1. Disparities in Regular Health Care Utilisation in Europe A Life-time Analysis SHARELIFE Meeting – Svendborg, (DK) July 20 th, 2010 Nicolas Sirven *, Zeynep Or Institute for Research and Information on Health Economics Paris, France (*) sirven@irdes.fr

2. 1.What do we know? Regular Health Care utilisation is a public policy matter (prevention, early detection, care) contribute to improved health status Despite common social security systems in Europe, disparities in care utilisation across countries are significant 2.What is less well known? What are dynamics of these disparities? - How the utilisation of the health care system evolved across generations? - What contributes more to changing habits? Econ. developt. or health system? What are the determinants of cross-country differences? - Few cross-country analysis - No analysis of individuals’ long term care habits 3. Our contribution Life-time analysis of individual + system characteristics on people’s behaviour Comparison of 3 cohorts and 13 European countries over the last 35 years Introduction Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

3. 1.SHARE data Individuals 50+ in 15 European countries (on health, social, economic) Panel = 2 repeated cross-sections (2004, 2006) + retrospective (2008) Sharelife 2.Selected sample w3 + w1|w2 = 13 countries Born between ]1925-1955]  3 cohorts: 1925-35 ; 1935-45 ; 1945-1955 “Good understanding of Sharelife questions” = drop 0.6% of the sample Full rank = 22,814 obs. (12,440 for women only) 3.Dependant variables “Did you ever had regular checks…”  Blood tests, blood pressure, gynaecological, mammogram, vision Binary: 1 Yes (has started regular checks), 0 No (didn’t star so far) Data Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

4. Regular Health Care at a Glance Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

5. Age Start Regular Health Care Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

6. 200519951985 1975 Cohort 1 Born ]1925-35] Cohort 2 Born ]1935-45] Cohort 3 Born ]1945-55] Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010) Period 1Period 2Period 3 Analysing Cohort Effects in a Given Country Age 40-59 Age 30-49 Age 20-39

7. 200519951985 1975 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010) Period 1Period 2Period 3 Analysing Cohort Effects in a Given Country Age 40-59 Cohort 1 Born ]1925-35] Cohort 2 Born ]1935-45] Cohort 3 Born ]1945-55]

8. 200519951985 1975 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010) Period 1Period 2Period 3 Context Variables in a Given Country Age 40-59 OECD Series statisticsGDP per capita Total health expenditure per capita Public expend. on health (as % of total exp. on health) Practising physicians (Density /1000 pop.) Cohort 1 Born ]1925-35] Cohort 2 Born ]1935-45] Cohort 3 Born ]1945-55] What context variables explain differences in individual behaviour across cohorts?

9. 200519951985 1975 Context Variables in a Given Country Age 40-59 Cohort 1 Born ]1925-35] Cohort 2 Born ]1935-45] Cohort 3 Born ]1945-55] Period 1Period 2Period 3 OECD Series statisticsGDP per capita Total health expenditure per capita Public expend. on health (as % of total exp. on health) Practising physicians (Density /1000 pop.) Total growth rate over period p average volume/level over period p Mean average annual growth rate over period p Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

10. 200519951985 1975 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010) Context Variables in a Given Country Age 40-59 Cohort 1 Born ]1925-35] Cohort 2 Born ]1935-45] Cohort 3 Born ]1945-55] Period 1Period 2Period 3 OECD Series statisticsGDP per capita Total health expenditure per capita Public expend. on health (as % of total exp. on health) Practising physicians (Density /1000 pop.) Total growth rate over period p 1 variable taking 3 different values (cohort) for each country average volume/level over period p Mean average annual growth rate over period p CONTEXT VARIABLES = The influence of public policy at different times for individuals having the same age

11. Econometric Methodology Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010) 1.Country × Cohort effects Retrospective data allow disentangling age/cohort effects Idea: cluster (C=39) = country (J=13) × cohorts (T=3)

12. Y* ic =  0c + X ic  + e ic with Hyp. 1:  0c =  0 +  0c Hyp. 2:  0c =  0 +  01 Z c +  0c Econometric Methodology Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010) 1.Country × Cohort effects Retrospective data allow disentangling age/cohort effects Idea: cluster (C=39) = country (J=13) × cohorts (T=3) 2.Multilevel Model (parsimonious) 3. Two-Step Multilevel - Gives same results (Coeffs. & S.E.) when comparing with HLM - Allows more interesting Level 2 specification 4. Variables Set - Age, gender, education, income, Employment status, ADL, Chronic illnesses (Cancer) - Initial conditions (Index of comfort, SRH child, Relative School Performance) + Context variables (Z c )

13. Step 1: Individual level regressions 1/2 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

14. 2/2 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010) Step 1: Individual level regressions

15. Step 2: Country × Cohorts level regressions 1/2 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

16. Step 2: Country × Cohorts level regressions 1/2 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

17. Step 2: Country × Cohorts level regressions 1/2 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

18. Step 2: Country × Cohorts level regressions 1/2 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)

19. Step 2: Country × Cohorts level regressions 2/2 Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010) Purge the effect of health policies from economic conditions Volume effect (no price effects)

20. 1. Summary At the individual Level: Health! & Healthy Worker Effect Education & economic conditions … but still significant differences between countries & cohorts Cohort effect: General shift towards more preventive care across generati Cross-country: Investment in health care matters - (Time invariant unobserved heterogeneity) - People in times & places with higher spending in health have more chances to have regular care (Economic growth per se matters less) 2. Further Work… Duration analysis of “Age start regular health care”... Any suggestions? Thank you! Discussion Disparities in Regular Health Care Utilisation in Europe: A Life-time Analysis – Nicolas Sirven & Zeynep Or (2010)