Long-Term Care in a Global Context

1. Long-Term Care in a Global Context

2. 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

3. 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?

4. 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

5. 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

6. 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

7. 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

8. Future viability? • Currently, program is financially sound • Has reduced the number of LTC patients on public assistance • Concerns about viability as population aging continues

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. What are some of the differences? • Type of eligibility • Social insurance • Universal • Means-tested • Role of families • Cash vs. services • Consumer direction