Long-Term Care in a
Global Context
Demographics



Population aging globally
Increased numbers of older adults (esp. oldestold) means increased need for LTC
Lower birth rates affect the supply of people to
provide care
 Smaller
families
 Smaller paid workforce

Other demographic trends important
 Less marriage, increased
 Blended families
divorce
Policy Frameworks
Social values are key to understanding
LTC policies
 Is LTC a private issue (families) or a public
issue (government)?
 Should we rely on the private market
(private insurance) or on public funding?
 How different is LTC from health care?

History
LTC needs, like most other needs, were
originally filled by families
 In every country, families are still the main
provider of LTC
 Global perspective can show under what
circumstances LTC has become a public
concern

Germany
Probably the most comprehensive
government system for LTC
 Long-Term Care Insurance Act

 Passed
1994, effective 1996
 New, mandatory social insurance program
 Funded with payroll tax

Additional premium on those with no children
 Can
opt out if buy private insurance
Three types of benefits

Unrestricted cash payments
 Can
 Can

pay family members
make home modifications
Service benefit
 Agencies


provide services
Combination of cash and services
Cash benefit is lower than direct service benefit
 Round-the-clock
care services $1900/month
 Cash payment would be $895/month
More about German program…
Participants are responsible for room and
board at all levels of care
 Includes assistance for family caregivers

 Skills
training
 Home visits
 Up to 4 weeks per year of respite care
 Caregiving “counts” towards state pension
Future viability?
Currently, program is financially sound
 Has reduced the number of LTC patients
on public assistance
 Concerns about viability as population
aging continues

Japan’s system

Long-Term Care Insurance Plan
 Passed

in 1997, effective in 2000
Japan’s fifth social insurance program
 Health
care
 Pensions
 Unemployment
 Workman’s compensation

Replaced a welfare-based system
 Stigmatizing
Japan (cont.)

Only available to those 65 and older
 Germany’s

program is available to all ages
Payroll tax for workers aged 40-64
 Those 65+ pay a premium
 Users pay a copayment
 Central

government pays about half of cost
One incentive for government was to reduce
hospital use
 Because
hospitals were free, older adults traditionally
had long hospital stays
Supply of care is an issue
Government is working to increase supply
of workers and facilities
 But demand continues to outstrip supply
 Big social change from society where
caregiving by women and home has been
the norm

France

Personalized Independence Allowance
 Adopted
2002
 Available at ages 60 and over

Cash benefits
 May
be used to pay family members (not spouses)
 Must need help with at least 3 ADLS to get benefit
 Level of assistance declines with income
United Kingdom


Most similar to U.S.
Nursing care part of National Health Service
 At

home or in skilled nursing facilities
Personal care financed separately
 By local governments
 Means-tested benefit


Low-income families also eligible for Carer’s
Allowance
Scotland has a slightly different approach
Denmark


Welfare state
Municipalities responsible for health and social
services
 Financed

through general taxes
Stopped building nursing homes in the 1980s
 Instead,
supportive housing and 24-hour home
support services
 Housing and health care considered separately

Assessment team determines services needed,
makes arrangements
What are some of the differences?

Type of eligibility
 Social
insurance
 Universal
 Means-tested
Role of families
 Cash vs. services

 Consumer
direction