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Activate the most vulnerable? The case of the Disability Insurance reveals many paradoxes

The three most recent reforms of DI in Switzerland have sought to stem rising costs by requiring insured persons to make greater efforts to rejoin the labour market. Emilie Rosenstein has examined this development from both a quantitative and a qualitative perspective, and highlights the ambivalence of the changes made: her thesis identifies several asymmetries between the stated objectives and the results obtained, as well as between the standards promoted and the actual effects they have on people with disabilities.

“Only those who use their freedom remain free and (...) the strength of a people is measured by the well-being of its weakest members.” This excerpt from the preamble of the Swiss Constitution completes Emilie Rosenstein's doctoral thesis on the contradictions of an important part of social policy in Switzerland, which, despite advocating integration of beneficiaries, actually leads to forms of exclusion.

This thesis in sociology, which was defended at the University of Geneva on 12 February 2018 and prepared under the supervision of Prof. Jean-Michel Bonvin, analyses the recent developments in Disability Insurance (DI) on the basis of two theoretical frameworks: from Nobel laureate Amartya Sen’s perspective on capabilities, which examines social regimes from the point of view of individuals' ability to make choices that they have reason to value; and the life course approach developed within the National Centre of Competence in Research LIVES, which perceives vulnerability as a lack of resources affecting several life domains, on various levels and over time.

Emilie Rosenstein's research uses both quantitative and qualitative methods and combines a wealth of data to assess the consequences of the successive DI reforms which took place in 2004, 2008 and 2012. One of the main objectives of these changes was to reduce the number of annuitants, particularly among young people suffering from mental disabilities, a category that has seen a significant increase since the 1990s.

In an attempt to achieve their goal, these reforms have followed three specific guidelines: stricter assessment of the right to benefit, earlier intervention by DI (primarily as a result of disabilities being detected earlier) and additional measures for vocational rehabilitation and labour market inclusion.

Contrasting results

Emilie Rosenstein's observations lead to contrasting results: while the number of people in receipt of the benefit has fallen sharply at national level, the proportion of the youngest beneficiaries - aged from 18 to 34 - has not decreased; around one in every two beneficiaries are in receipt of disability annuities due to mental illness.

Sequence analyses, conducted by the researcher in partnership with Prof. Felix Bühlmann from the University of Lausanne using representative samples of people in receipt of DI in the canton of Vaud, provide an insight into the trajectories of insured persons over time and across the successive system reforms.

There has been a considerable increase in the number of claims being rejected by the DI and a clearly perceptible acceleration in the processing of cases. Conversely, the provision of vocational rehabilitation measures is on the increase, although it remains marginal.

Stricter criteria and requirements

According to Emilie Rosenstein, “the decline in numbers is due to the eligibility criteria being tightened, rather than more people exiting DI, including as a result of rehabilitative measures.”

Her thesis identifies several paradoxes brought about by the successive reforms. She questions the very concept of activation in relation to people affected by health problems, who are often asked to come up with a reintegration project when they are sometimes in a state of great vulnerability.

Not the least of the contradictions here is the fact that in order to reduce expenses, the DI urges insured persons to make their declarations as soon as possible, taking the view that early intervention will prevent annuities having to be paid over the medium and long term. However, this pressure has a dissuasive effect on beneficiaries, either because they are unaware of the range of benefits provided by DI, or because their health is too unstable for them to take decisions at that stage, or because they are still in denial about their disability.

These discrepancies in timing between the DI and its insured persons are an obstacle to professional retraining. “The activation paradigm therefore appears to be profoundly paradoxical, because it increases the risk of non take-up while at the same time trying to reduce it,” the researcher notes with concern.

Risk of inauthenticity

Emilie Rosenstein believes therefore that there is a risk of “inauthenticity” in the reintegration projects, and therefore of failure if the needs and expectations of the beneficiaries are not sufficiently taken into account. “The use of the project as an insertion tool is therefore indicative of a potentially selective approach, or even one that promotes exclusion,” comments the researcher.

She is also critical of the “significant asymmetry between the individual responsibility of insured persons regarding their reintegration projects and the limited professional opportunities available.” From a capabilities perspective, Emilie Rosenstein calls for greater attention to be paid by the labour market and wider society to the “conversion factors” necessary to reduce inequalities between able-bodied people and those with disabilities, and promote real access, not just a formal right, to professional reintegration.

Feelings of ineligibility

A series of interviews with beneficiaries supports the thesis, enabling the researcher to focus on the feelings of ineligibility or shame experienced by DI users. These accounts confirm the hypothesis that a section of the insured persons engage in a kind of auto-selection and risk missing out on the benefits of DI, either because they do not understand their rights or because they refuse to be seen as disabled, or they are afraid of being stigmatised as opportunists taking advantage of the system.

Before the public defence of her thesis, Emilie Rosenstein took several opportunities to present her research to professionals in the field. Her thesis panel was particularly appreciative of her efforts to communicate with the stakeholders involved and advised her to publish her empirical results in ambitious scientific journals.

At a time when the seventh review of DI is already under way, her new title of doctor now confers on her all the legitimacy necessary to speak out for those who are not generally heard and to whom we would do well to listen more, as is shown in her work.

>> Emilie Rosenstein (2018). Activer les publics vulnérables ? Le cas de l'Assurance-invalidité. Under the supervision of Jean-Michel Bonvin. University of Geneva

New address for the Centre for the Interdisciplinary Study of Gerontology and Vulnerability

New address for the Centre for the Interdisciplinary Study of Gerontology and Vulnerability

As from March 2018, the CIGEV in Geneva will leave its current position at the Route des Acacias and move into new offices at the first and second floors of the Boulevard du Pont d'Arve 28, just opposite the Uni Mail building across the street. This new location will allow the Geneva teams of the Swiss National Centre of Competence in Research LIVES, which were split into two separate places, to be reunited under the same roof, together with the Cognitive Aging Lab (CAL) ant the psycholinguistcs of the University of Geneva.

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Poverty in childhood has long-term effects on health, especially among women

An interdisciplinary research project shows that some inequalities may be irreversible. Based at the University of Geneva and funded by the National Centre of Competence in Research LIVES, the team examined several aspects of health in people over 50 across Europe. It found that men are better able to compensate for a difficult start in life than women. The researchers advocate much earlier interventions in terms of education and prevention.

People who are materially and socially disadvantaged at the very beginning of their life course are more likely to have fragile health in later life, according to the "LIFETRAIL" project, conducted since the end of 2016 within the NCCR LIVES by Stéphane Cullati and several colleagues from the University of Geneva.

With an article by Boris Cheval et al. soon to be published in the journal Age and Ageing 1 following another that recently appeared in the journal Medicine and Science in Sports and Exercise 2, now is a good time to take stock of all this interdisciplinary research involving sociologists, psychologists, epidemiologists and physicians, and on which several papers are currently being submitted or published, mostly showing marked divergence between the sexes.

Rich longitudinal data

All are based on data from SHARE (Survey of Health, Ageing and Retirement in Europe) and cover nearly 25,000 people aged 50 to 96, interviewed six times between 2004 and 2016 in 14 European countries.

Seven health indicators are examined: self-reported health, i.e. how respondents subjectively assess their own health; muscular strength, checked by means of a portable dynamometer; respiratory capacity, measured by a peak flow meter that measures how quickly respondents are able to blow out air; the quality of sleep; cognitive disorders; depression, assessed by means of a questionnaire repeatedly validated by research; and finally the level of frailty, which is calculated by taking into account the body mass index and the degree of autonomy in several everyday actions.

To determine the socio-economic situation in childhood (at age 10), the analysis is based on four variables: occupation of the main breadwinner (often the father), number of books available in the household, quality of the housing (whether or not there was running water, toilets and central heating), and number of people per room in the home.

Importance of social mobility

According to all these criteria, unfavourable socio-economic conditions in childhood are associated – to varying degrees – with poorer health in middle and old age, except for those men who have managed to climb the social ladder.

This upwards social mobility, which is so beneficial for men, can be observed by comparing the initial socio-economic status with that achieved in adulthood, in terms of education, type of occupation and current economic situation. Those who have completed university education, had careers of responsibility and who easily manage to make ends meet are clearly privileged from the point of view of health, even where they suffered from poverty in childhood. This is less commonly the case for women in the cohorts studied.

Reduced muscular strength

Boris Cheval's article on muscular strength found a significant link between childhood poverty and physical weakness at an advanced age. Even taking into account health practices in adulthood (sports, tobacco, alcohol, nutrition), the impact of childhood remains preponderant, especially for women.

"It would seem that women who have never worked have not been able to acquire certain behavioural skills," says Stéphane Cullati, for whom the paradox of women's longer life expectancy is nothing but an illusion: "Just because people are kept alive longer doesn't mean they are necessarily healthy."

The researcher expects to see gender differences wane in the future, thanks to better access to education and the world of work for new generations of women, while warning against the 'double sentence' of those who combine low-skilled professional work with domestic chores.

Earlier action required

The work of the LIFETRAIL project has clear implications for public policy. "For physical activity, for example, we see that a high level of education cancels out the effect of unfavourable socio-economic circumstances in childhood," says Boris Cheval. "But for peak flow or muscular strength, on the other hand, the effect remains marked in women, regardless of their socio-economic trajectory into adulthood. We should therefore act much earlier!"

Part of the research project, led by Stefan Sieber, compares the self-reported health of respondents across different types of welfare systems and concludes that childhood poverty remains strongly associated with poor health conditions later in life, regardless of the social regimes throughout Europe. So the challenge is tremendous.

Now that the link between socio-economic conditions in childhood and health in later life has been established, the team will be taking a closer look at the timing of certain events, such as material losses, periods marked by hunger or parental death, in order to better understand what the most critical phases are in a child's development that can lead to long-term health problems. Researchers are testing this model on the probability of starting smoking again. Who are the most vulnerable candidates, those most at risk of relapse? The SHARE data still hold many possibilities, which are still waiting to be explored by this dynamic team.

  • 1. Cheval, B. et al. (2018). Association of Early- and Adult-Life Socioeconomic Circumstances with Muscle Strength in Older Age. Age and Ageing. DOI 10.1093/ageing/afy003
  • 2. Cheval, B. et al. (2017). Effect of Early- and Adult-Life Socioeconomic Circumstances on Physical Inactivity. Medicine and Science in Sports and Exercise. DOI 10.1249/MSS.0000000000001472