Eligibility or use? Disentangling the sources of horizontal inequity in home care receipt in the Netherlands

We study horizontal inequity in home care use in the Netherlands, where a social insurance scheme aims to allocate long-term care according to care needs. Whether the system reaches its goal depends not only on whether eligible individuals have equal access to care but also on whether entitlements for care reflect needs, irrespective of socioeconomic status and other characteristics. We assess and decompose total inequity into inequity in (i) entitlements for home care and (ii) the conversion of these entitlements into actual use. This distinction is original and important, because inequity calls for different policy responses depending on the stage at which it arises. Linking survey and administrative data on the 65 and older, we find higher income elderly to receive less home care than poorer elderly with similar needs. Although lower income elderly tend to make greater use of their entitlements, need-standardized entitlements are similar across income, education, and wealth levels. However, both use and entitlements vary by origin and place of residence. The Dutch need assessment seems effective at restricting socioeconomic inequity in home care use but may not fully prevent inequity along other dimensions. Low financial barriers and universal eligibility rules may help achieve equity in access but are not sufficient conditions.