ETHNICITY AND EQUITY IN THE USE OF HEALTH CARE SERVICES IN THE SPANISH NATIONAL HEALTH CARE SYSTEM

An important recent change in the Spanish society is the increasing proportion of the population who are immigrants. Immigrants often face situations of social exclusion and disadvantage, circumstances that may affect their health status. Empirical evidence about differences in health status or the utilisation of health services between native and immigrant population is however insufficient. This paper uses the 2003 National Health Survey to explore whether non-Spaniards, for the same level of need, use health care services at the same rate as national citizens. The findings show different patterns of health care use to the disadvantage of immigrants.Equity in health care, immigrant population, Spanish National Health System

Ethnicity and equity in the use of health care services in the Spanish National Health Care System

An important recent change in the Spanish society is the increasing proportion of the population who are immigrants. Immigrants often face situations of social exclusion and disadvantage, circumstances that may affect their health status. Empirical evidence about differences in health status or the utilisation of health services between native and immigrant population is however insufficient. This paper uses the 2003 National Health Survey to explore whether non-Spaniards, for the same level of need, use health care services at the same rate as national citizens. The findings show different patterns of health care use to the disadvantage of immigrants

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.Ministry of Science, Innovation and Universities PID2019-105688RB-I00Ministry of Economics and Competitiveness PID2020-114040RB-100Tomas y Valiente Fellowship - Madrid Institute for Advanced Study (MIAS) Comunidad de Madrid SI1/PJI/2019-0032

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.Spanish GovernmentMinistry of Science, Innovation and Universities Spanish Government PID2019-105688RB-I00 ECO2015-66553-R FPU18/0266

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.Ministerio de Economia Industria y Competitividad, y Ministerio de Ciencia Innovación y Universidades: PID2019-105688RB-I00 and ECO2015-66553-

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.Universidad de Granada/ CBU

The Challenge of Sustaining Long-term Care in Aging Societies: Lessons From Japan and SpainComment 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

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 individuallevel data from a large municipality in Spain. This approach allows estimating the causal impact of a type-2 diabetes diagnosis on clinical depression 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 particularly 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 information and lifestyle behaviours: the impact of a diabetes diagnosis

We estimate short- and long-term causal impacts of a type-2 diabetes mellitus (T2DM) diagnosis on lifestyle behaviours. We employ a fuzzy regression discontinuity design exploiting the exogenous cut-off value in the diagnosis of T2DM provided by a biomarker (glycated haemoglobin, HbA1c). We make use of unique administrative longitudinal data from Spain and focus on the impact of a diagnosis on clinically measured BMI, smoking and alcohol consumption. We find that, following a T2DM diagnosis, individuals appear to reduce their weight in the short-term. These effects are particularly large among obese individuals and those diagnosed with depression. Patients who are younger, still in the labour market and healthier also present increased short-term probabilities of quitting smoking. In addition, we provide evidence of statistically significant long-term impacts of a T2DM diagnosis on BMI up to three years from the diagnosis. Our results are consistent across parametric and non-parametric estimations with varying bandwidths

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.Spanish Ministry of Science, Innovation and Universities (grant number PID2019-105688RB-I00)The Tomás y Valiente Fellowship, Madrid Institute for Advanced Study (MIAS),Universidad Autónoma de Madrid (UAM),the Regional Government of Madrid (grant number H2019/HUM-5793)The Spanish Ministry of Science, Innovation and Universities (grant number PID2019-111765 GB-I00)