Access to Medical Care Depending on the Employment

Status and History of Unemployment in different

welfare regimes and healthcare systems

First draft June 2016

Ave Roots

University of Tartu

First draft prepared for session “Health, labour markets & (un)employment II”

in the European Social Survey Conference “Understanding key challenges for

European societies in the 21st century“ in Lausanne 13-15th July 2016.

Please do not quote or cite without permission of the authors.

Contact:

Ave Roots, University of Tartu, ave.roots@ut.ee

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Abstract

Health inequalities between employed and unemployed have been widely studied and found

that unemployed have systematically lower health status. Inequalities in access to health care

depending on the employment status have not been studied that much. Different welfare

regimes and health care systems both play their role as mediators between employment status

and access to health care. Using the gradual approach of employment status between

employed and unemployed, the group of employed was divided into those with the experience

of unemployment and those without it.

In 2014 European Social had the special health inequalities block and it has been utilised in

current study. European Social Survey data shows that employed with the experience of

unemployment are in several countries more likely not to get medical consultation or

treatment in case of need compared to the employed who have never been unemployed,

whereas the last group often does not differ from unemployed. The worse access to medical

care of the employed with unemployment history is associated with worse working conditions

compared to those who have not been unemployed in Estonia, Great Britain, Ireland, Poland

and Portugal. These countries have strict access restrictions on the primary level of health care

and the Anglo-Saxon and the Eastern-European countries also have more liberal labour

markets and that amplifies the differences between mentioned groups on the labour market.

Keywords: access to health care, impact of unemployment, health care systems, welfare state

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Introduction

Unequal access to medical care is one of the factors that influence socioeconomic inequality

in health. If people who have a disadvantaged position on the labour market, have also worse

access to medical care, it leads to multidimensional accumulation of disadvantages.

Virtanen et al. (2006) have found that there is rather gradual and not strict difference between

employed and unemployed in terms of health care utilization, the marginal groups on the

labour market (employees with fixed term contracts) are doing worse than employees with

permanent contracts and the health care utilization is the lowest among unemployed. This

article compares the access to medical care based on unmet need between different groups

according to their unemployment experience (currently unemployed, employed with the

experience of unemployment as a more marginal group on the labour market and employed

with no previous unemployment experience).

The purpose of this article is to study how the position on the labour market is associated with

the access to the medical care in case of need and how health care systems and welfare state

types moderate this association.

Unemployment and health

The association between unemployment and worse health outcomes compared to the

employed has been well documented. For example Bambra and Eikemo (2008) study the

impact of unemployment in different welfare regimes. Unemployment had the most negative

effect on women in Anglo-Saxon and Scandinavian regimes. Inequality between employed

and unemployed was the greatest in Anglo-Saxon regime, but also for men in Bismarkian and

women in Scandinavian regime, the smallest difference between employed and unemployed

was among Southern women. In Anglo-Saxon countries there is the greatest income

deprivation and stigmatisation (means tested benefits). In Bismarkian familial approach men

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are more treated as breadwinners. The authors claim that in Scandinavia many women work

part time and do not meet the benefits criteria and therefore there is much income inequality

between working and not working women. The small differences in Southern regime can be

explained by traditional family model and additional resources by the family.

Long term unemployment has become a stronger predictor of healthy life years at the age of

50 in European countries between 2005 and 2010 (Fouweather et al. 2015).

Unemployment and the access to health care

Access to health care be measured based on health care utilisation as it is done very often or

based on unmet need, which is individuals’ subjective assessment that they did not receive the

needed health care (Allin, Grignon, and Le Grand 2010:465). EU-SILC 2004 data show that

of the surveyd countries the highest unmet need was perceived in Sweden (13%), followed by

Estonia (11%) and Italy (%) and the lowest proportion of people with unmet need was in

Denmark (1%), Belgium and Austria (2% in both) (Koolman 2007:188). The same study

shows that in the majority of surveyed countries the cost of the services has been hindrance

for access (in Belgium, Greece, Estonia, France, Ireland, Italy and Portugal), waiting list has

been the greatest problem in Spain, Finland and Sweden, having no time in Austria and care

being too far in Norway (Koolman 2007:188).

There is plenty of articles that establish the relationship between unemployment and worse

access to health care in US. In US unemployed are often also uninsured and therefore have

less access to healthcare (Driscoll and Bernstein 2012). There is only some research that

studies the relationship between unemployment and access to healthcare in Europe. In macro

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level increase of unemployment is connected to worse health outcomes in European Union

countries and the reasons assumed to be worse access to health care for the unemployed

(Maruthappu et al. 2016). In Greece, in 2013, the unemployed with chronic illness were more

likely to experience the economic, but also waiting lists access barrier to health care

(Kyriopoulos et al. 2014). A Swedish study shows that non-employed (people with no

employment income) have lower access to ACE Inhibitors (that reduce mortality and

morbidity from heart failure), even when other factors, including medical literacy are

controlled for (Ohlsson et al. 2016). The same study found that the impact of non-

employment to the choice of medical treatment is more important than material resources and

ability to access and understand medical information. Different treatment of the non-

employed might be associated with their lower status. It has also been found about underclass

in Canada, that they are stereotyped and treated differently than others in medical system

(Tang et al. 2015).

In terms of the utilisation of the mental care there are different results. Alonso et al. (2007)

and Gouwy, Christiaens, and Bracke (2008) have fount that in case of mental health

problems, unemployed seek less often medical care than the employed. However, Buffel, van

de Straat, and Bracke (2015) have found that the unemployed use medical care more than

employed, even regardless of their mental health status.

A Finnish study (Virtanen et al. 2006) shows that the border between employed and

unemployed is not clear-cut. People at margins of the labour market differ from the people at

the core. Permanently employed differ from both, fixed term employed and unemployed in

terms of using dental care and primary care in case of cardiovascular, respiratory and

skeletomuscular disease, permanently employed visit the healthcare specialists most often,

followed by fixed term employed and the least amount of visits are made by unemployed and

the differences between these groups widened after controlling for need (Virtanen et al. 2006).

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People have unemployment in their work history are not vulnerable only during that moment

of unemployment, but unemployment has a “scarring” effect on their work career later and

can have a negative cumulative outcome during their life course (Layte et al. 2000;

Vandecasteele 2011). The long term negative effects of unemployment during the working

career are lower salaries, more downwards mobility, less upwards mobility compared to the

employed who have not experienced unemployment and also reoccurring unemployment

episodes (Gangl 2006; Layte et al. 2000; McManus and DiPrete 2000; Vandecasteele 2011).

Context: welfare state and health care system

There is a very important mediator between the access to health care and employment status.

It is the institutional context of the state. In this study, the 2 concepts have been chosen to

explain the mediating role of the institutional context. These concepts are welfare state, labour

market type and healthcare system type.

Welfare state has a direct effect to health outcomes but is also a mediator between labour

market status, access to healthcare and health outcomes (Beckfield et al. 2015).

Studying social inequalities in health, several authors cluster countries in 5 welfare regime

types: Scandinavian (Denmark, Finland, Norway, Sweden), Anglo-Saxon (UK and Ireland),

Bismarckian (Germany, France, Austria, Belgium, the Netherlands), Southern (Greece, Italy,

Portugal, Spain) and Eastern-European (Czech Republic, Estonia, Hungary, Poland, Slovenia,

Slovakkia) (Bambra 2009; Bambra and Eikemo 2008; Bambra, Netuveli, and Eikemo 2010;

Eikemo, Bambra, Joyce, et al. 2008; Eikemo, Bambra, Judge, et al. 2008; Eikemo, Huisman,

et al. 2008). Scandinavian regime can be described by universalism, generous transfers, strong

interventionist state and promotion of social equality through social security system; Anglo-

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Saxon regime has modest social transfers and minimal level of provision and dominance of

the market; Bismarckian regime is characterized by often earnings related benefits,

administration through employer, the role of the family is emphasized and the role of the

market marginalized; Southern welfare regime has strong reliance on family and only

fragmented provision, health care system provides only limited and partial coverage; Eastern-

European system includes post-socialist countries where there have been great reforms with

direction of decentralization and liberalization since the beginning of 90s (Eikemo, Bambra,

Joyce, et al. 2008).

Wendt (2014) divides European countries between 4 main types of healthcare systems. First

type is described by high share of public financing, moderate level of out-of-pocket payments

and very high access regulation. Australia, Denmark, Ireland, Italy, the UK, Czech Republic,

Estonia, Hungary, Poland, the Slovak Republic, Slovenia and the Netherlands can be

described by this type. The second type of healthcare systems have high share of public

financing as well as out-of-pocket payments and high access regulation. The countries in this

type are Finland, Iceland, Portugal, Spain and Sweden. The third type with Greece, Israel and

Turkey can be described by low level of public financing and no control over patients accsess

to medical care. The medical systems in the last group, Austria, Belgium, France, Germany,

Luxembourg, have the highest share of public financing, the lowest share of out-of-pocket

payments and free choice of medical doctors.

Based on this context, it can be hypothesised that first unemployment as a status might play a

greater role in a system with strict gate keeping (like healthcare system types 1 and 2 by

Wendt 2014), because might make their decisions based on the status of the patient and labour

market status makes a contribution in general status. Second, it can be hypothesized, that

unemployment in the past which leads to cumulative disadvantage on the labour market, plays

a greater role in the Anglosaxon and Eastern-European welfare regimes, because less state

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intervention leads to greater inequality on the labour market (for example less flexible

working conditions, more job insecurity, working contract with no entitlement to health

insurance coverage), which can be a hindrance accessing health care.

Data and methods

European Social Survey (ESS) where the sample are non-institutionalized persons 15 years

old and older. In current study there is only active population (working and unemployed) and

in the regression analysis only those who had need for medical treatment or consultation

during last 12 months. In 2014 there was the special block on health inequalities in ESS.

There was all together 15054 individuals in the analysis. The countries in the analysis were

Austria (781 individuals), Belgium (728), Switzerland (671), Czech Republic (664), Germany

(1429), Denmark (625), Estonia (785), Spain (855), Finland (851), France (840), Great Britain

(829), Hungary (420), Ireland (617), Lithuania (696), The Netherlands (662), Norway (627),

Poland (571), Portugal (517), Sweden (616), Slovenia (405).

The dependent variable in the regression analysis measures whether the respondent was able

to get or was not able to get medical consultation or treatment in case of need.

The central independent variable of interest was labour market status connected to

unemployment (unemployed, currently employed, who have been unemployed and as a

reference category, employed who have never been unemployed).

To further study the wider relationship with labour market, there are some characteristics of

the working conditions in the analysis: the type of the contract (permanent as reference,

compared to fixed and no contract), total working hours normally per week and work

autonomy (to what extent allowed to decide, how daily work is organized, on the scale 0-10).

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The control variables on the regression models were age, gender, marital status, children at

home, place of residence, ethnic minority, migration background, citizen of country (except in

Czech Republic, Hungary and Poland due to lack of variation), life satisfaction, subjective

health, hampered in daily life, assessment of current household income.

Results

The proportion of the respondents with met and unmet need varies country by country as can

be seen in Graph 1. Only 5% of respondents in the Netherlands felt that they needed medical

consultation or treatment, but did not get it, followed by 5% in Austria and Hungary. At the

same time almost a fourth of the respondents in Poland and around a fifth of the respondents

in Finland, France, Portugal and Estonia perceived the need for medical consultation or

treatment, but did not receive it.

Graph 1. Met and unmet needs by country

4% 5% 5% 7% 7% 7% 7% 8% 10% 11% 13% 13% 13% 13% 16% 18% 19% 19% 20% 23%

65%76%

47% 47% 51%

72% 68% 65% 53%69%

47%61% 62% 69%

71%52%

66% 63% 59% 48%

31%19%

48% 46% 42%

21% 24% 27%36%

21%

41%26% 24% 18% 12%

30%14% 18% 21%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Needed,but did not receive Needed and received Did not need

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The proportion of respondents with unmet need is broken down by the position on the labour

market on the graph 2.

Graph 2. Proportion of those who needed, but did not get medical consultation or treatment by

employment status.

In France clearly unemployed are the most disadvantaged in terms of getting medical

consultation or treatment, when needed, half of them did not receive it. Also in Finland, like

in France, the unemployed are the most disadvantaged. However in several countries (like

Great Britain, Portugal, Poland, Norway, Lithuania etc) working people with the history of

unemployment are the most disadvantaged one in terms of the access to the health care.

Table 1 presents the results of the regression analysis.

4%6% 6% 6% 7% 7% 8% 9% 10% 10% 11%

15% 16%18%

20% 21% 21%25% 25%

49%

6%

11% 10%

15%

10%

6%

20%

9%

15%

9%11%

19%

18% 19%

26%

21% 21%

20%

30%

23%

3% 5% 6% 12% 5% 3% 12% 8% 4% 4% 10% 12% 15% 9% 21% 18% 15% 16% 14% 20%0%

10%

20%

30%

40%

50%

60%

Currently unemployed Employed, been unemployed Employed, never been unemployed

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Table 1. Logistic regression predicting not getting medical consultation or treatment in case of

need.

Employment status Working conditions

Country

Unem-

ployed

Employed,

been

unem-

ployed

Fixed-term

contract No contract

Working

hours

Auto-

nomy

B Sig B Sig B Sig B Sig B Sig B Sig

Austria -0.02 0.28

-0.48 0.14 1.59 *** 1.25 0.01 0.01

Belgium 0.29 0.57 *

0.24 0.50 0.49 0.63 -0.01 0.04

Switzer- 0.35 1.37 ***

land -0.07 1.34 *** -0.13 0.62 0.00 -0.06

Czech -0.33 0.42

Republic -0.91 0.21 -0.37 -1.70 0.02 0.08

Germany -0.48 0.08

-0.39 0.08 0.08 -0.56 0.00 0.03

Denmark -0.42 0.24

-0.70 0.19 -0.13 0.1 0.01 -0.07

Estonia 0.32 0.39 *

0.05 0.41 0.34 1.34 0.00 0.07 *

Spain -0.21 0.04

-0.17 -0.03 0.02 -2.83 ** 0.02 * 0.06

Finland 0.14 0.05

0.15 0.05 -0.04 2.56 ** 0.03 * -0.06

France 0.79 ** -0.03

0.82 ** -0.14 -0.13 -0.55 0.02 0.01

Great -0.95 * 0.47 *

Britain -0.91 0.4 0.89 ** 0.42 0.00 -0.08 *

Hungary 0.28 0.26

0.25 -0.14 -1.24 -0.27 -0.03 -0.03

Ireland -0.34 0.81 **

-0.08 0.64 0.30 0.6 0.00 0.07

Lithuania -1.40 * 0.00

-3.03 ** -0.26 0.64 0.27 0.02 -0.11 **

The -0.78 0.52

Netherlands -0.88 0.26 0.64 -1.48 -0.01 -0.08

Norway -0.6 0.39

-0.6 0.31 0.71 0.06 0.03 * 0.00

Poland -0.04 0.39 *

0.05 0.24 -0.49 * 0.48 0.00 0.06

Portugal 0.65 * 1.23 ***

0.96 * 1.08 *** -0.49 0.01 -0.01 0.15 **

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Sweden -0.16 -0.02

0.12 0.10 -0.13 2.07 * 0.00 0.13 *

Slovenia -0.34 0.34

0.65 0.82 -0.10 2.07 0.05 * 0.03 *** p<0.001; ** p<0.01; * p<0.05

Dependent variable: not receiving or receiving (reference category) medical consultation or treatment in case of

need.

Controls: age, gender, marital status, children at home, place of residence, ethnic minority, migration

background, citizen of country (except in Czech Republic, Hungary and Poland due to lack of variation), life

satisfaction, subjective health, hampered in daily life, assessment of current household income

Table 1 shows that in France and Portugal, unemployed have better access to medical care

than employed who have never been unemployed, but in Lithuania unemployed are

disadvantaged in terms of access to the health care. In Belgium, Estonia, Great Britain,

Ireland, Poland and Portugal, employed with unemployment history were more likely not

getting medical consultation or treatment in case of need, but this association looses statistical

significance after adding working conditions to the model. In case of Portugal having been

unemployed still significantly predicts no access to medical care in case of need, but the

coefficient is somewhat reduced. Adding working conditions to the model does not influence

the association between unmet need and unemployment background in Switzerland. The

concrete working conditions seem to have different influence on the relationship between

access and employment status in different countries.

Discussion and conclusions

Although in the Bismarkian system, the labour market based entitlement to heal care

insurance is more expected, the analysis shows that of the Bismarkian countries, only in

France the unemployed are much more likely to get no medical consultation or treatment in

case of need.

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Following Virtanen et al. (2006) and dividing the employed into groups, has showd some

important differences between the employed with and without the experience of

unemployment. The employed with the history of unemployment differed in terms of access

to the health care from the employed who had never been unemployed in Belgium,

Switzerland, Estonia, Great Britain, Ireland, Poland and Portugal. In all of these countries

other than Switzerland, difference in working conditions was behind the difference between

employed with and without the experience of unemployment. Going back to the healthcare

system types described by Wendt (2014), all these countries other than Belgium are in types

1(Estonia, Great Britain, Ireland, Portugal, Poland) and 2 (Portugal) according to Wendt 2014

in both of these clusters there is high access regulation.

Gatekeepers can play a role in two ways. First they can be influenced by the unemployment

as a status. The research of Ohlsson et al. (2016) and Buffel et al. (2015) has shown that

unemployment works in medical system as low status compared to employed. Second, people

with the history of unemployment might also possess different characteristics than people

without that experience and these characteristics might play an important role getting through

and around the gatekeepers.

Working conditions play also a role in enabling or disabling access to needed medical care.

First people with less autonomy, higher work strain and longer working hours may encounter

more difficulties to get time off for doctor’s appointment. Also people with the history of

unemployment and temporary or no contract might feel less job security and therefore are

more hesitant to take time off of work for the doctor’s appointment and they also might be

more reluctant to indicate their health problems, not to be seen as less productive due to

health issues. The more liberal and less regulated labour markets in Eastern European and

Anglo-Saxon countries is likely to amplify the inequality of working conditions between the

workers with and without the experience of unemployment.

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