Health care utilisation and immigration in Spain

According to the health production function approach, older individuals experience a faster depreciation of their stock of health, and people with higher education are more efficient at maintaining good health status.

Winkelmann [3] also points out that if immigrants are screened for good health before entering the country (as they are in the United States or New Zealand), this can result in lower health services utilisation rates. This argument does not apply to Spain, since immigrants are not screened and (again) no clear prediction arises of whether it is possible to control for health status.

The influence of risk attitudes and their variation across races has been documented by Rosen, Tsai and Downs [51].

For example, Bach et al. [52] report that black patients are treated by less trained physicians with less access to health care resources than doctors treating white patients.

In the last wave of the ECHP, there were only 109 observations of people born outside the EU.

See Durán et al. [61] for a detailed description of the National Health System in Spain, and Navarro [53] for a comprehensive analysis of the main levels and trends in social and health spending in Spain compared to the other countries in the EU.

See Romero-Ortuño [54] for details and for a comparative analysis of the Spanish legislation with other European regimes.

It is worth mentioning that the NHS was carried out since 1987, roughly every 2 years since 2001, by the Spanish Ministry of Health.

This is the criterion followed, for example, by Borjas and Trejo [55], Boeri et al. [34], and Hansen and Lofstrom [56].

For example, in general terms, naturalisation takes 10 years of residence in Spain. However, it can be reduced in some circumstances, such as in the case of marriage with a national, and, notably, for people born in certain countries. For example, people born in Latin America, the main home country of origin of immigrants to Spain, can obtain Spanish nationality after only 2 years of residence or even immediately if they prove the existence of a Spanish ancestor.

This database can be accessed at http://​www.​ine.​es/​inebmenu/​mnu_​salud.​htm.

Windmeijer and Santos Silva [57] suggest a solution based on the Generalised Method of Moments in order to address the simultaneity problem. However, it is hard to find instruments correlated with subjective health-status and at the same time independent of health care use utilisation, and their implementation involves complexities that reduce the range of econometric models to be used. Anyway, if the determinants of the type of insurance are among the covariates included in the models, estimates will be consistent as selection will be based on observables.

See Grogger and Carson [58] and Cameron and Trivedi [38] for a detailed derivation of the log-likelihood function of truncated and non-truncated Poisson and negative binomial models.

Examples of the use of these criteria to evaluate the goodness-of-fit of different models in health economics can be found in, among others, Gerdtham and Trivedi [59], Jiménez-Martín et al. [32], and Cotter [49].

For reasons of space, we show only the results of models that best fit data. Detailed results from other econometric models and specifications are available on request.

We tried to estimate the same models using LIMDEP, another econometric package with canned routines for fitting zero-truncated negative binomial models and the same convergence problems remained, even for very parsimonious specifications.

It is also worth mentioning that some authors, e.g. Jiménez-Martín et al. [32] in their comparative work for European countries, find that two-part models perform worse than other single-stage models in health care systems with gate-keepers, such as latent class models that are based on the distinction between low and high users. These latter authors use the ECHP 1996, which includes annual visits to GPs and specialists. As mentioned, the database used in this study comprises only monthly visits, which greatly reduces the variability of health care utilisation among users, making a latent class model based on a distinction between low and high users less appropriate.

The main results of this survey can be found on the website of the Spanish National Statistics Institute at http://​www.​ine.​es/​inebase/​cgi/​um?​M=​%2Ft15%2Fp414&​O=​inebase&​N=​&​L.