The packaging puzzle. An investigation into the Income and Care Packages of the Belgian Elderly Population. Rika VERPOORTEN

Transcription

1 FACULTEIT SOCIALE WETENSCHAPPEN The packaging puzzle An investigation into the Income and Care Packages of the Belgian Elderly Population Rika VERPOORTEN Proefschrift aangeboden tot het verkrijgen van de graad van Doctor in de Sociale Wetenschappen Promotor: Prof. Dr. J. Berghman + Promotor: Prof. Dr. W. van Oorschot Copromotor: Em. Prof. Dr. J. Billiet Onderzoekseenheid: Centrum voor Sociologisch Onderzoek Nr

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3 FACULTEIT SOCIALE WETENSCHAPPEN The packaging puzzle An Investigation into the Income and Care Packages of the Belgian Elderly Population Rika VERPOORTEN Proefschrift aangeboden tot het verkrijgen van de graad van Doctor in de Sociale Wetenschappen Promotor: Prof. Dr. J. Berghman + Promotor: Prof. Dr. W. van Oorschot Copromotor: Em. Prof. Dr. J. Billiet Onderzoekseenheid: Centrum voor Sociologisch Onderzoek 2015 Samenstelling van de examencommissie: Prof. Dr. Rudi Laermans (voorzitter) Prof. Dr. Jos Berghman + (promotor) Prof. Dr. Wim van Oorschot (promotor) Em. Prof. Dr. Jaak Billiet (copromotor) Em. Prof. Dr. Jef Breda [Universiteit van Antwerpen] Prof. Dr. Anja Declercq Prof. Dr. Jozef Pacolet Dr. Lieve Vanderleyden [Studiedienst Vlaamse Regering]

4 De verantwoordelijkheid voor de ingenomen standpunten berust alleen bij de auteur. Gepubliceerd door: Faculteit Sociale Wetenschappen - Onderzoekseenheid: Centrum voor Sociologisch Onderzoek [CeSO], KU Leuven, Parkstraat 45 bus Leuven, België by the author. Niets uit deze uitgave mag worden verveelvoudigd zonder voorafgaande schriftelijke toestemming van de auteur / No part of this book may be reproduced in any form without permission in writing from the author. D/2015/8978/10

5 CONTENT Acknowledgments Disclaimer List of tables List of figures Abbreviations vii ix x xviii xx CHAPTER 1. INTRODUCTION 1 1. The context: Population ageing Recent trends in population ageing Increasing importance of old age related social risks 4 2. SOS old age: Protection against old age related social risks 7 3. Main research questions and hypotheses 8 4. Research design Outline of the study 10 CHAPTER 2. THE PACKAGING PUZZLE The packaging approach as the basic theoretical framework The basics: claims, rewards and institutional spheres Claims Three institutional spheres Rewards and claim packages Critical reflections on the packaging theory Applying the packaging approach to old age protection Claims Three institutional spheres The rewards: the old age income and care package Conclusion 24 CHAPTER 3. THEORETICAL EXPLORATION OF THE OLD AGE INCOME PACKAGE General insights Exploring the potential income package components within the Belgian context Public pension protection Public retirement pension Minimum retirement pension and minimum right per year worked Public survivor pension Holiday allowance Public minimum income protection Some facts and figures on the Belgian public pension protection 36 i

6 2.2 Occupational pension protection Occupational pension protection for retired employees Occupational pension protection for retired self-employed persons Some facts and figures on the Belgian occupational pension protection Fiscally stimulated private pension protection Financial assets Property ownership Conditional public cash transfers Care related benefits Housing benefits Heating allowance Determinants of the old age income package Sex and gender Labour market history Socioeconomic status Marital status and household composition Health and functional status Conclusion 57 CHAPTER 4. THEORETICAL INSIGHTS IN THE OLD AGE CARE PACKAGE General insights Exploring the care package composition within the Belgian context Health care services Delivery of health care services National health insurance scheme Private health insurance Social care services Organisation of social and old age care services Delivery of old age care services Care insurance Determinants of the care package The health services utilisation framework The role of income in explaining health and social care services use Income and health care services use Income and the use of social care services Other determinants Predisposing factors Need factors Conclusion 90 CHAPTER 5. RESEARCH QUESTIONS AND HYPOTHESES The old age income package The old age care package 96 ii

7 3. Guaranteeing protection against the financial and physical dimension of old age dependency? 97 CHAPTER 6. RESEARCH DESIGN, DATA AND POPULATION Research design The use of secondary survey data A quantitative analysis of survey data A cross-sectional research design A single-country study Exploration of the available data sources Data from survey research Register data from administrative sources Survey of Health, Ageing and Retirement in Europe An introduction to the SHARE Target population, sampling and sample design The target population The sample population, sample frame and sample design The realised sample Data collection and survey structure Assessment of data quality Dealing with survey errors Dealing with undercoverage: the (non)sense of weighting Dealing with item non-response Sensitivity analysis Conclusion 124 CHAPTER 7. OPERATIONALISATION OF THE OLD AGE INCOME PACKAGE Income sources with personal ownership Assessing personal income source ownership Defining clusters of personal income sources via hierarchical cluster analysis Assessing the income package generosity Income sources shared within the household Financial assets and property ownership The contribution from assets The (potential) contribution from financial assets and secondary residence The (potential) contribution from home ownership Reflections on the inclusion of assets in the extended income package Taking account of financial solidarity within the household Overview of the generated variables Assessing the quality of the old age income package Protecting against old age poverty Contributing to income equality Conclusion 153 iii

8 CHAPTER 8. THE OLD AGE INCOME PACKAGE UNRAFFLED Overall research strategy The old age income package of personal income sources Description of the old age income package The personal income package: tracing vulnerable groups A multinomial logit model explaining the income package composition Construction of the model Interpretation of the model results A multivariate regression model explaining the generosity of the personal income package Construction of the model Interpretation of the model results Additional protection from the asset package Description of the asset package Financial asset and property ownership The contribution from financial assets and property Quality of the asset package The asset package along the lines of the personal income package Asset ownership versus the personal income package The contribution from assets versus the personal income package Quality of the asset package versus the personal income package The asset package: Tracing vulnerable groups Two binary logit models explaining asset ownership Construction of the models Interpretation of the results in the logit models Multivariate regression models explaining the asset contribution Construction of the models Interpretation of the results in the multivariate regression models Combining personal income and asset sources in the extended income package The generosity of the extended income package Tracing vulnerable groups Assessing the quality of the extended income package Protection against old age poverty Enhancing old age income equality Conclusion 207 CHAPTER 9. OPERATIONALISATION OF THE OLD AGE CARE PACKAGE Composition of the old age care package The use of health care services The use of social care services Defining care clusters via a hierarchical cluster analysis Intensity of care use Intensity of health care services use Intensity of social care services use 226 iv

9 3. Assessing the quality of the old age care package The quality of health care services Appropriate health care contacts Appropriate medication Reflections on the health care quality indicators The quality of social care services Receipt of personal care and home help Satisfaction with social care Preferences on the main care provider Reflections on the social care quality indicators Conclusion 238 CHAPTER 10. THE OLD AGE CARE PACKAGE UNRAFFLED Overall research strategy The old age care package Composition of the old age care package Intensity of care use Composition of the care package versus the intensity of use Tracing vulnerable groups Investigating the relationship between the income package and the care package The care package composition along the lines of the old age income package The care package composition versus the generosity of the old age income package The care package composition versus the income package composition The intensity of care use along the lines of the old age income package Explaining the care package composition Construction of the logit models A multinomial logit model explaining the care package composition A binomial logit model explaining the use of health care services A multinomial logit model explaining the use of social care services Explaining the intensity of care use Construction of the models A multinomial logit model explaining the intensity of health care services use A multinomial logit model explaining the intensity of social care services use Assessing the quality of the old age care package The quality of the health care package The quality of the social care package Conclusion 277 CHAPTER 11. FINAL REFLECTIONS ON THE PACKAGING PUZZLE Where did we start? What does our research contribute? What could have been better? 288 v

10 4. What s in it for the future? Opportunities for researchers Opportunities for policy makers 292 BIBLIOGRAPHY 297 APPENDICES 321 Appendix 1. SHARE Data structure 322 Appendix 2. The calculation of the weights 323 Appendix 3. Consequences of the methodological choices: A sensitivity analysis 325 Appendix 4. Comparing observations with and without imputations 342 Appendix 5. Principal Limit Factors 344 Appendix 6. Simulating the potential contribution from assets 345 Appendix 7. Operationalisation of the background variables 347 Appendix 8. Analysis of deleted observations with missing information 356 Appendix 9. The quality of the care package by a number of background characteristics 366 Appendix 10. Detailed logit models explaining the use of health and social care services371 Summary 393 Nederlandstalige samenvatting 394 Resumé en Français 395 Lijst van doctoraten in de sociale wetenschappen en doctoraten in de sociale en culturele antropologie 396 vi

11 ACKNOWLEDGMENTS Eindelijk ligt het er! Dat is het eerste wat me door het hoofd schoot toen ik de laatste puntjes op de vele i tjes in dit doctoraat zette. Toen ik in 2010 aan dit doctoraat begon, wist ik niet goed wat ik mocht verwachten. Het bleek een uitdagende, soms moeizame, maar veelal leerrijke periode te zijn waar ik voor stond. Vooral in de beginperiode waren er meer downs dan ups, en zeggen dat ik nooit aan opgeven gedacht heb zou een leugen zijn, maar de laatste twee jaren heb ik meestal met plezier aan dit doctoraat gewerkt. Dit deed ik uiteraard niet alleen, ook al wordt onderzoek soms terecht, soms onterecht afgeschilderd als een eenzame bezigheid. Volgende mensen verdienen dan ook een persoonlijke vermelding in dit voorwoord. Ten eerste wil ik mijn promotor, prof. Dr. Jos Berghman, bedanken omdat hij in mij doctoraatsmateriaal zag, mij de vrijheid gaf om zelf een onderwerp te kiezen en me het vertrouwen gaf om mijn eigen ding te doen. In tijden van nood kon ik altijd op hem rekenen, ook die ene keer dat ik in tranen op zijn bureau bekende dat ik het eigenlijk niet meer zag zitten. Zelfs toen ik in de laatste fase besliste een nieuwe carrière-uitdaging aan te gaan bleef hij me onvoorwaardelijk steunen, uiteraard op voorwaarde dat ik mijn doctoraat zou afwerken. Het viel me dan ook bijzonder zwaar dat hij de laatste maanden van mijn werkproces niet hebt kunnen meemaken. Zijn overlijden in oktober sloeg in als een bom. Ik pikte de draad snel terug op, omdat ik wist dat ik hem nog één ding verschuldigd was: het doctoraat afwerken. Zijn vertrouwen en opbeurende woorden leveren hun vruchten af: het doctoraat is klaar, het boek ruikt zelfs nog een beetje naar verse inkt. Mijn co-promotor, prof. Dr. Em. Jaak Billiet, verdient een pluim voor zijn kritische blik op de methologische aspecten van mijn onderzoekswerk. Meermaals leende je me je methodologische bril om naar mijn denkproces en mijn onderzoeksresultaten te kijken. Mijn dank gaat ook naar prof. Dr. Wim Van Oorschot. Na het overlijden van Jos bood je spontaan aan om het promotorschap over te nemen, ook al ligt het onderwerp van mijn doctoraat ver af van waar je dagelijks mee bezig bent. Bedankt voor de begeleiding die je me bood bij de eindsprint. Voorts ook een woord van dank voor de leden van mijn begeleidings- en examencommissie: prof. Dr. Anja Declercq (LUCAS, KULeuven), Dr. Jef Pacolet (HIVA, KULeuven), Dr. Lieve Vanderleyden (Studiedienst Vlaamse Regering) en prof. Dr. Em. Jef Breda (UAntwerpen) voor de nuttige inzichten en opmerkingen die van mijn eerste onderzoeksvoorstel het afgewerkte product gemaakt hebben dat hier voor u ligt. Ook een bedankje aan het adres van het secretariaat van het CeSO en dat van de PhD School mag hier niet ontbreken. Voor alle administratieve en financiële aangelegenheden vii

12 kon ik steeds bij hen terecht, maar ook hun niet aflatende vriendelijke, opbeurende en aanmoedigende woorden de afgelopen jaren heb ik zeker weten te appreciëren. De afgelopen vijf jaar waren uiteraard meer dan vijf jaar van onderzoek en denkwerk. Naar kantoor gaan voelde niet altijd als werken, en met veel plezier denk ik terug aan de oppeppende fruitjespauzes, de slaapverwekkende Maltezers, en de verkwikkende terrasjes samen met de vele collega s die in de afgelopen jaren de revue zijn gepasseerd. Namen noemen lijkt me hier overbodig, met één uitzondering: Hans, jij was met stip de beste bureaugenoot die iemand zich kon inbeelden. Een bijzondere vermelding voor mijn ouders (in al hun vormen), (schoon)zussen, (schoon)broers mag uiteraard niet ontbreken. Bedankt dat jullie me hebben laten groeien tot de vrouw die ik vandaag ben. Luc, ik weet dat je trots zou geweest zijn op mij, al was het maar omdat ik netjes heb afgemaakt waar ik jaren geleden aan begonnen ben. Tot slot, als een typisch product van de Y-generatie wilde ik ook op niet-professioneel vlak niet ter plaatste blijven trappelen. Drie kindjes, bouwen, verhuizen en één man konden er ook nog bij. Seth, Isa, Hannah, jullie laten me lachen na zo n typisch slechte dag waarop je meer achteruit dan vooruit gewerkt hebt. Bert, van jou leerde ik niet op te geven en het hoofd niet te laten hangen. Bedankt om me een beetje van jouw doorzettingsvermogen, je rationaliteit en je nuchterheid te lenen de afgelopen jaren. Bedankt om gewoon te zijn wie je bent, en om mij te laten zijn wie ik wil zijn. viii

13 DISCLAIMER This dissertation uses data from SHARE wave 2 release 2.5.0, as of May 24 th 2011 and SHARELIFE release 1, as of November 24th 2010 (DOI: /SHARE.w3.100). The SHARE data collection has been primarily funded by the European Commission through the 5th Framework Programme (project QLK6-CT in the thematic programme Quality of Life), through the 6th Framework Programme (projects SHARE-I3, RII-CT , COMPARE, CIT5- CT , and SHARELIFE, CIT4-CT ) and through the 7th Framework Programme (SHARE-PREP, N , SHARE- LEAP, N and SHARE M4, N ). Additional funding from the U.S. National Institute on Aging (U01 AG S2, P01 AG005842, P01 AG08291, P30 AG12815, R21 AG025169, Y1-AG , IAG BSR06-11 and OGHA ) and the German Ministry of Education and Research as well as from various national sources is gratefully acknowledged (see for a full list of funding institutions). ix

14 LIST OF TABLES Table 2.1. Composition of the income package 18 Table 3.1. Components of the income package and the welfare state configuration 29 Table 3.2. Overview of the potential components of the income package of the Belgian elderly population 31 Table 3.3. An overview of the most important differences between the pension system of employees, the self-employed and statutory civil servants 34 Table 3.4. Public pension protection: facts and figures (2007) 37 Table 3.5. Occupational pension protection: Facts and figures (2007) 40 Table 4.1. Components of the care package and the welfare state configuration 64 Table 4.2. Division of responsibilities on care services among federal and regional policy makers 72 Table 4.3. Residential long-term care in Belgium (resp. number of nursing homes and elderly homes and beds), by region (2012) 74 Table 4.4. Estimation of the availability of service flats in Belgium (resp. number of facilities and accommodations), by region (2011) 75 Table 4.5. Short stay and day care centres in Belgium (number of facilities and number of places), by region (2011) 77 Table 6.1. Overview of most important Belgian surveys for our research 104 Table 6.2. The sampling probabilities of households in the Belgian SHARE 112 Table 6.3. Strategies to minimise the occurrence of survey errors in SHARE 118 Table 6.4. Comparison of the realised sample (unweighted) and the population aged 60 and over by sex, age, region of residence and living situation (2007) 120 Table 6.5. Average item response rate on selected income variables, before and after unfolding brackets, SHARE wave 2 (%) 122 Table 7.1. Including retrospective information on the receipt of second and third pillar pensions (unweighted, 2007) 130 Table 7.2. Personal income sources ownership of the research population (unweighted, 2007) 131 Table 7.3. Overview of the hierarchical cluster analysis statistics to decide on the number of income clusters 133 Table 7.4. Relative distribution of the research population by cluster and personal income source ownership (unweighted, 2007) 134 x

15 Table 7.5. Relative distribution of the research population according to imputations for first, second and third pillar pensions (unweighted, 2007) 136 Table 7.6. Financial assets sources ownership of the research population (unweighted, 2007) 139 Table 7.7. Property ownership of the research population (unweighted, 2007) 140 Table 7.8. Overview of strategies to include the contribution from home ownership 143 Table 7.9. Relative distribution of the research population according to imputations for assets (unweighted, 2007) 145 Table Overview of the most commonly used equivalence scales 147 Table Overview of the generated income variables 148 Table Calculating the EU-SILC adjusted SHARE at-risk-of-poverty threshold for Belgium 150 Table The age-specific poverty threshold before and after the inclusion of assets in the old age income package (weighted, 2007) 151 Table 8.1. Distribution of the research population by personal income package composition (weighted, 2007) 159 Table 8.2. Mean and median monthly equivalent net income from the personal income package by personal income package composition (weighted, 2007) 161 Table 8.3. EU-SILC adjusted at-risk-of-poverty rate of the research population by the personal income package composition (%, weighted, 2007) 163 Table 8.4. Relative distribution of the research population by the personal income package composition and by sex, age, occupational status, level of education and living situation (weighted, 2007) 164 Table 8.5. Mean and median monthly equivalent net income from the personal income package and EU-SILC adjusted at-risk-of-poverty rate, by sex, age, occupational status, level of education and living situation (weighted, 2007) 166 Table 8.6. Results of the multinomial logit model with composition of the personal income package as dependent variable (weighted, 2007) 168 Table 8.7. Results of the multinomial logit model with composition of the personal income package as dependent variable (weighted, 2007) 169 Table 8.8. Independent variables in the multivariate regression model and their reference category 171 Table 8.9. Results of the multivariate robust regression model with equivalent net monthly income from the personal income package (in Euro) as the dependent variable (weighted, 2007) 173 Table Distribution of the research population by asset ownership (weighted, 2007) 176 Table Mean and median equivalent monthly direct contribution from financial assets and property ownership by asset ownership (weighted, 2007) 177 Table Mean and median simulated equivalent monthly contribution from financial assets and property ownership by asset ownership (weighted, 2007) 178 xi

16 Table Relative distribution of the research population by personal income package and asset ownership (weighted, 2007) 180 Table Relative distribution of the research population by personal income decile and asset ownership (weighted, 2007) 180 Table Relative distribution of the research population by asset ownership and by sex, age, occupational status, level of education and living situation (weighted, 2007) 186 Table Mean and median direct and simulated equivalent monthly contribution from asset sources by sex, age, occupational status, level of education and living situation (weighted, 2007) 187 Table Independent variables in the logit models testing asset ownership and their reference category 189 Table Overview of the global model statistics of the logit regression models with financial asset ownership (LM1) and property ownership (LM2) as dependent variables (weighted, 2007) 189 Table Results of the binary logit models with financial asset ownership (LM1) and property ownership (LM2) as dependent variables (weighted, 2007) 190 Table Results of the multivariate robust regression models with direct (MM1) and simulated (MM2) equivalent monthly contribution from assets (in Euros) as dependant variable (weighted, 2007) 193 Table Mean and median available and simulated equivalent monthly income from the extended income package by income source (weighted, 2007) 195 Table Mean and median direct and simulated equivalent monthly contribution from the extended income package by sex, age, occupational status, level of education and living situation (weighted, 2007) 200 Table EU-SILC at-risk-of-poverty rate before and after assets by sex, age, occupational status, level of education and living situation (weighted, 2007) 202 Table Age-specific at-risk-of-poverty rate before and after assets by sex, age, occupational status, level of education and living situation (weighted, 2007) 203 Table Income quintile share and Gini coefficient before and after adding assets to the old age income package (weighted, 2007) 205 Table 9.1. Use of health care services by the research population (unweighted, 2007) 217 Table 9.2. Use of social care services by the research population (unweighted, 2007) 219 Table 9.3. Overview of the hierarchical cluster analysis statistics to decide on the number of care clusters 221 Table 9.4. Relative distribution of the research population by care cluster and health and social care services use (unweighted, 2007) 222 Table 9.5. Distribution of the research population by the intensity of health care services use (unweighted, 2007) 225 Table 9.6. Distribution of the research population, receiving social care services, by the intensity of care services use (unweighted, 2007) 227 Table 9.7. Distribution of the research population, receiving social care, by the most important source of care (formal and/or informal) (unweighted, 2007) 228 xii

17 Table 9.8. Matching health problems (based on item ph006) to contacts with specialists (based on item hc004) to assess health care quality 231 Table 9.9. Distribution of the research population by the ratio of success of health care contacts (unweighted, 2007) 232 Table Matching health problems (based on item ph006) to medication use (based on item ph011) to assess health care quality 233 Table Distribution of the research population by the ratio of success of medication (unweighted, 2007) 234 Table Distribution of the research population receiving social care by the match between the care received and limitations with ADL and IADL (unweighted, 2007) 236 Table Distribution of the research population receiving social care by satisfaction with the care received (unweighted, 2007) 236 Table Distribution of the research population receiving social care services by the match between the care they receive and their preference on who should provide this care (unweighted, 2007) 237 Table Distribution of the research population by care package composition (weighted, 2007) 244 Table Relative distribution of the research population by the intensity of health and social care services use (weighted, 2007) 244 Table Mean intensity of health and social care services use by the care package composition (weighted, 2007) 246 Table Relative distribution of the research population by the care package composition and by sex, age, occupational status, level of education and living situation (weighted, 2007) 247 Table Mean intensity of care use by sex, age, occupational status, level of education and living situation (weighted, 2007) 248 Table Mean and median monthly equivalent net income from the personal and the extended income package by care package composition, use of health and social care services (weighted, 2007) 252 Table Relative distribution of the research population by care package composition and personal income package composition (weighted, 2007) 256 Table Relative distribution of the research population by asset ownership and care package composition (weighted, 2007) 257 Table Mean and median monthly equivalent net income from the personal and the extended income package by the intensity of health and social care use (weighted, 2007) 258 Table Mean and median monthly equivalent net income from the personal and the extended income package by relying primarily on formal or informal care services (weighted, 2007) 259 Table Independent variables in the logit models testing the care package composition and their reference category 261 xiii

18 Table Overview of the global model statistics of the logistic regression models on the use of care services (weighted, 2007) 263 Table Overview of the global model statistics (p-values) of the logistic regression models on the intensity of the use of care services (weighted, 2007) 268 Table Distribution of the research population by the ratio of successful health care contacts and medication (weighted, 2007) 272 Table Relative distribution of the research population by the individual income quintile distribution and the ratio of successful health care contacts and medication (weighted, 2007) 273 Table Distribution of the research population by the receipt of appropriate social care and the preferential care provider (weighted, 2007) 275 Table Distribution of the research population by the patient satisfaction with the social care services received (weighted, 2007) 275 Table Relative distribution of the research population by the individual income quintile distribution and the social care quality indicators (weighted, 2007) 276 Table A2.1. Distribution of the unweighted sample by age and sex 323 Table A2.2. Distribution of the sample by age and sex, after the design weight 323 Table A2.3. Population distribution by age and sex 324 Table A2.4. Poststratification weights by age and sex 324 Table A2.5. Distribution of the sample by age and sex, after the application of the combined and rescaled weights 324 Table A3.1. Comparison of the weighted and unweighted distribution of the research population by personal income package composition, asset package composition, and care package composition (2007) 326 Table A3.2. Comparison of the weighted and unweighted mean and median contribution from the personal income package and the asset package (2007) 327 Table A3.3. Comparison of the weighted and unweighted global parameter statistics of the multinomial logit model with composition of the personal income package as dependent variable (2007) 328 Table A3.4. Comparison of the weighted and unweighted detailed parameter statistics of the multivariate robust regression model with equivalent net income from the personal income package (in Euro) as the dependent variable (2007) 329 Table A3.5. Comparison of the weighted and unweighted global parameter statistics of the binomial logit models with financial asset ownership and property ownership as dependent variables (2007) 330 Table A3.6. Comparison of the weighted and unweighted detailed parameter statistics of the multivariate robust regression model with direct and simulated equivalent monthly contribution from assets (in Euro) as dependent variable (2007) 331 Table A3.7. Comparison of the global parameter statistics of the weighted and unweighted multinomial logit model with the care package composition as dependent variable (2007) 332 xiv

19 Table A3.8. Comparison of the mean and median contribution from the personal income package and the asset package, with and without imputations (weighted, 2007) 334 Table A3.9. Comparison of the detailed parameter statistics of the multivariate robust regression model with equivalent net income from the personal income package (in Euro) as the dependent variable, with and without imputations (weighted, 2007) 335 Table A3.10. Comparison of the global parameter statistics of the binomial logit models with financial asset ownership and property ownership as dependent variables, with and without imputations (weighted, 2007) 336 Table A3.11. Comparison of the detailed parameter statistics of the multivariate robust regression model with direct and simulated equivalent monthly contribution from assets (in Euro) as dependent variable, with and without imputations (unweighted, 2007) 337 Table A3.12. Comparison of the global parameter statistics of the multinomial logit model with the care package composition as dependent variable, with and without imputations (weighted, 2007) 338 Table A3.13. Overview of three commonly used equivalence scales 340 Table A3.14. Comparison of the mean and median net monthly equivalent income from the personal old age income package and the age-specific at-risk-of-poverty rate, by the Oxford equivalence scale, the OECD modified equivalence scale and the square root equivalence scale (weighted, 2007) 341 Table A4.1 Distribution of the research population without and with imputations on the personal income level by sex, age, occupational status, level of education, living situation and region of residence (weighted, 2007) 343 Table A4.2 Distribution of the research population without and with imputations on the personal income level by personal income package composition (weighted, 2007) 343 Table A5.1 Principal limit factors used for the simulation of reverse mortgages, by age, at an interest rate of 4.33% 344 Table A6.1. Simulating the potential contribution from assets 346 Table A7.1. Distribution of the research population by sex, age and living situation (weighted, 2007) 347 Table A7.2. The European Socio-economic classification of occupations 348 Table A7.3. Occupational status 350 Table A7.4. Distribution of the research population by occupational status (2007, weighted) 351 Table A7.5. Distribution of the research population by level of education (weighted, 2007) 352 Table A7.6. Distribution of the research population by health status and functional level (weighted, 2007) 355 xv

20 Table A8.1 Deleted observations in model 1 with the personal income package composition as the dependent variable 357 Table A8.2 Deleted observations in model 2 with the level of the personal income package as the dependent variable 358 Table A8.3 Deleted observations in model 3 with financial asset ownership as the dependent variable 359 Table A8.4 Deleted observations in model 4 with property asset ownership as the dependent variable 360 Table A8.5 Deleted observations in model 5 with level of the direct asset contribution as the dependent variable 361 Table A8.6 Deleted observations in model 6 with level of the simulated asset contribution as the dependent variable 362 Table A8.7 Deleted observations in the models with health and social care services as the dependent variables 364 Table A9.1. Relative distribution of the research population by the ratio of successful specialist contacts by sex, age, occupational status, level of education, living situation and region of residence (weighted, 2007) 366 Table A9.2. Relative distribution of the research population by the ratio of successful medication by sex, age, occupational status, level of education, living situation and region of residence (weighted, 2007) 367 Table A9.3. Relative distribution of the research population by the receipt of appropriate social care by type of care and by sex, age, occupational status, level of education, living situation and region of residence (weighted, 2007) 368 Table A9.4. Relative distribution of the research population by the preferential care provider by sex, age, occupational status, level of education, living situation and region of residence (weighted, 2007) 369 Table A9.5. Relative distribution of the research population by the patient satisfaction with the social care services received by sex, age, occupational status, level of education, living situation and region of residence (weighted, 2007) 370 Table A10.1 Results of the multinomial logit model with composition of the care package as dependent variable and the personal income package as the main independent variable (weighted, 2007) 372 Table A10.2 Results of the multinomial logit model with composition of the care package as dependent variable and the personal income package and the background variables as the independent variables (weighted, 2007) 373 Table A10.3 Results of the multinomial logit model with composition of the care package as dependent variable and the extended income package as the main independent variable (weighted, 2007) 375 Table A10.4 Results of the multinomial logit model with composition of the care package as dependent variable and the extended income package and the background variables as the main independent variables (weighted, 2007) 376 xvi

21 Table A10.5 Results of the binomial logit model with the use of second-line health care as dependent variable and the personal income package as the main independent variable (weighted, 2007) 378 Table A10.6 Results of the binomial logit model with the use of second-line health care as dependent variable and the extended income package as the main independent variable (weighted, 2007) 379 Table A10.7 Results of the multinomial logit model with the use of social care services as dependent variable and the personal income package as the main independent variable (weighted, 2007) 380 Table A10.8 Results of the multinomial logit model with the use of social care services as dependent variable and the extended income as the main independent variable (weighted, 2007) 382 Table A10.9 Results of the multinomial logit model with the intensity of health care services use as dependent variable and the personal income package as the main independent variable (weighted, 2007) 384 Table A10.10 Results of the multinomial logit model with the intensity of health care services use as dependent variable and the extended income package as the main independent variable (weighted, 2007) 386 Table A10.11 Results of the multinomial logit model with the intensity of formal care services use as dependent variable and the personal income package as the main independent variable (weighted, 2007) 388 Table A10.12 Results of the multinomial logit model with the intensity of social care services use as dependent variable and the extended income package as the main independent variable (weighted, 2007) 390 xvii

22 LIST OF FIGURES Figure 1.1. Evolution of the proportion of the population aged 60 and over in the overall population from 1950 to Figure 1.2. Evolution of the proportion of the population aged 80 years and over in the population aged 60 years and over from 1950 to Figure 1.3. Employment rate in the EU-27 and Belgium, by age group (2011) 5 Figure 1.4. Proportion of the Belgian population with moderate to severe restrictions in day-to-day and basic activities, by age group (2008) 6 Figure 1.5. Evolution of the life expectancy (in years) and the healthy life years at 65 (as % of the total life expectancy at 65) in Belgium between 1995 and Figure 3.1. Multi-pillar composition of the old age income package 28 Figure 4.1. Composition of the old age care package 62 Figure 4.2. Overview of the main characteristics of social care services 71 Figure 4.3. Andersen s health services utilisation framework 81 Figure 6.1. SHARE Waves of data collection and participating countries 107 Figure 6.2. From the initial sample of households to the realised sample of individuals in the first wave of the Belgian SHARE 114 Figure 6.3. Decomposition of the second wave of the Belgian SHARE 115 Figure 6.4. Illustration of the unfolding bracket procedure 122 Figure 7.1. Illustration of income decile distribution 152 Figure 7.2. Illustration of the Lorenz curve and Gini coefficient 153 Figure 8.1. The old age income package: Conceptual scheme 158 Figure 8.2. Distribution of the research population by the monthly equivalent net income from the personal income package, in categories (weighted, 2007) 160 Figure 8.3. Personal income package composition by income decile distribution (weighted, 2007) 162 Figure 8.4. Relative distribution of the research population by personal income decile and property ownership (weighted, 2007) 181 Figure 8.5. Mean and median equivalent monthly direct contribution from assets by personal income decile (weighted, 2007) 182 Figure 8.6. Mean and median equivalent monthly simulated contribution from assets by personal income decile (weighted, 2007) 183 xviii

23 Figure 8.7. Proportion of the research population with an asset stock below the asset poverty threshold by personal income decile (weighted, 2007) 184 Figure 8.8. Mean available equivalent monthly income from the extended income package, by income source and income decile (weighted, 2007) 197 Figure 8.9. Mean simulated equivalent monthly income from the extended income package, by income source and income decile (weighted, 2007) 198 Figure Relative composition of the simulated equivalent monthly income from the extended income package, by income source and income decile (weighted, 2007) 199 Figure Lorenz curve of the equivalent monthly income from resp. the personal income package and the extended income package (direct and simulated total income) (weighted, 2007) 206 Figure The care package: Conceptual scheme 242 Figure Care package composition by personal income decile distribution (weighted, 2007) 253 Figure Health care services use by personal income decile distribution (weighted, 2007) 254 Figure Use of social care services by the personal income decile distribution (weighted, 2007) 255 Figure Mean intensity of health and social care services use by the personal income decile distribution (weighted, 2007) 259 xix

24 ABBREVIATIONS ADL AIC B.A. BIC CAPI CD DB2P DWH LM&SP ECHP ESeC EU-SILC E x FACH FCS FPS GP HIS HECM IADL ILO IMA ISCED ISCO JPI LASA LOVO MAR NIHDI N.S. OECD OLO OR P1 P2 Activities of Daily Living Akaike Information Criterion Bulletin of Acts [Belgisch Staatsblad] Bayesian Information Criterion Computer Assisted Personal Interview Inter-cluster distance Database Supplementary Pensions Datawarehouse Labour Market and Social Protection European Community Household Panel European Socio-economic Classification European Survey on Income and Living Conditions Life expectancy Flemish Agency for Care and Health [Vlaams Agentschap Zorg en Gezondheid, VAZG] Fully Conditional Specification Method Federal Public Service General practitioner Health Interview Survey Home Equity Conversion Mortgages for Seniors Instrumental Activities of Daily Living International Labour Organisation Intermutuality Agency [InterMutualistisch Agentschap] International Standard Classification of Education International Standard Classification of Occupations Joint Programming Initiative Longitudinal Aging Study Amsterdam Survey on the Living situation of Flemish Elderly [LeefsituatieOnderzoek Vlaamse Ouderen] Missing At Random National Institute for Health and Disability Insurance [Rijksdienst voor Ziekte- en Invaliditeitsverzekering, RIZIV] Not statistically significant at the 0,05 level Organisation for Economic Co-operation and Development Linear Bond [Obligation Linéaire/Lineaire Obligatie] Odds Ratio First pillar pensions Second pillar pensions xx

25 P3 PCSW PLF PS PSBH r Third pillar pensions Public Centre for Social Welfare [Openbaar Centrum voor Maatschappelijk Welzijn, OCMW] Principal Limit Factor Poststratification Panel study of Belgian Households Interest rate R² Determination coefficient RM Reverse mortgage RMS STD Root-mean-square standard deviation R.R. Response rate RS R-squared SHARE Survey of Health, Ageing and Retirement in Europe SPR Semi partial R-square SS Social security benefits VOZS Flemish Elderly Care Survey [Vlaamse OuderenZorgStudie] xxi

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27 CHAPTER 1 INTRODUCTION 1

28 CHAPTER 1. INTRODUCTION The population is ageing. Related topics are high on the agenda of policy makers and researchers. One of these topics, often the subject of debate, involves the risks of financial and functional dependency that are related to old age. Associated to this, our PhD research focuses on the wide range of mechanisms that are available to the elderly population to limit the consequences of financial and functional old age dependency. In this chapter we describe the broad outline of the dissertation. Firstly, the demographic context of population ageing is illustrated. This is linked to the growing importance of old age related social risks, more specifically the risks of old age financial and functional dependency. Secondly, we introduce the main mechanisms that are available to protect the elderly population against the negative consequences of the financial and physical dimension of old age dependency. In this light, the packaging approach of Rainwater, Rain and Schwartz (1986) is presented as the main theoretical framework of our study. In section three, the main research questions and hypotheses are presented. A short introduction into the research design is given in section 4. The last section presents the outline of the dissertation. 1. The context: Population ageing In this section, we address the recent trends in population ageing, that go together with important increases in the older population, and specifically in the population of 80 years and over. 1.1 Recent trends in population ageing The attention for old age social protection by researchers and social policy makers stems from an important increase in the relative importance of the elderly in the overall population. This trend is observed not only in Belgium, but all over Europe, and by extension all over the world. Even less developed countries do not escape the increase of the elderly population. Yet, the increase in the elderly population is considerably more important in Western Europe than in the rest of the world (see Figure 1.1). Whereas in the 1950s about 15% of the Western European population was aged 60 years and over, the relative importance of this age group increased to 24% in 2010 (an increase of 60%). A similar, yet less strong, increasing trend is observed in Belgium, where the relative importance of the population aged 60 years and over rose from 16% in 1950 to 23% in 2010 (an increase of 44%). 2

29 Figure 1.1. Evolution of the proportion of the population aged 60 and over in the overall population from 1950 to % 20% 15% 10% 5% 0% World Europe Western Europe Belgium Source: Author s calculations based on United Nations, Department of Economic and Social Affairs, Population Division, 2011 Further, this increase in the elderly population has gone hand in hand with an increase in the population aged 80 years and over (the so-called oldest old). In Western Europe, the relative weight of the population aged 80 years and over within the age group of 60 years and over increased from about 8% in 1950 to 21% in 2010 (see Figure 1.2). A similar trend is discerned in Belgium. Figure 1.2. Evolution of the proportion of the population aged 80 years and over in the population aged 60 years and over from 1950 to % 20% 15% 10% 5% 0% World Europe Western Europe Belgium Source: Author s calculations based on United Nations, Department of Economic and Social Affairs, Population Division,

30 The increase in the elderly population is considered as the final stage of the 20 th century demographic transition, that marks a transition from a society with high rates of births and deaths to a society characterised by low rates of births and deaths. Improvements in health care and medical science, changes in the living conditions, the introduction of widespread social security, etc. have managed to reduce the mortality rate and lead to an increase in the life expectancy over the last decades. This trend of lowering mortality and increasing life expectancy went hand in hand with decreasing fertility rates and a decline in the relative proportion of the younger population group in the overall population. Consequently, the size of the younger age groups is no longer in balance with that of the older age groups, leading to an increase in the dependency ratio (i.e. the ratio of the size of the non-active population and the active population). 1 For example, in Western Europe the ratio of the population aged 60 years and over versus the population between 20 and 60 years increased from 0.28 in 1950 to 0.44 in 2010 (based on the population statistics provided by United Nations, Department of Economic and Social Affairs, Population Division, 2011). 1.2 Increasing importance of old age related social risks The increase in the relative importance of the elderly population in the overall population makes that old age related social risks have become more important in the last decades. These risks refer to a certain degree of dependency that is associated to old age, with many different dimensions (e.g. functional dependency, mental dependency, economic dependency) (Pacolet, Bouten, Lanoye, & Versieck, 2000). In this study, we focus on two dimensions of old age dependency, namely financial or economic dependency and functional or physical dependency. These dimensions of dependency are strongly related to the welfare and wellbeing of the elderly population (cf. infra). Already in the 1960s old age has been acknowledged as a risk for labour market participation (International Labour Organisation, 2006). Because of their age, elderly are faced with decreases in their productivity, for example because of health problems, and thus are confronted with limitations in their labour market participation. To overcome the risk of financial destitution that is associated with labour market withdrawal, the International Labour Organisation advised that subsistence after the age of 65 should be guaranteed via the provision of financial compensations, replacing the former labour market income. Mechanisms have been set up to provide sufficient protection against the financial dimension of dependency. These mechanisms have to provide an alternative income to prevent the elderly population from becoming poor and to ensure their 1 The age limits used to calculate the dependency ratio can differ. For example, the United Nations limits the non-active elderly population to the population aged 60 and over, while the active population refers to the population between 20 years and 59 years of age. 4

31 standard of living. The most important mechanism is the public retirement pension, that provides a replacement income based on the previous labour market participation and the social security contributions paid during the active labour market career (Baltes, 1996). However, despite these alternative income mechanisms, the loss of labour market income makes the elderly population particularly vulnerable for poverty. According to statistics from the European Survey on Income and Living Conditions (EU-SILC), in 2011 about one fifth of the Belgian population aged 65 years and over was found to be at-risk-of-poverty, compared to about 14% of the population younger than 65 years (Eurostat, 2013a). 2 The introduction of widespread income replacement schemes for the elderly population has led to very low levels of labour market participation from the age of 60. This is illustrated in Figure 1.3, which shows the employment rate in Europe for different age groups. The majority of the population aged 65 years and over is no longer active on the labour market. Within Europe about 5% of the population aged 65 years and over still is in employment, while in Belgium only 2% of this age group is still active on the labour market. Figure 1.3. Employment rate in the EU-27 and Belgium, by age group (2011) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EU27 Belgium Source: Author s calculations based on Eurostat (2013) Besides the withdrawal from the labour market and the increase in financial dependency, the elderly population is also confronted more with health problems and limitations in their daily activities than younger population groups. Statistics from the Belgian Health Interview Survey (HIS) 2008 show that the incidence of restrictions in the basic and daily activities increases importantly with age (see Figure 1.4) (Charafeddine, Demarest, 2 The at-risk-of-poverty threshold is calculated as 60% of the EU-SILC equivalised median income. 5