Choice and vulnerability in aging societies: Understanding the impact of age on user capacity

Date01 September 2019
AuthorAgnete Aslaug Kjær
Published date01 September 2019
Choice and vulnerability in aging societies:
Understanding the impact of age on user capacity
Agnete Aslaug Kjær
The Danish Center for Social Science Research
(VIVE), Denmark
Agnete Aslaug Kjær, The Danish Center for
Social Science Research (VIVE), Herluf
Trollesgade 11, 1052 Copenhagen K,
One necessary condition for realizing the benefits of choice-based
models of public service provision is that the service users in a
given sector are capable of exercising choice. However, along with
population aging, critics may question the level of user capacity in
the growing user group consisting of older citizens with healthcare
needs. For the first time in an older-aged sample (52 to 97 years,
N~ 10,000), this study examines the link between age and user
capacity (public service efficacy). Our results from the hospital sec-
tor in Denmark reveal a negative age gradient, where those of
advanced age and declining health report significantly lower public
service efficacy. However, when examining this age gap, much is
attributable to cohort differences in educational attainment. Thus,
while current generations of older service users constitute a vulner-
able group under choice-based policies, this challenge is likely to
diminish in the future.
In recent decades, most Western welfare states have seen a restructuring of their public service provision through
the introduction of large-scale service reforms, the creation of quasi-markets, and the pursuit of the choice agenda
(Le Grand 2009, 2011). A central aim of these reforms has been to create a public service provision that is efficient,
responsive, accountable, equitable, and of high quality (Le Grand 2010), through offering citizens a role as consumers
rather than passive recipients (Clarke et al. 2007). Usersnow treated as consumersare assumed to be empowered
by the opportunity to choose and exit; in turn, and as a result of the risk of losing their share of the market, providers
are incentivized to be more responsive to the needs and preferences of users (Hirschman 1970; Le Grand 2002,
2003, 2009; Vigoda 2002).
However, a key condition for deriving the suggested benefits of choice-based policies is that service users in a
given sector are capable of influencing the process by making well-informed choices and selecting optimal providers
(Le Grand 2003, 2007; Jilke 2015a); it is debatable whether all user groups are equally able to do so (Dowding and
John 2009, 2011; Greener and Powell 2009; Kristensen et al. 2012; Jilke 2015a). One particular concern is that ill-
informed users may not be equipped to perform qualified choices and that providers will exploit this knowledge gap
and be responsive only to users of high capacity, at the expense of low-capacity users (Dowding and John 2009;
Received: 8 August 2018 Revised: 17 December 2018 Accepted: 31 December 2018
DOI: 10.1111/padm.12584
Public Administration. 2019;97:639653. © 2019 John Wiley & Sons Ltd 639

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