Long-term Care Insurance Scheme Research Articles

Does income matter for the policy effect of public long-term care insurance on informal care use in China? A quasi-experimental study.

Since 2016, the Chinese government has been piloting a public long-term care insurance (LTCI) scheme. This study examined whether the LTCI scheme reduced the use of informal care and how this has varied across income groups. We used data from the 2011, 2014, and 2018 waves of Chinese Longitudinal Healthy Longevity Survey, focusing on community-dwelling older adults aged 65 years and older. We used staggered difference-in-differences analyses with propensity score matching to examine the effects of the policy. The LTCI scheme reduced the probability and intensity of informal care use by 5.7% (p < .05) and 17.4% (p < .05), respectively. The policy impact was limited to older people in the middle-income group, reducing the probability and intensity of informal care use by 15.6% (p < .001) and 43.1% (p < .05), respectively. We did not find a statistically significant policy effect for older adults with high or low incomes. The LTCI scheme had different effects on reducing the informal care burden for family caregivers by income level. We suggest that the scheme should entitle people with low incomes to a preferential co-payment rate, thereby enhancing their access to formal care.

ELEVATING LONG-TERM ELDERLY CARE IN MALAYSIA: A CLUSTER ANALYSIS APPROACH BASED ON BENCHMARKING WITH SELECTED COUNTRIES

Malaysia is expected to become an aged society with a 14.1% ageing ratio in 2039, boosting demand for Long-Term Care (LTC). Nonetheless, a thorough review of current LTC systems is crucial due to their complexity, encompassing numerous ministries and departments. In analysing LTC systems in various countries based on components of effective LTC systems, this research suggests a new LTC framework for Malaysian systems. Cluster analysis is used across benchmarked nations: Australia, Germany, Japan, Singapore, Thailand, the United Kingdom, and the United States of America. There are two typologies used, with a total of ten variables employed: a) organisational depth with seven variables: legal framework, policy objectives, policy approach, means-tested assessment, entitlements, cash benefits, and choice of care provider; b) financial generosity and sustainability with three variables: financing mechanism, cost-sharing, and LTC expenses. Four key takeaways from the benchmarked countries: a) LTC insurance scheme, as adopted in Germany and Japan, proves effective with universal coverage, greater disclosure, and a structured approach; b) community-based model, widely adopted across all countries, fosters active stakeholders engagement in meeting elderly’s needs; c) Centralised Administration (CA) provides a structured avenue to manage LTC services and expenses; and d) cost-sharing via private-public arrangements ensures the sustainability of the LTC expenses. The study suggests five improvements for effective LTC systems: a) broaden the recipients’ pool to include the bottom 40% of the population to accommodate their financial constraints; b) implement a robust means-tested evaluation for equity, transparency, and inclusivity; c) incorporate a community-based model for comprehensive coverage; d) create a CA to handle complexity; and e) use public-private partnerships for sustainable financing model. In summary, this study aids policymakers in tackling the intricacies of Malaysia’s LTC systems in line with the intended policy goals of guaranteeing a healthy ageing population, advocating comprehensive protection, and stimulating community-based care.

5 THE WEALTH SHIELD: A MICROSIMULATION OF INEQUALITIES, INHERITANCE AND THE IRISH FAIR DEAL

Abstract Background The article analyses the inequalities resulting from the long-term funding scheme in Ireland with a unique focus on intergenerational obligations. With the Fair Deal scheme of 2009, officially the Nursing Homes Support Scheme (NHSS), Ireland introduced a unique inheritance clawback clause. The state covers long term care costs for those in need up-front and claims the costs back from the estate after the older person deceases. The article focusses on the emerging income and wealth inequalities and intergenerational redistributive effects. Methods We estimate micro simulations to show the distributional effects based on income and housing wealth. The simulations are based on aggregate data from the Central Statistics Office, Nursing Homes Ireland, Eurostat and the European Central Bank. Each simulation estimates the individual contributions based on 50, 100, 150 and 200 percent of average income and wealth, while keeping either income or wealth constant at the average. Based on average nursing home fees, the simulations show the relative contributions from the state, income and wealth. These simulations are contrasted to the funding gaps of the old subvention scheme in place until 2009. Results The Fair Deal has expanded eligibility to the middle class and shields property wealth after three years. Nursing home residents with above average pension income and housing wealth benefit disproportionately from the reform and can pass on more relative wealth to their kin. Overall, the wealth distribution of the Fair Deal scheme is regressive, despite the inclusion of the middle class. Conclusion The increased eligibility of the fair deal has the benefit of increased legitimacy for the welfare state. However, considerable inequalities of risks exposure remain as less than 50 percent of older people will need nursing home care. Estimations for a long-term care insurance scheme at 3 percent social contributions would reduce the lifetime wealth contribution of nursing home residents by about 35 percent.

Public long-term care insurance scheme and informal care use among community-dwelling older adults in China.

The public long-term care insurance (LTCI) scheme has been implemented in a few countries. Although the hypotheses of crowding-out, crowding-in and specialisation can facilitate our understanding of the relationship between LTCI and informal care use, existing studies may suffer from reverse causality. Employing a quasi-experimental design, this study examined the policy effect of LTCI on informal care use among community-dwelling older adults in China. Based on the data from three waves of the Chinese Longitudinal Healthy Longevity Survey, a staggered difference-in-differences (DID) with propensity score matching (PSM) approach was used to analyse the impact of LTCI on probability and hours of informal care use. The results showed that, for disabled older adults, LTCI reduced 43.3% of the probability and 82.4% of the weekly hours of informal care. LTCI also exhibited a spillover effect among nondisabled older adults through reducing the probability and weekly hours of informal care by 5.2% and 12.2%, respectively. Therefore, we argue that policymakers can consider rolling out the scheme for the entire country. Meanwhile, measures are needed to avoid a sharp decrease in informal care provision.

Application of Smart Healthcare in LTCI, Outpatient Mutual-Aid Guarantee Mechanism, and Sustainability of Medical Insurance Fund for Urban Employees.

With the aggravation of population aging and the increase of life expectancy, long-term care insurance (LTCI) system has been established to meet the medical and long-term care needs of the increasing elderly population. In China, LTCI system is currently not a stand-alone insurance, but it is attached to the national basic medical insurance fund for urban employees (MIUE). As a result, the expenditure of LTCI is a part of the expenditure of the MIUE, which has an impact on the sustainability of the MIUE. By modeling the income and expenditure of MIUE, especially including the expenditure of LTCI, this study optimized an LTCI system with a higher individual out-of-pocket payment ratio of LTCI and implementation of the outpatient mutual-aid guarantee mechanism (OMAGM), which could improve the sustainability of the MIUE. The study also reveals the following: (i) solely increasing individual out-of-pocket payment ratio of LTCI to 20%–50% can only postpone the deficit on Social Pooling Accounts (SPAs) by 1 or 2 years, and the effect is very limited. (ii) Besides a higher individual out-of-pocket payment ratio, further implementation of a partial OMAGM from 2022 will postpone the deficit on SPAs by 7–9 years, and the implementation of a complete OMAGM from 2022 will postpone the deficit by 14–18 years. Accordingly, China should implement OMAGM as soon as possible to enhance the solvency of MIUE fund, and, in the long run, an independent LTCI scheme should be established to ensure the stability and sustainability of the LTCI fund and the MIUE fund.

Complex Multimorbidity and Incidence of Long-Term Care Needs in Japan: A Prospective Cohort Study.

Complex multimorbidity (CMM) has been proposed as a more nuanced concept of multimorbidity (MM). We sought to quantify the association of CMM and MM on the incidence of long-term care (LTC) needs in a cohort of older Japanese people. Our follow-up was based on a nationwide longitudinal cohort study of people aged over 65 years who were functionally dependent at baseline. Our outcome was incident LTC needs, based on certification under the Japanese LTC insurance scheme. We used both propensity score matching and inverse probability of treatment weights (IPTW) to compare individuals with and without MM versus CMM. A total of 38,889 older adults were included: 20,233 (52.0%) and 7565 (19.5%) adults with MM and CMM, respectively. In propensity-matched analyses, both MM (n = 15,666 pairs) and CMM (n = 7524 pairs) were statistically significantly associated with the six-year LTC insurance certification rate (MM, hazard ratio (HR) 1.07, 95% confidence interval (95%CI) 1.02–1.12; CMM, HR 1.10, 95%CI 1.04–1.16). Both MM and CMM were associated with a modest but statistically significantly higher rate of LTC insurance certification. These findings support the inclusion of multimorbidity in the assessment of LTC insurance needs, although the Japanese government currently has not adopted this.

Long-Term Care Insurance Reform in Singapore

ABSTRACT In recent years, governments in rapidly aging countries have looked toward the implementation of public insurance schemes to help cover the costs of care for their aging citizenry. This article presents a comprehensive overview of long-term care insurance policy in Singapore. We discuss the successes and challenges of nearly two decades (2002–2019) of policy experimentation with a voluntary long-term care insurance scheme, which was replaced by mandatory social insurance in the 2019 reform. Various aspects of the new scheme, including mode of financing, eligibility criteria, benefit design, and potential impacts are assessed. The article concludes that, in the inherent tension between the breadth and depth of public long-term care social insurance coverage, Singapore has opted for breadth at the expense of depth.

Long-Term Care Financing for an Aging Population: The Experience of Singapore

Singapore has a rapidly aging population. Long-term care (LTC) is one of the largest financial risks facing elderly in Singapore. Singapore implemented Eldershield, a long-term care insurance scheme which provided defined cash benefit payouts in the event of severe disability; but capped at a maximum of six years. Eldershield enrolled people at age 40, but offered an opt-out option. As of 2015, 65% of those aged 40 to 83 opted to be covered by Eldershield, making Singapore as having the highest voluntary LTC insurance rate in the world. This paper uses an actuarial multi-state disability model and calibrates the transition probabilities and duration-of-stay at various health (disability) states to assess the adequacy and comprehensiveness of Eldershield. The time-limited cash benefit design in Eldershield helped defray about 13% of LTC costs. Removing the time cap will help defray 23% and 26% of the LTC costs for elderly male and female respectively. Furthermore, the simulation results demonstrate that relaxing the trigger benefit and having staggered payouts will improve the adequacy of long-term care insurance. The experience of Singapore’s LTC insurance offers insights into the challenges of designing an insurance that tends to occur at higher age and insuring against a cost that could range from zero to a significantly large sum over a long period. Even with the enhanced Careshield Life, which provides cash payouts for life, other policy designs, for example caregiver grants, may be needed to ensure more adequate financing of long-term care.

Impact of increased long-term care insurance payments on employment and wages in formal long-term care

This paper examines the effect of raising Long-term care insurance (LTCI) payments on employment and wages of workers in the long-term care (LTC) industry. Specifically, I use the change in the regional premium in 2012 as an exogenous shock to the insurance fee schedule: the change in the unit price of LTCI service ranges from a decrease of 2.8% to an increase of 4.2%. I find no increase in the number of employees in the establishments, registered under the LTCI scheme, in municipalities where the regional premium increased. The earnings and working hours of LTC workers did not increase, either.

Impact of Increased Long-Term Care Insurance Payments on Employment and Wages in Formal Long-Term Care

This paper examines the effect of raising Long-term Care Insurance (LTCI) payments on employment and wages of workers in the long-term care (LTC) industry. Specifically, I use the change in the regional premium in 2012 as an exogenous shock to the insurance fee schedule: the change in the unit price of LTCI service ranges from a decrease of 2.8% to an increase of 4.2%. I find no increase in the number of employees in the establishments, registered under the LTCI scheme, in municipalities where the regional premium increased. The earnings and working hours of LTC workers did not increase, either.

Universal Health Insurance Reform in China

This article uses a refined version of historical institutionalism to critically examine the complex interplay of forces that shape the health insurance reform trajectory in China since the mid-1980s, problems that plague the current multi-layered social medical insurance system and solutions to these problems. It shows that achieving universal health coverage (UHC) requires the government to ensure financing equity between urban and rural insured participants, access to affordable health care and the financial sustainability of medical insurance funds. Facing the challenges of rapidly aging population, the government implements a pilot scheme that integrates medical and nursing care for the elderly and a pilot long-term care insurance scheme for disabled elderly. It is expected that these two pilot schemes can provide better financial protection and quality of medical services for the elderly.

Can universal access and competition in long-term care insurance be combined?

In countries with a public long-term care (LTC) insurance scheme administered by multiple non-competing insurers, these insurers typically lack incentives for purchasing cost-effective LTC because they are not at risk for LTC expenses. Plans to introduce these incentives by allowing competition among risk bearing LTC insurers are likely to jeopardize universal access. Combining universal access and competition among risk bearing LTC-insurers requires an adequate system of risk adjustment. While risk adjustment is now widely adopted in health insurance, LTC-specific features cause uncertainty about the feasibility of risk adjustment for LTC insurance. We examine the feasibility of appropriate risk adjustment in LTC insurance by using a rich set of linked nationwide Dutch administrative data. As expected, prior LTC use and demographic information are found to explain much of the variation in individual LTC expenses. However, we find that prior health care expenditures are also important in reducing predicted losses for subgroups of health care users. Nevertheless, incentives for risk selection against some easily identifiable subgroups persist. Moreover, using prior utilization and expenditure as risk adjusters reduces incentives for efficiency, creating a trade-off between equity and efficiency. To ease this trade-off, data on individuals’ underlying needs for LTC are required.

Cognitive impairments and functional declines in older adults at high risk for care needs

Functional status of those who have very mild cognitive impairment have not been sufficiently investigated. In the current study, we analyzed the characteristics of functional awareness in older adults who had cognitive impairment and were at high risk of requiring support/care (termed as specified elderly at high risk for care needs in the long-term care insurance scheme). The answers of a health check, which is provided by the local municipal government for those aged 75 years or older who have not been certified as eligible for care services, were analyzed. The differences of the variables between the two groups regarding yes/no answers to each of three cognition-related questions were analyzed. Then, a multiple logistic analysis was carried out to investigate the association of yes/no answers of the three cognition-related questions and the awareness of functional decline. The participants who had cognitive impairment had greater awareness of functional declines. Multiple logistic regression analysis showed that subjective memory impairment and disorientation were significantly associated with a wider range of awareness of functional decline. Subjective cognitive impairment was associated with a wide range of awareness of functional decline in older adults at high risk for care need.

Exploring strategies to alleviate caregiver burden: Effects of the National Long‐Term Care insurance scheme in Japan

The ever-increasing population of older people with disabilities, including dementia, has been accompanied by a corresponding growth in the number of family caregivers, who are themselves at risk of developing mental and physical health problems. As a result, the need for practical and effective approaches for alleviating caregiver burden has become a major public health concern. One approach involves the development of public policy initiatives to allow the caregiver burden to be borne partly by society as a whole, rather than falling solely on individuals. In 2000, Japan introduced a National Long-Term Care (LTC) insurance scheme that requires adults over the age of 40 years to pay compulsory monthly premiums, with one aim of the program being to reduce caregiver burden. The present paper reviews the effects of this scheme on caregivers' and the general public's perception of caregiver burden and assesses what other measures are needed to further reduce and/or prevent burden. Drawing on recent studies, four questions are addressed: (i) have caregivers' attitudes towards caregiving changed since the implementation of the scheme; (ii) do services provided under the scheme alleviate caregiver burden; (iii) what are the general public's attitudes to and understanding of family caregiving; and (iv) what is the general public's level of understanding of dementia? Results from recent studies suggest that the LTC insurance scheme in Japan appears to be an effective measure for alleviating the burden of caregiving among current family caregivers, but larger studies are needed to determine overall effectiveness.

On the consumption insurance effects of long-term care insurance in Japan: Evidence from micro-level household data

Using micro-level household data in the 2001 Comprehensive Survey of the Living Conditions of the People on Health and Welfare compiled by the Japanese Ministry of Health, Labor and Welfare, this paper examines how having a household member in need of long-term nursing care can result in welfare losses measured in terms of consumption. In so doing, this study evaluates the role of the public long-term care insurance scheme implemented in Japan in April 2000. The results indicate that when households include a disabled family member, household consumption net of long-term care costs do not decrease as much as before the introduction of long-term care insurance. Further, when compared with the surveys conducted in 1998, the adverse effects on consumption net of long-term care costs have become much weaker. These findings suggest that the introduction of social insurance in 2000 helped Japanese households to reduce the welfare losses associated with a disabled family member.

Daring to Take On Female Roles: Japanese Male Retirees as Volunteer Carers

AbstractIn the 1990s, several Japanese men established organizations that incorporate volunteering to provide new directions for older Japanese after retirement. They have encouraged male members to become involved in care work, traditionally the preserve of women. The time that these individuals give to others while in their active third age entitles them to reciprocal help in their frail fourth age, satisfying traditional Japanese ideals of reciprocity.This paper examines the life of the founder of one of these groups, Takahata Kei'ichi, his organization NALC, and some of the older men within NALC who have become volunteer carers. These individuals are adding support that goes beyond that provided by the long-term care insurance scheme, while gaining personal satisfaction from feeling useful. The post-retirement years can encompass moving beyond previous roles to take on new ones that benefit both the individual and society. The rapid ageing of the Japanese population has been portrayed as posing a thre...

Supplier density and at-home care use in Japan: Evidence from a micro-level survey on long-term care receivers

Following the introduction of the long-term care insurance scheme and deregulation of the market for at-home care services, Japan experienced a substantial increase in expenditure on care for the elderly. Using household-level survey data, we empirically examine whether the increase in care expenditure is associated with supplier density springing from the rise in the number of care providers following deregulation. We provide weak evidence that supplier density in the at-home care market is positively correlated with probability to use care or expenditure on care. Moreover, we find no link between the share of for-profit providers and the demand for at-home care services.

Modelling an entitlement to long-term care services for older people in Europe: projections for long-term care expenditure to 2050

As the numbers of older people rise in Europe, the importance of long-term care services in terms of numbers of users and expenditures can be expected to grow. This article examines the implications for expenditure in four countries of a national entitlement to long-tem care services for all older people, based on assessed dependency. It is based on a European Commission-funded cross-national study, which makes projections to 2050 of long-term care expenditure in Germany, Italy, Spain and the UK. The policy option investigated is based on the German long-term care insurance scheme, which embodies the principle of an entitlement on uniform national criteria to long-term care benefits. The research models this key principle of the German system in the other three participating countries, with respect to home care services. The study finds that, if all moderately/severely dependent older people receive an entitlement to formal (in-kind) home care, the impact on expenditure could be considerable, but would vary greatly between countries. The impact on long-term care expenditure is found to be the least in Germany, where there is already an entitlement to benefits; and the greatest in Spain, where reliance on informal care is widespread. This article discusses the policy implications of these results.

The socialization of at-home elderly care and female labor market participation: Micro-level evidence from Japan

This study takes advantage of the introduction of Japan's public long-term care insurance scheme in 2000 as a unique natural experiment to evaluate how the socialization of long-term care affects female labor participation. Our difference-in-differences estimates suggest that the introduction of the scheme had no effect on female labor market participation in 2001, but a large and positive effect in 2002. The new long-term care scheme raised the probability that female caregivers were employed by 8 percentage points and, on average, the number of days per week and hours per day worked by female caregivers by 10–20 percent age points.

医療経済・政策学の視点から

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