Alexandrina Stoyanova and Raquel Andres
As populations age, one of the most urgent questions for European welfare states is not only how to provide more long-term care, but how to provide it fairly. Long-term care (LTC) is essential for many older people who need help with daily activities such as bathing, dressing, eating, or moving around the home. Yet having care needs does not always mean receiving enough support. In Spain, the formal framework for supporting people with dependency needs is the Sistema para la Autonomía y Atención a la Dependencia (SAAD), introduced through the 2006 Dependency Act as a landmark step toward universal entitlement to care (Costa-Font et al., 2023). So, nearly two decades later, how well is it working?
Our study, “Socio-economic inequalities in unmet long-term care needs in Spain,” published in the European Journal of Ageing, examines who is most likely to experience unmet LTC needs in Spain and why these inequalities arise. Using data from the 2019 European Health Interview Survey for Spain, the study focuses on older adults with care needs and analyses whether the care they receive is sufficient, partially insufficient, or entirely absent (Andres and Stoyanova, 2026).
Unmet long-term care needs occur when a person requires support but does not receive it, or receives less than needed. This gap is not only a matter of service availability. It reflects broader social inequalities: income, living arrangements, health status, and the capacity of families to provide support all shape whether older people receive adequate care. This is particularly important in Southern European welfare systems, where informal family care continues to play a central role in meeting older adults’ needs (Albuquerque, 2022).
A key contribution of our study is that it does not treat unmet care simply as a yes-or-no issue. Instead, we distinguish between fully unmet needs, partially unmet needs, and no unmet needs, and we also measure the care gap in hours. This allows for a more nuanced view of how much care is missing and who is most affected.
The results show that unmet LTC needs are not equally distributed. They disproportionately affect women, people living alone, and the oldest old aged 85 and over. These groups are often more exposed to dependency, but may have fewer financial, social or family-based resources to compensate when formal care is insufficient.
Socio-economic status is central. Poorer individuals bear a higher burden of unmet care needs, especially when they also have severe limitations in activities of daily living. This means that those who need care the most are not always those who receive the most support. From an equity perspective, this is particularly concerning: a fair LTC system should allocate resources according to need, not according to income or family circumstances.
The study also examines whether inequalities differ depending on eligibility for publicly funded long-term care. This is important because public systems are designed to protect people with substantial needs. However, even among those who appear eligible, inequalities remain. This suggests that formal entitlement does not automatically translate into sufficient care in practice.
Living alone stood out as the single largest driver of inequality among people with severe limitations. Having a partner, who often provides a large share of informal care, significantly reduces unmet need. Living alone amplifies it. Since living alone is itself more common among lower-income older adults, this creates a compounding disadvantage.
This finding raises an important policy question: should access to adequate LTC depend so much on whether someone has a partner or family member available to help? As societies age and household structures change, relying heavily on informal care is increasingly risky. More people are living alone in later life, and family networks may be smaller or less available than in previous generations (ECSPC, 2021).
The decomposition analysis shows that health status, income, and living arrangement explain much of the observed inequality in unmet care needs. This means that reducing inequalities requires more than expanding services in general. Policies must identify and support those at greatest risk: low-income older adults, people with severe limitations, and those living alone.
The implications are clear. Spain, like many other ageing societies, needs a LTC system that is not only sustainable but also equitable. Better resource allocation, stronger support for people living alone, and targeted policies for low-income groups could help reduce care gaps. Measuring unmet needs in hours can also help policymakers understand not only whether people are underserved, but how large the shortfall is.
Spain’s SAAD system was a landmark achievement when it was introduced. But nearly two decades on, this research shows that the gap between the law’s promise of universal coverage and the lived experience of many older adults remains wide and that it is widest for those who can least afford it.
Unmet LTC needs represent real limitations in daily life, pressure on families, and unequal opportunities to age with dignity. Addressing these gaps is essential for building a fairer care system that supports people according to their needs, regardless of income, gender, or family situation.
References:
Andres, R., & Stoyanova, A. (2026). Socio-economic inequalities in unmet long-term care needs in Spain. European Journal of Ageing, 23, 11. .
Albuquerque, P. C. (2022). Met or unmet need for long-term care: Formal and informal care in southern Europe. Journal of the Economics of Ageing, 23, 100409.
Joan Costa-Font, Sergi Jimenez-Martin, Cristina Vilaplana-Prieto, and Analía Viola,(2023)Universalizing the Access to Long-term Care: Evidence from Spain, NBER Working Paper 31825 .
European Commission & Social Protection Committee. (2021). 2021 Long-Term Care Report: Trends, challenges and opportunities in an ageing society. Publications Office of the European Union.
