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Conclusions
No matter how efficient the design of public insurance and the
corresponding administrative process, they will have little effect unless
the frontline actors follow the regulations and the internal administrative
guidelines. Caseworker discretion is necessary because it is not possible to
legislate for all possible circumstances of a case. With the public sickness
insurance system in Sweden amounting to about 10 percent of total
government spending, the caseworkers’ attitudes towards central aspects
of the SI system could be of great economic importance.
On the basis of a nationwide survey among caseworkers in the sick-leave
process, we analyze the impact of caseworkers’ attitudes towards current
SI rules and existing rehabilitation on initiatives taken during sick leave
and on the individuals’ sick-leave length. The attitudes are to some extent
expected to capture the twofold role of the caseworker, both assisting
the individuals to get back to work and monitoring benefit entitlement.
We find that the more positive the caseworkers are towards rehabilitation
programs, the lower the return to work is. The size of the effects, when
we compare the 25 percent most positive caseworkers with the 25 percent
least positive, corresponds to three days' longer sickness absence spells
(2.5 percent) on average. Also, a more positive attitude towards current SI
rules shortens sickness absence duration and increase return to work. The
effect corresponds to 3.5 fewer sickness absence days (3 percent) when we
compare the top and bottom 25 percent of the caseworkers.
The results are in accordance with findings from studies on the associated
unemployment insurance, where a demanding and less cooperative attitude
among caseworkers towards job-seekers has proven to increase return
to work (Behncke et al, 2010a). The results also correspond well with
studies within the SI, finding no strong support for rehabilitation programs
increasing return to work (Johansson et al, 2010), and finding positive
effects from control and checks of benefit eligibility (Hesselius et al, 2013;
Hägglund, 2012; Johansson & Lindahl, 2012). Analyzing the caseworkers´
initiatives during their clients' sick leave shows that caseworkers who are
relatively positive towards the rehabilitation programs more often assess
the individuals´ need for rehabilitation and less often check the individuals´
right to benefits. Caseworkers positive about the SI rules perform more
rehabilitation assessments (Sassam) and eligibility checks (at 90 days).
The most important conclusion of the paper is that caseworker attitudes
towards important aspects of the sickness insurance system could have
considerable impact on both actions taken during the sick leave and on
sickness absence. The results show that sickness absence can be reduced
by increasing the legitimacy of the SI rules. This stresses the importance of
establishing an organizational ethos and implementing new regulations in
such a way that legitimacy is gained. The results also stress the potentially
negative impact of rehabilitation assessments and rehabilitation programs
during sickness absence.