INTERNATIONAL REPORTS

Responses to 1.03. Long-term care financing arrangements and coverage


Austria

In 2016 public spending on LTC represented 1.9% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Funding for long-term care is the responsibility of the federal state, through taxes (national, regional and local) and using cash for care allowances, with universal cash-benefits and co-payments for some services (but assets are not included in means-test) (source: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en).

There is a LTC fund (“Pflegefonds”) for the federal government to redistribute to the states and municipalities, which also covers palliative and hospice care (source: https://apps.who.int/iris/bitstream/handle/10665/330188/HiT-20-3-2018-eng.pdf?sequence=7&isAllowed=y).

Last updated: August 2nd, 2021


Australia

In 2018-19 government spending on LTC in Australia was estimated to be equivalent to 0.9% of Gross Domestic Product (source: https://agedcare.royalcommission.gov.au/sites/default/files/2020-06/consultation_paper_2_-_financing_aged_care_0.pdf).

Australia has universal health care through Medicare. The Australian government subsidizes aged care services so anyone who received aged care is eligible for financial support. In 2018-2019, $27.0 billion was spent on aged care, $19.9 billion of which came from Australian Government (source: https://agedcare.royalcommission.gov.au/sites/default/files/2020-06/consultation_paper_2_-_financing_aged_care_0.pdf). People who use aged care are expected to contribute in the form of co-payments and means tested fees. People receiving aged care services contributed $5.6 billion to the cost of their aged care in 2018–2019. Aged care homes are subsidised by the Australian government. The subsidies are paid directly to the aged care home and the amount of funding that a home receives is based on an assessment of individual needs by the home using a tool called the Aged Care Funding Instrument (ACFI) and how much an individual can afford to contribute to the cost of their care and accommodation (using a means assessment).  Aged care services are rationed and access is determined by where people live, their needs, and availability of services. There is significant reliance on informal carers in the community, to reduce the need for formal care. In 2018, there were around 428,500 informal primary carers providing support to someone aged 65 years or older (sources: https://www.health.gov.au/about-us/the-australian-health-system; https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf; https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp1819/Quick_Guides/AgedCare2019; https://www.myagedcare.gov.au/aged-care-homes).

Family carers have access to shared care planning tools. Professional carers are also increasingly asked to collaborate with family carers, providing skills training and directing family carers to the services available for them (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

The Royal Commission into Aged Care Quality and Safety found that there is no universal entitlement to aged care as services are strictly rationed and access is determined by where people live, their needs, and availability of services (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

Last updated: August 2nd, 2021


Belgium

In 2016 public spending on long-term care was estimated to represent 2.3% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Long-term care is part of an integrated system of health care, complemented by social service provision. Medical care is financed by the federal health insurance system, whereas personal care is organized and financed by the regional governments. Cash benefits only play a small role in the system. Co-payments are means-tested and subject to a maximum limit. Additionally, Flanders has a compulsory social insurance system specifically for non-medical help services that provides cash benefits to people with reduced self-sufficiency (source: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en).

Last updated: August 2nd, 2021


Brazil

Some public LTC services are provided through the Unified Social Assistance System, this is means-tested and targeted to people without family support, and increasing availability of private care options (source: https://ltccovid.org/wp-content/uploads/2020/05/COVID-19-Long-term-care-situation-in-Brazil-6-May-2020.pdf).

Last updated: August 2nd, 2021


Bulgaria

In 2016 public LTC represented 0.4% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). People in need of care are covered by social assistance, which is managed at municipal level and by disability benefits (as a supplement to pensions for older people, for example). The country was reported in need to develop governance, financing and regulatory framework for LTC (source: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en).

Last updated: August 2nd, 2021


Canada (British Columbia)

In total, LTC services in British Columbia  cost $2 billion CAD per year, with the majority, $1.3 billion CAD, spent in the contracted sector (source: https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2020/02/ABillionReasonsToCare.pdf).

LTC services are available through publicly subsidized and privately funded services. Some publicly subsidized home and community care services are provided free of charge. For example, British Columbia has the highest recommended funded hours per resident day at 3.36 hours, higher than the Canadian average of 3.30. For other services, the cost is shared between the Ministry of Health and the person receiving services. The amount paid by individuals receiving care is called the client rate. Client rates are determined by BC’s health authorities and may be calculated based on income or set as a fixed rate, depending on the type of care received. For most LTC facilities, the person receiving care pays up to 80% of their income taxation and can also apply for a reduced rate due to financial hardship (source: https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/who-pays-for-care; https://rsc-src.ca/sites/default/files/LTC%20PB%20%2B%20ES_EN_0.pdf).

Unpaid carers (commonly referred to as family caregivers in Canada) are represented by the Family Caregivers of British Columbia (FCBC), a provincial non-profit. FCBC represents over 1 million people in British Columbia. Although there is no data yet on how many family caregivers are present in the province. FCBC provides access to information and education and acts as a voice for family caregivers when liaising with other stakeholders in the health and social sector (source: https://www.familycaregiversbc.ca/).

LTC residents and individuals receiving continuous care in the community are charged a portion of their after-tax income. Individuals may apply for a reduction in rates due to financial hardship. For the most part, anyone requiring care should be able to receive it (source: https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/who-pays-for-care).

Last updated: August 2nd, 2021


Cyprus

Public LTC expenditure in Cyprus was estimated to represent 0.3% of the Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021


Czech Republic

Public LTC expenditure in the Czech Republic was estimated to represent 1.3% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Some LTC services such as home care are covered by the health insurance system (if indicated by a general practitioner). Institutional care costs are mostly paid by out-of-pocket payments (source: https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-and-fiscal-sustainability-country-documents-2019-update_en). Informal care plays an important role in the sustainability of LTC, there is growing emphasis on support of informal carers and on improving the availability of respite services and counselling, and the coordination and management of care (source: CEQUA – Czech Country Report (filesusr.com).

Last updated: August 2nd, 2021


Denmark

Denmark spent 2.5% of GDP on publicly funded LTC in 2016, almost twice the EU average (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Denmark is one of the few EU countries to spend more on outpatient care than inpatient care. Municipalities are responsible for allocating resources; they obtain funding from the national government, local taxes and equalization money from other municipalities. Health expenditure per capita is €3831, comprising 10.2% of the country’s gross domestic product (GDP). No co-payments are applied for using long-term home-based care services (cleaning and personal care), although users who choose private providers can purchase additional optional services. Help with personal care and domestic tasks are not subject to fees (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Eligibility for long-term care is based entirely on needs assessment carried out by the municipalities. There are no thresholds or minimum dependence required for in-kind or cash benefits. Needs assessment for long-term care is multidimensional in nature and generally captures a wide range of aspects related to a person’s situation and well-being. Access is based on the principle of free and equal access, regardless of income, wealth, age or household situation (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

It has been estimated that 16% of the total population provides unpaid care for a relative, neighbour or friend at least once a week (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019). The availability, or not, of informal care is not considered as a criterion for assessing needs and entitlements. Unpaid caregivers experience less burden and are less likely to report difficulties in reconciling work and caregiving compared with the rest of the EU (source: https://www.euro.centre.org/publications/detail/415). Family members may apply to be formally recognised as informal carers by applying to the municipality. If eligible, and after consultation with the person with care needs, the caregiver gets employed by the municipality, up to six months, with a prespecified salary calculated based on the national yearly income. Alternatively, municipalities can compensate for lost earnings individuals caring for close relatives with a terminal illness. Additional services include training and education programmes, often focused on improving knowledge and ability to provide the needed support and on attaining coping skills, such as self-help and peer groups (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: August 2nd, 2021


England (UK)

In 2018, LTC expenditure in the United Kingdom was estimated to represent 1.8% of Gross Domestic Product (source: https://stats.oecd.org/Index.aspx?QueryId=30140).

Local authorities are funded largely through a combination of a grant from central government and local revenue-raising mechanisms, including council tax for example. Social care funding is not ring-fenced, which means that local authorities can decide how much of their budget they allocate to care. Unlike the NHS, where healthcare is free to those using it, access to social care is determined by both need and means. A restrictive means test, which has not been adjusted since 2010, means that people with property (including housing), savings or income in excess of £23,250 must meet the entirety of their care costs alone. Those with means below the threshold of £23,250 may be eligible for part or full state funding for their care but they must also be deemed to have sufficiently severe care needs.

The distinction between ‘health’ and ‘care’ creates further inequity. A person deemed to have health needs may be able to access social care via the NHS’s continuing healthcare programme (although subject to restrictive eligibility criteria and long waiting times), but someone with personal care needs (e.g. arising from dementia) and no medical requirements is subject to the means test (source: https://www.nuffieldtrust.org.uk/news-item/other-types-of-support-how-do-the-countries-compare#support-for-health-needs).

In 2018/19, total expenditure on social care by councils amounted to £22.2 billion. There are few estimates of private spending on care, however the National Audit Office has estimated the size of the self-funder market (i.e. those who pay for their care) at £10.9 billion in 2016/17 (source: https://www.kingsfund.org.uk/publications/social-care-360/expenditure).

During the last decade, funding to councils has been cut by almost 50% (source: https://www.nao.org.uk/wp-content/uploads/2018/07/Adult-social-care-at-a-glance.pdf), which has put pressure on councils to spend less on care either through reducing the rates they pay providers or by reducing the number of people they fund. Because local authorities have a responsibility to revenue locally to subsidise the grant they receive from national government, those local authorities in more affluent areas are able to raise more (source: https://www.ifs.org.uk/uploads/publications/bns/BN227appA.pdf). The result is wide variation in the eligibility for care between local areas, despite the intention of the Care Act (2014) being to standardise eligibility.

Last updated: August 2nd, 2021


Estonia

In 2016 public LTC expenditure in Estonia was estimated to represent 9.9% of Gross Domestic Product (source: The 2018 Ageing Report: Economic and Budgetary Projections for the EU Member States (2016-2070) (europa.eu).

Last updated: August 2nd, 2021


Finland

Public LTC expenditure in Finland represented 2.2% of Gross Domestic Product in 2016 (source https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). LTC services are part of the universal health and social care system in Finland, with organization of services allocated primarily to local municipalities. The state government and municipalities are the major funders of LTC care, however despite most costs being covered by taxes, there are client fees. For example, in 2014, clients paid 18.5% of the costs of elderly people’s services (source: http://urn.fi/URN:ISBN:978-952-302-236-2). These LTC fees are defined by the user’s ability to pay. There are differences in the LTC provisions between different municipalities, as population demographics as well as availability of services vary between municipalities. Although Finland assigns its municipalities a legal responsibility to provide care services, families still play a major role in unpaid care provision. A restructuring of elder care services over the past few decades has resulted in an increased responsibility for care on individual families, which is financially supported through various cash-for-care schemes (e.g. informal care allowances); amounts and access to these types of supports is, however, relatively low. Municipal informal care support requires a contract between the municipality and the caregiver (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: August 2nd, 2021


France

In 2016 public LTC expenditure in France was estimated to represent 1.7% of Gross Domestic Product (https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

LTC funding is fragmented and divided across a complex web of actors, at a regional level (conseils generaux), health insurance (CNAM), not-for-profit (mutuelles) and private insurance policies, long-term care insurance (CNSA), central government, pensions, towns (municipalities) and individuals (source: https://www.alzheimer-europe.org/Policy/Country-comparisons/2007-Social-support-systems/France)

In terms of public spending, costs are shared between: long-term care insurance (CNSA), regions, the state, which in 2011 contributed approximately 9.7bn€, health insurance (CNAM), which contributed 11bn€, accommodation costs 7.5bn€ adding to a total of 21bn€, which amounted to 1.05% of GDP. Including the costs of household contributions would brought total spending to 28bn€, 1.41% of GDP (source: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

A market for private insurance for LTCI has developed as contributions are tax-free and is reported to be one of the largest (source: https://www.kingsfund.org.uk/sites/default/files/media/commission-background-paper-social-care-health-system-other-countries.pdf).

The country’s LTC policy is based on cash-for-care scheme called the Allocation Personalisee a l’Autonomie (APA), which provides some assistance to people over 60 with care needs above a government determined threshold of need (AGGIR 1-6) and is concerned mostly with homecare. In 2018 8% of people over 60s were APA beneficiaries (Source: https://halshs.archives-ouvertes.fr/halshs-02058183/document). APA is means-tested based on taxable income and some assets. There are high levels of out-of-pocket payments, individuals pay up to 90% of the care costs. For example, whereas individuals with below a monthly income of €800 do not contribute to the funding of the care, those with income of above €2945 contribute 90% of the care costs. Moreover, the level of the allowance depends on the need level (source: document (archives-ouvertes.fr).  Median cost of a room in a care home in 2018 was 1977€.

There were 4.8 million carers recorded in France in 2011. France is a country with a strong family tradition, where unpaid informal carers have always played an essential role. Support is delivered in-kind rather than in-cash. Some of the benefits for carers include the ability to take unpaid leave from employment and paid ‘solidarity’ leave for 3 months with an additional maximum 3 months which must be justified by medical certificate. Although researchers suggested that there is low take up and awareness of these schemes. Other services to support carers include respite care and training (sources: CEQUA France Country report (filesusr.com); https://halshs.archives-ouvertes.fr/halshs-02058183/document).

Last updated: August 2nd, 2021


Germany

In 2018, Germany’s expenditures for LTC amounted to 2.1% of GDP, including voluntary insurance and out-of-pocket-spending. Expenditures for compulsory government schemes amounted to 1.5% of the GDP, which is below the OECD average of 1.7% Germany has a LTC insurance system, which is the dominant financing scheme for LTC and is mandatory for enrolees in the statutory or private health insurance (source: Germany_draft.pdf (who.int). The LTC insurance is financed through equal contribution between employer and employees. Childless people pay a slightly higher contribution rate than those with children (3.30% of gross wages versus 3.05%) (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view). Financial situation of LTC funds in 2020 can be found online.

In 2019, 4.25 million inhabitants received benefits from the LTCI. Of them, 3.34 million received home care and 0.91 million received residential care, and 4 million were covered by social LTCI and 0.25 million by private compulsory LTCI (source: Germany_draft.pdf (who.int). The LTC insurance is designed to cover only a share of the LTC-related costs. With regards to residential care, people in need of long-term care have to pay up to €2,400 per month out of pocket. This includes costs for food and the resident’s room. Where individuals/families cannot shoulder these costs, this will be provided through social security mechanisms. Costs vary substantially between the different Lander. While the private share of costs for care in residential care settings amounts to more than €1,000 in Baden-Württemberg, they are less than €450 in Thuringia (source: http://www.sozialpolitik-aktuell.de/files/sozialpolitik%20aktuell/_Politikfelder/Gesundheitswesen/Datensammlung/PDF-Dateien/abbVI49_Thema_Monat_02_2020.pdf).

LTCI grants access to services on the basis of LTC needs and it is not means-tested. Everyone with LTC needs is entitled to receive the services they require regardless of age, income, wealth, personal circumstances (such as living with a carer) and medical diagnosis (whether physical or cognitive). A needs assessment recognizes whether an individual should receive benefits and the amount. Individuals have to take a needs-based, uniform assessment test, which assigns them to one out of five potential “care degrees” ranging from 1 – “little impairment of independence” to 5 – “hardship”. The “care degrees” define the amount of benefits that the individual receives (source: Germany_draft.pdf (who.int).

Last updated: August 2nd, 2021


Greece

In 2016 public expenditure on LTC was estimated to represent 0.1% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021


Hungary

In 2016 public LTC expenditure in Hungary was estimated to represent 0.9% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021


Iceland

In 2018 total LTC expenditure in Iceland was estimated to represent 1.7% of Gross Domestic Product (https://stats.oecd.org/Index.aspx?QueryId=30140).

Last updated: August 2nd, 2021


India

Public funding for LTC is very limited, but there are a few public benefit schemes such as disability benefits and pension schemes that offer modest support. Most formal LTC is paid for through out of pocket payments (source: https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID-situation-in-India-30th-May.pdf).

Last updated: August 2nd, 2021


Israel

In 2016 total LTC expenditure in Israel was estimated to represent 0.6% of Gross Domestic Product (source: https://stats.oecd.org/Index.aspx?QueryId=30140). The National Insurance Institute (NII) is the primary public funder of home-based long-term care services and does so through the Long-Term Care Insurance Program (LTCIP).  LTCIP is income-tested with the aim of excluding the highest income earners. As of 2014, the NII subsidizes the care of approximately 160,000 seniors at a cost of NIS 5.31 billion (appx. 1.2 bill GBP). Assisted living (e.g. LTCFs) is primarily funded by the Ministries of Health and of Labour and Social Affairs, and accounts for 14% of publicly-funded LTC services. Complex inpatient care is funded by NII and accounts for 6% of public LTC funds. In all, public funds account for 55% of LTC services, with the remaining 45% found in the private sector (sources: http://taubcenter.org.il/wp-content/files_mf/longtermcare.pdf; The Long-Term Care Insurance Program in Israel: solidarity with the elderly in a changing society | Israel Journal of Health Policy Research | Full Text (biomedcentral.com).

Home care and community-based services are the main LTC service for older people in Israel. At the beginning of 2020, 220,830 individuals (of retirement age) were eligible to receive publicly financed LTC services at home (sources: https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Israel-4-May.pdf; https://www.btl.gov.il/English%20Homepage/Publications/AnnualSurvey/2016/Documents/Chapter%203_Long-term%20care.pdf).

There are also geriatric hospitals and sheltered housing facilities, many of which are owned and managed by the coordinated governmental healthcare system, Kupoth Cholim. These provide long-term geriatric treatment (including wards for older people with cognitive disabilities) as well as departments for active geriatric care (including complex nursing, hospice, and rehabilitative care) (source: https://journal.ilpnetwork.org/articles/10.31389/jltc.75/); they became the primary source for concern and emergency response during the COVID-19 pandemic.

LTC insurance in Israel is neither universal or mandatory and LTC services are substantially funded by private and out-of-pocket expenditure (45%). This is a reality many Israeli social policy think tanks and NGOs believe to be unsustainable alongside the rapid increase in Israel’s older population (sources: http://taubcenter.org.il/wp-content/files_mf/longtermcare.pdf; https://www-tandfonline-com.gate3.library.lse.ac.uk/doi/full/10.1080/13537121.2020.1832329). The country heavily relies on unpaid carers: an estimated million and a half Israelis, mostly women,  serve as primary caregivers and typically provide 21 hours of caregiving a week (source: https://www.scirp.org/journal/paperinformation.aspx?paperid=67223). In April 2018, as part of the LTC reform, the National Insurance Institute launched a program to entitle home-based unpaid caregivers to long-term care benefits. Made a national policy in August 2019, family members can be paid as caregivers under certain conditions; statistics on the implementation of the policy are unavailable (source: https://adva.org/wp-content/uploads/2019/03/Care-Deficit-EN.pdf).

Last updated: August 2nd, 2021


Italy

In 2016 public LTC expenditure in Italy was estimated to represent 1.7% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Public expenditure on Long Term Care (LTC) includes three components: i) LTC  services to dependent people provided by the  public health care system, ii) the social component  of LTC provisions provided by municipalities and  iii) attendance allowances (source: update_joint-report_it_en.pdf (europa.eu). Unpaid carers provide the bulk of LTC services in the country, it has been estimated in 2017 that the overall number of carers of adult people in Italy was well over 4 million. The country also heavily relies on privately employed, primarily migrant care workers in household-based care (source: Italy Country Report (filesusr.com).

Last updated: August 2nd, 2021


Japan

Japan has a relatively well-funded system, based on mix of tax, social insurance and individual co-payments. Revenue raising mechanisms are flexible to allow for extra top ups in difficult times. However, the system is under financial pressure due to the rapid rise in need as a result of rapid ageing. Its generosity has been reduced over time over affordability concerns (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan).

On being assessed as needing care by the Long-Term Care Insurance system (LTCI), service users are assigned a monthly in-kind budget to spend on care according to their level of need. Service users pay a co-payment on accessing services which ranges from 10% for most people to 30% for most affluent. Co-payments are capped at fixed monthly level on a sliding scale according to income. People can opt to buy more care beyond assigned level at 100% cost, but care packages are thought to be generous and few people top up beyond their allocated budget. The re-imbursement for care services from the LTCI does not cover room or board.

The 50% of the funding for the LTCI system is from mandatory insurance contributions from all residents aged 40 and older and the rest is from taxation: 25% from the national government and 12.5% each from the prefectural and municipal governments. The insurance rates are set by each municipality on the basis of the insured resident’s income levels (source: https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

The extent to which the system relies on unpaid care is unclear. The recent reforms were successful in largely shifting the responsibility of caring from families to the state by offering in-kind benefits to those in need. However, there are no cash benefits for people with needs, hence there is no option to use cash benefits to pay for care to relatives or friends. At first, there was concern that people would not take the in-kind benefits up due to stigma attached to using public care provision (traditionally it has always been a family duty), however the design and generosity of the system quickly changed societal views. However, there still is reliance on unpaid care – benefits are generous but may not cover all needs. There is also a 10% co-payment on accessing care, therefore poorer people may need to avoid using formal care for that reason (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan).

Last updated: August 2nd, 2021


Latvia

Public LTC expenditure in Latvia was estimated to represent 0.4% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). The availability of unpaid carers is considered during assessment for formal provision of home care, consequently, home care is provided mostly for people living alone who have no help from family or close neighbours. No policy planning concerning support for informal carers have been developed in Latvia. In 2017, there were neither cash nor in-kind benefits for carers of dependent adults (source: CEQUA Latvia Country report (filesusr.com).

Last updated: August 2nd, 2021


Luxembourg

Public LTC expenditure in Luxembourg was estimated to represent 1.3% of Gross Domestic Product in 2016 (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021


Netherlands

Public expenditure on LTC as percentage of GDP was estimated to be 3.5% in 2016, more than twice the European Union average of 1.6% (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). Seventy five percent of spending is allocated to residential care. Private expenditure on LTC (co-payments and out of pocked payments) is relatively low. However, in residential care, residents have to contribute to their board and accommodation. Co-payments have increased considerably for those with higher incomes. Cash for care has been a recent addition for people receiving community care, but in 2016, only 4.7% of recipients of home care aged 65 and over had a personal budget. Benefits are universal but needs tested. There has been a marked shift over time from institutionalisation to community care, with substantial involvement from patient and client organisations. There has been another more recent shift from collective (state) responsibility to individual responsibility and self-reliance. Involvement of unpaid carers, especially families, is now part of the official policy. This however goes against the widespread view that the state should take responsibility for older people in need of care. It is also recognised that this shifts the burden of care back to women (source: https://drive.google.com/file/d/1P5J1JQlr-ts65lknBwBFtTkJNXHLDyrL/view).

Last updated: August 2nd, 2021


Norway

In 2016 public LTC expenditure in Norway was estimated to represent 3.7% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021


Portugal

In 2016 public LTC expenditure in Portugal represented an estimated 0.5% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021


Republic of Korea

Total LTC expenditure in Korea represented 1.0% of Gross Domestic Product (GDP) in 2019 (source: https://stats.oecd.org/Index.aspx?QueryId=30140), of this, expenditure through the public LTC Insurance system accounts for 0.37% of GDP (source: https://www.sciencedirect.com/science/article/pii/S016885102030275X).

A universal, public LTC insurance (LTCI) for the older population was introduced in 2008, and it requires no means-test (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf ). Services include institutional and home/community care (https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

In terms of eligibility, the intended beneficiaries of the system are all Koreans, it mainly targets older people (age 65+).  In 2018 around 8.8 % of the total older population were covered by LTCI (source: https://www.sciencedirect.com/science/article/pii/S016885102030275X), which comprises 2.7% of older adults living in LTCFs (2018) and 6.2% of older adults in receipt of community based LTC (2018) (source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: August 2nd, 2021


Romania

In 2016 public LTC expenditure in Romania represented 0.3% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021


Singapore

Financing for LTC and support to older adults exists within an overall health-care financing that, in turn, is linked to the way in which social care and pension funding is organized. There are three complementary insurance schemes for disability cover: ElderShield and ElderShield Plus, and CareShield. ElderShield is a severe disability insurance scheme under which all citizens and permanent residents born before 1979 who have a MediSave account are automatically covered from 40 years of age (opt-out is possible). To be eligible for the scheme, individuals must be unable to carry out at least three out of six basic activities of daily living. ElderShield Plus offers higher monthly payouts or payouts for a longer period or a combination of both. CareShield Life is a compulsory insurance policy introduced in 2020 that provides payouts for people who are severely disabled. Everyone born between 1980 and 1990 is enrolled automatically and younger cohorts will be enrolled as they turn 30. Another funding scheme introduced in 2020, ElderFund, provides financial support for low income, severely disabled Singaporeans. Additional subsidies and schemes exist to finance LTC. Some schemes focus on financial support to informal caregivers and home-based care (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf).

Last updated: August 2nd, 2021


Slovakia

In 2016 public LTC expenditure represented 0.9% of Gross Domestic Product in Slovakia (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021


Slovenia

In 2016 public LTC expenditure represented 0.9% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: August 2nd, 2021


Sri Lanka

Health spending was 3.8% of GDP in 2017, of which 1.6% was accounted for by public health expenditure and 2.2% by other financing. The government finances most social services, while non-profit sector and private donation financing is limited.  Families currently bear most LTC costs.  Residential care homes are financed by the non-profit sector and fees are paid by the resident or covered by charitable donations. In-home nursing care services are financed by out-of-pocket payments (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (adb.org).

Last updated: September 6th, 2021


Sweden

In 2016 public long-term care expenditure represented an estimated 3.2% of Gross Domestic Product (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf). About 90% of health and social care is financed by local government, the counties and municipalities, through taxation. The user pays only a fraction (4% or 5%) of the cost and the remaining 5% is covered by national taxes (source: Sweden Country Report (filesusr.com). LTC in Sweden has been affected by financial cutbacks, which has had negative consequences for e.g. care workers’ working conditions as care workers are increasingly working in under-staffed conditions (source: Johansson-L.-Schön-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf (aldrecentrum.se).

Public policies and programmes providing social services and support, as well as healthcare, are comprehensive. There are no national eligibility regulations, however for home care and institutional care, local governments decide on the service levels, eligibility criteria and a range of services provided. Although the general principle behind LTC policy in Sweden is to provide publicly subsidised, widely available in-kind services thereby removing the burden of providing services from the family; approximately two-thirds of all care for community-living older people is provided by unpaid caregivers. Unpaid carers can claim time off work (care leave) with compensation from national social insurance. Carers may receive cash benefits from municipalities (however these are not covered by national regulation and municipalities can choose whether or not to offer the allowances). Another option is carers’ allowance which involves the municipality employing a family member to provide care work, however it is not payable for people 65 years or older. Direct in-kind support for carers is provided by all municipalities as a general service and not based on needs assessment, it can be in the form of information and advice, counselling, support groups, respite care. The intensity, content and quality of the provided support can, however, vary between the municipalities (source: Sweden Country Report (filesusr.com).

Last updated: August 2nd, 2021


Switzerland

In 2018 LTC expenditure was estimated to represent 2.4% of Gross Domestic Product in Switzerland (source: https://stats.oecd.org/Index.aspx?QueryId=30140).

Last updated: August 2nd, 2021


Thailand

Total public spending on health-related LTC was 1.7 billion in 2012. The Ministry of Public Health is the major source of finance (1.6 billion). Spending by nongovernment organizations (NGOs) on health-related LTC was 70.3 million. Finance from family members is a major source of funding for LTC in Thailand. Government revenue is a source of finance for the Community-Based Long-Term Care Program, under the National Health Security Office (NHSO). But out-of-pocket payments are the main source of funding for LTC in private residential facilities (source: Country Diagnostic Study on Long-Term Care in Thailand (adb.org).

Last updated: September 6th, 2021


Turkey

Turkey has a familiarist welfare, placing intergenerational obligations to provide care on family members, but there are concerns about the sustainability of this model. There is growing support from the non-profit sector and other private providers, some of whom receive public funding from provision of services, this support is means and needs-tested (source: https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19-Long-Term-Care-situation-in-Turkey-1.pdf).

Last updated: August 2nd, 2021


United States

In 2018 LTC expenditure represented 0.8% of Gross Domestic Product in the United States (source: https://stats.oecd.org/Index.aspx?QueryId=30140). The financing of LTC in the United States is a continuous and growing challenge. Medicaid is the primary payer for formal LTC services, accounting for over half of national spending in 2017, however it is means-tested: it requires proof of need and exhaustion of individual financial resources (e.g. low-income status and/or limited savings). In 2016, the majority of Medicaid LTC funding was spent on home and community-based services (57%), but several states still apply their Medicaid dollars primarily to institutional care. Coverage and spending on LTC schemes also vary significantly by state (source: https://ldi.upenn.edu/sites/default/files/pdf/LDI%20Issue%20Brief%202019%20Vol.%2023%20No.%201_7_0.pdf).

Some states fund home and community-based services through Medicaid waivers, and some even allow for self-directed Medicaid funds for payment of informal carers (source: https://ltccovid.org/wp-content/uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf; https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf). An estimated 7.4 million Americans own private LTC insurance policy (around 15% of persons 65 and over). The system relies heavily on informal (unpaid) caregivers: 75% of those needing LTC rely solely on informal caregivers and approximately 41 million Americans are unpaid caregivers (source: https://ldi.upenn.edu/sites/default/files/pdf/LDI%20Issue%20Brief%202019%20Vol.%2023%20No.%201_7_0.pdf). These demands are also disproportionately experienced by women, individuals of low socioeconomic status, and minority racial and ethnic populations. Over the past 10 years some states used provisions in the Affordable Care Act to redistribute some Medicaid funds towards at-home, informal caregiving, nationally this shift has been small (source: https://ltccovid.org/wp-content/uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf).

Last updated: August 2nd, 2021