as a clear example of a social policy that, despite not being originally designed for pursuing health objectives, can have significant health effects, particularly on the worse-off.
What is the effect of Long-Term Care (LTC) benefits on healthcare use?
In the last chapter I use the case of an incipient LTC system in Spain, to see how such system can ease the burden that increasing functional disability imposes on healthcare. To do that, we link registered data from Social and Health services to estimate the causal effect of LTC benefits on healthcare use. Our results show that LTC benefits largely decreased avoidable non-scheduled healthcare use such as injury hospitalizations, and primary care visits due to poor social conditions. This might be a consequence of improved health of the LTC recipients due to better monitoring of their health of carers. On the other hand, LTC benefits promoted programmed healthcare use related with improved access to healthcare, rather than with a deterioration of health, such as programmed cataract surgeries or programmed cancer primary care visits.
These results show that the reception of LTC is significantly related with healthcare use. This has relevant policy implications for the organization of both LTC and healthcare system. Greater coordination of both systems with mechanisms such as pooling budgets might therefore increase the efficiency of the resource allocation between the two systems, by taking into account the externalities that LTC system creates on the healthcare system. In particular, results suggest that an allocation of resources to LTC may not only increase the wellbeing of LTC patients, but also help to contain increasing healthcare costs, by avoiding unnecessary healthcare use.
Summing up, this thesis shows how the increasing burden of functional disability is unequally distributed, hitting more severely those with a lower socioeconomic status. Additionally, it carries out three empirical evaluations of three policies targeted to middle-aged and older adults that may prevent or mitigate such burden of disability: tobacco control policies, long-term unemployment subsidy, and long-term care benefits. Results of these evaluations showed how these policies may decrease the social gap in disability and ease its burden on healthcare systems, even if it is not necessarily their main policy objective.
Postdoctoral researcher at Bocconi University, Dondena Research Centre
Personal website: https://sites.google.com/view/manuelserranoalarcon