Governments around the world have responded to growing long-term care needs to different degrees and at different levels. These responses by governments, are based in part, upon a public policy research agenda on long-term care which includes special population research, flexible models of services, and managed care models to control escalating costs and high private pay rates.
Europe Most
Western European countries have put in place a mechanism to fund formal care and, in a number of
Northern and
Continental European countries, arrangements exist to at least partially fund informal care as well. Some countries have had publicly organized funding arrangements in place for many years: the
Netherlands adopted the Exceptional Medical Expenses Act (ABWZ) in 1967, and in 1988
Norway established a framework for municipal payments to informal caregivers (in certain instances making them municipal employees). Other countries have only recently put in place comprehensive national programs: in 2004, for example,
France set up a specific insurance fund for dependent older people and in 2006,
Portugal created a public funded national network for long-term care. Some countries (
Spain and
Italy in Southern Europe,
Poland and
Hungary in Central Europe) have not yet established comprehensive national programs, relying on informal caregivers combined with a fragmented mix of formal services that varies in quality and by location. In the 1980s, some Nordic countries began making payments to informal caregivers, with
Norway and
Denmark allowing relatives and neighbors who were providing regular home care to become municipal employees, complete with regular pension benefits. In
Finland, informal caregivers received a fixed fee from municipalities as well as pension payments. In the 1990s, a number of countries with social health insurance (
Austria in 1994,
Germany in 1996,
Luxembourg in 1999) began providing a cash payment to service recipients, who could then use those funds to pay informal caregivers. Clare Ungerson, a professor of Social Policy, together with Susan Yeandle, Professor of Sociology, reported on the Cash for Care Demonstrations in Nation-States in Europe (Austria, France, Italy, Netherlands, England, Germany) with a comparative USA ("paradigm of home and community care"). In addition, direct payment schemes were developed and implemented in the UK, including in Scotland, for parents with children with disabilities and people with mental health problems. These "health care schemes" on the commodification of care were compared to individualised planning and direct funding in the US and Canada.
North America Canada In Canada, facility-based long-term care is not publicly insured under the
Canada Health Act in the same way as hospital and physician services. Funding for LTC facilities is governed by the provinces and territories, which varies across the country in terms of the range of services offered and the cost coverage. Canada-US have a long-term relationship as border neighbors on health care; however, Canada, has a national health care system in which providers remain in private practice but payment is covered by taxpayers, instead of individuals or numerous commercial insurance companies. In the development of home and community-based services, individualised services and supports were popular in both Nations. The Canadian citations of US projects included the cash assistance programs in family support in the US, in the context of individual and family support services for children with significant needs. In contrast, the US initiatives in health care in that period involved the Medicaid waiver authority and health care demonstrations, and the use of state demonstration funds separate from the federal programs.
United States Long-term care is typically funded using a combination of sources including but not limited to family members, Medicaid, long-term care insurance and Medicare. All of these include out-of-pocket spending, which often becomes exhausted once an individual requires more medical attention throughout the aging process and might need in-home care or be admitted into a nursing home. For many people, out-of-pocket spending for long-term care is a transitional state before eventually being covered by Medicaid, which requires impoverishment for eligibility. Personal savings can be difficult to manage and budget and often deplete rapidly. In addition to personal savings, individuals can also rely on an
Individual retirement account,
Roth IRA,
Pension,
Severance package or the funds of family members. These are essentially
retirement packages that become available to the individual once certain requirements have been met. In 2008, Medicaid and Medicare accounted for approximately 71% of national long-term care spending in the United States. Out-of-pocket spending accounted for 18% of national long-term care spending, private long-term care insurance accounted for 7%, and other organizations and agencies accounted for the remaining expenses. Moreover, 67% of all nursing home residents used Medicaid as their primary source of payment. Private Long-Term Care Insurance in 2017 paid over $9.2 Billion in benefits and claims for these policies continue to grow. The largest claim to one person is reported to be over $2 million in benefits Medicaid is one of the dominant players in the nation's long-term care market because there is a failure of private insurance and Medicare to pay for expensive long-term care services, such as nursing homes. For instance, 34% of Medicaid was spent on long-term care services in 2002. Medicaid operates as distinct programs which involve home and community-based (Medicaid) waivers designed for special population groups during deinstitutionalization then to community, direct medical services for individuals who meet low income guidelines (held stable with the Affordable Care Act Health Care Exchanges), facility development programs (e.g.,
intermediate care facilities for individuals with intellectual and developmental disabilities), and additional reimbursements for specified services or beds in facilities (e.g., over 63% beds in nursing facilities). Medicaid also fund traditional home health services and is payor of adult day care services. Currently, the US Centers for Medicaid and Medicare also have a user-directed option of services previously part of grey market industry. In the US,
Medicaid is a government program that will pay for certain health services and nursing home care for older people (once their assets are depleted). In most states, Medicaid also pays for some long-term care services at home and in the community. Eligibility and covered services vary from state to state. Most often, eligibility is based on income and personal resources. Individuals eligible for Medicaid are eligible for community services, such as home health, but governments have not adequately funded this option for elders who wish to remain in their homes after extended illness
aging in place, and Medicaid's expenses are primarily concentrated on nursing home care operated by the hospital-nursing industry in the US. Generally,
Medicare does not pay for long-term care. Medicare pays only for medically necessary skilled
nursing facility or
home health care. However, certain conditions must be met for Medicare to pay for even those types of care. The services must be ordered by a doctor and tend to be rehabilitative in nature. Medicare specifically will not pay for custodial and non-skilled care. Medicare will typically cover only 100 skilled nursing days following a 3-day admission to a hospital. A 2006 study conducted by
AARP found that most Americans are unaware of the costs associated with long-term care and overestimate the amount that government programs such as Medicare will pay. The US government plans for individuals to have care from family, similar to Depression days; however, AARP reports annually on the Long-term services and supports (LTSS) for aging in the US including home-delivered meals (from senior center sites) and its advocacy for caregiving payments to family caregivers.
Long-term care insurance protects individuals from asset depletion and includes a range of benefits with varying lengths of time. This type of insurance is designed to protect policyholders from the costs of long-term care services, and policies are determined using an "experience rating" and charge higher premiums for higher-risk individuals who have a greater chance of becoming ill. There are now a number of different types of long-term care insurance plans including traditional tax-qualified, partnership plans (providing additional dollar-for-dollar asset protect offered by most states), short-term extended care policies and hybrid plans (life or annuity policies with riders to pay for long-term care). Residents of LTC facilities may have certain
legal rights, including a Red Cross ombudsperson, depending on the location of the facility. Unfortunately, government funded aid meant for long-term care recipients are sometimes misused.
The New York Times explains how some of the businesses offering long-term care are misusing the loopholes in the newly redesigned New York Medicaid program. Government resists progressive oversight which involves continuing education requirements, community services administration with quality-of-life indicators, evidence-based services, and leadership in use of federal and state funds for the benefit of individual and their family. For those that are poor and elderly, long-term care becomes even more challenging. Often, these individuals are categorized as "
dual eligibles" and they qualify for both Medicare and Medicaid. These individuals accounted for 319.5 billion in health care spending in 2011. ==See also==