Strategic cost-shifting in long-term care. Evidence from the Netherlands

With the reform in 2015 of the system of long-term care (LTC) in the Netherlands, responsibilities for the provision of social support and assistance were delegated from the central government to the municipalities. Unintentionally, the way municipalities are financed created incentives to shift cost from the local level back to central level. In this paper we examine whether municipalities respond to the prevailing financial incentives by shifting costs to the public LTC insurance scheme. Using data on almost all Dutch municipalities over the period 2015-2019, we estimate that municipalities with a solvency rate below 20% have a 2.5% higher admission rate to the public LTC scheme. Furthermore, we show that the tightening municipal budgets for social care since 2017 were accompanied with about 14% higher admission rates in 2018 and 2019 compared to 2015. The results point to strategic cost shifting by municipalities that can be counteracted by changing the financial incentives for municipalities and by reducing the existing overlap between the local and central care domains.