Long-Term Care in a Global Context

Demographics Population aging globally Increased numbers of older adults (esp. oldest- old) 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 divorce  Blended families

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 pay family members  Can 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  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