Equity and efficiency in long-term care policies: empirical evidence from France and the Netherlands

In France, the year 2018 startedwith an unprecedented strike hitting the news: that of the employees of nursing homes. Nurses and other professional caregivers are claiming more financial resources from the government, in order to improve their working conditions, increase the quality of care and guarantee the elderly residents’ dignity. Although the protest
was unexpected, it did not come as a surprise. Even though the strike was led by the workers of a sector that is structurally little prone to collective protests, it echoes a feeling largely shared by the public opinion: too little is done to help our most fragile elders. Behind this apparent consensus, many fundamental questions arise, relating to the sense thatwe should give to this diagnosis and the remedies to offer. Who should be more involved in supporting the disabled individuals, in particular the elderly: the government? In such a case, which budgetary trade-offs have to be accepted? Should we rather expect more from the families? Those are already greatly involved in the provision of informal care; in addition, they are being reconfigured by lower fertility rates and the evolution of behaviors in terms of unions and females’ labor market participation. Should we then call for more individual responsibility and more room for market-based solutions? At the individual level, the onset of physical, sensory or cognitive limitations in adult life is a risk, whose probability can increase along with the rise of longevity. At the level of the countries that have completed their demographic transition, it is certain that the number of the disabled elderly will keep increasing and represent a growing share of total population. In the countries of the Organization for economic co-operation and development (OECD), the economic and public finance crisis came on top of population aging; this has resulted in a context in which the role of the government at large in the financing and in the organization of care provision for disabled individuals is being challenged. The question of the human and financial resources that should be devoted to long-termcare arises both in the intimacy of families but also in Parliamentary discussions; it is one of the major societal and political questions of our time. Thanks to its conceptual and empirical tools, economics can shed light on this question, even if it is certainly not the only relevant disciplinary approach to it. It showswell adapted to tackle the following question: to what extent are public long-termcare policies efficient and equitable? This is the general issue that this thesis intends to address and thereby contribute to the public debate. The thesis starts with a general introduction. The first part aims at exposing the general topic, starting with definitions of the concepts of disability, dependency and long-termcare. It also offers a broad overview of the demographic and epidemiological trends as well as of the long-termcare policies in OECD countries. The second part relates the general question addressed in the thesis to the existing economic literature. It also presents the long-term care systems in the two countries under investigation in the empirical analysis, France and the Netherlands, and highlights the interest of their institutional features with respect to the questions being discussed. The third section reviews the specific research questions that are tackled in each Chapter, the main results and their implications. It also presents the conceptual tools, the empirical methods, the data aswell as the empirical definitions of longtermcare, care needs and the equity principles that are used in this thesis.