Long-term care use and socio-economic status in Belgium: a survival analysis using health care insurance data

Background: The small but growing literature on socio-economic inequality in morbidity among older persons suggests that social inequalities in health persist into old age. A largely separate body of literature looks at the predictors of long-term care use, in particular of institutional care. Various measures of socio-economic status are often included as control variables in these studies. Review articles generally conclude that the evidence for such variables being a predictor for institutionalization is “inconclusive”. In this paper we look at the association among older persons in Belgium between one particular measure of socio-economic status – preferential status in public health care insurance – and first use of home long-term care and residential care. Preferential status entitles persons to higher reimbursement rates for health care from the public health care insurance system and is conditional on low income. We also study whether preferential status is related to the onset of five important chronic conditions and the time of death. Methods: We use survival analysis; the source of the data is a large administrative panel of a sample representative for all older persons in Belgium (1,268,740 quarterly observations for 69,562 individuals). Results: We find a strong association between preferential status and the likelihood of home care use, but for residential care it is small for men and non-existent for women. We also find that preferential status is significantly related to the chance of getting two out five chronic conditions – COPD and diabetes, but not dementia, hip fracture and Parkinson’s disease – and to the probability of dying (not for women). For home care use and death, the association with preferential status declines with increasing age from age 65 onwards, such that it is near zero for those aged around 90 and older. Conclusion: We find clear associations between an indicator of low income and home care use, some chronic conditions and death. The associations are stronger among men than among women. We also find that the association declines with age for home care use and death, which might be explained by selective survival.