EUROPEAN PAPERS ON THE NEW WELFARE

Health and Ageing: The Case for Long-Term Care

3. Health and Ageing

The health situation is deteriorating with age for two main reasons. First, because it is a fact of life: older persons are less healthy than younger ones. Second, because of a cohort effect: older people have accepted more risky behaviours and have benefited from less care when they were young and, as a consequence, they have accumulated more health disequilibrium during their lifetime than will current young people. This is an objective situation. Moreover, healthier behaviours, such as reduction in smoking and control of blood pressure, have significantly contributed to increased life expectancy as pointed out by empirical studies (cf. Table 2 which illustrates the situation in United States)8.

Table 2
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At the same time, being healthy ensues not only from objective data but also from subjective feelings: I am in good shape when I feel in good shape and recent empirical studies have underlined the fact that deteriorated subjective feeling may induce, at the end of the day, not only increased health expenditures but also a deterioration of the objective health situation. Interactions between objective health and subjective feelings are complex and difficult to untangle at the empirical level. Apart from the greater difficulties among younger cohorts with physical tasks and pain, many factors, all of which involve, at some point in time, specific individual behaviours, are currently contributing to this deterioration:
• early retirement whose effects are less known but are significant : empirical results indicate that complete retirement leads to a 23-29% increase in difficulties associated with mobility and daily activities, an eight percent increase in illness conditions and an 11% decline in mental health9;
• the rise of psychological illness, such as depression, which is better known and identified even if its effects on the health of older people are less well known;
• the HIV epidemic in less developed countries, especially in Africa;
• the growing rates of obesity, which is not confined to the less educated or the poor but occurs across all demographic and economic groups10 and which can significantly alter current longevity trends (cf. table below which illustrates the situation in the United States)11.

Table 3
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4. Long-term Care and Ageing

Ageing has a special relationship with poor health. But poor health in old people is itself related to loss of autonomy. Of course, loss of autonomy has two main characteristics:
• it is linked to old age as illustrated by the OECD graph below which presents the prevalence of dependency by age group for four great European countries:

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• it is triggered by standard diseases or accidents as pointed out by the SCOR-INSERM table below and its trend is largely dependent on the nature and the speed of current and future medical progress:

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Most of the time, because of this relationship, one is tempted to mix up the concept of loss of autonomy with the concept of poor health in older people. In fact, loss of autonomy has to be clearly distinguished from illness, disability and handicap, although these four concepts are not totally independent of each other:
• illness denotes an objective, temporary situation of ill health (i.e. fever etc.) and a need for therapeutic care (i.e. medication, surgical intervention etc.);
• disability denotes a reduced capacity for normal activity following an accident or an illness, and does not necessarily imply the need for assistance;
• handicap denotes a physical or psychological limitation in the accomplishment of normal activity and may be associated with a need for assistance;
• long-term care denotes an inability to perform some of the most basic everyday activities due to old age and the need for assistance in order to carry out such activities.
Loss of autonomy as an inability to perform basic everyday activities is difficult to assess. In order to limit the weight of subjectivity when making such an assessment, objective criteria have been defined. Three main criteria grids are currently used (cf. Table 3). Two of them are based on the Katz list of the main basic everyday activities, the loss of autonomy being then defined as the inability to perform two, three or four of these basic every day activities. So, French insurers define the loss of autonomy as the inability to carry out without the help of a third person two of the four activities of the daily life they have along the Katz scale while American insurers define it as the inability to carry out without the help of third person four of the six activities they have. French public authorities take a different approach where loss of autonomy is defined by one of five specific situations where these different situations are scaled in relation to the level of the loss of autonomy and where the inability to carry out activities of daily life corresponds to the two first levels of the loss of autonomy (occasional help for bathing and home care is not considered as a loss of autonomy situation).

Table 3
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Finally, long term care combines individual, social and public patterns. More precisely it is the result of four random factors: lifespan, lifespan without losing one’s autonomy, lifespan when one’s autonomy has been lost, presence of close support (spouse survival, child and neighbours)12. The second and the fourth factors are, to some extent, not fully objective random variables. As we have seen, the margin of subjectivity concerning the second factor has been limited thanks to the definition of criteria grids. The fourth factor is much more difficult to control because it relies more on the good will of interested parties and their good relationships.

8 Cf. Cutler, D.M., Glaeser, E.L. and Rosen, A.B. (2007): “Is the US Population Behaving Healthier?”, NBER Working Paper, No 13013.
9 Dave, D., Rashad, I. and Spasojevic, J. (2006): “The Effects of Retirement on Physical and Mental Health”, NBER Working Paper, No. 12123.
10 Lakdawalla, D.N., Bhattacharya, J. and Goldman, D.P. (2004): “Are the Young Becoming More Disabled? Rates of Disability Appear to Be on the Rise Among People Ages Eighteen to Fifty-Nine, Fuelled by a Growing Obesity Epidemic”, Health Affairs, Vol. 23, No. 1, January/February.
11 Cf. Cutler et alii (2007).
12 Cf. Lakdawalla, D.N. and Philipson, T. (2002) : “The Rise in Old-Age Longevity and the Market for Long-Term Care”, American Economic Review, Vol. 92, No. 1.


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