LONG-TERM CARE FOR THE ELDERLY: THE EXPERIENCE OF FOUR NATIONS
CRS Report for Congress
Long-Term Care for the Elderly:
The Experience of Four Nations
April 27, 2000
Mayra M. De La Garza
Specialist in Social Legislation
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress
Long-Term Care for the Elderly:
The Experience of Four Nations
Providing long-term care for growing elderly populations is a major concern in
many industrialized countries. Germany, Japan, Canada, and the United Kingdom
address long-term care issues in various ways. A comparison of these differing
approaches may help inform U.S. policy makers as they face challenges presented by
the retirement of the baby boom generation and the growing number of older persons.
There are some common policy themes across each of the four countries.
Projections about the increasing share that the elderly will represent in the coming
decades have spurred policymakers to review and improve existing financing and
service delivery systems. Each country is striving to create greater incentives for
home and community-based care, and in some cases, to correct incentives that favor
more costly institutional care. Each country recognizes the important role of unpaid
care provided by family and friends to assist older persons with functional and/or
cognitive disabilities. The role of women in providing unpaid care is especially salient.
Countries differ in their financing methods although each requires contributions from
beneficiaries, either through deductions of insurance premiums from wages
(Germany), premiums for social insurance (Japan), or fees and contributions for
services received (United Kingdom and Canada).
Germany established mandatory long-term care insurance in 1994. This social
insurance approach provides for pre-determined services or cash allowances to
eligible individuals based on their level of need. The insurance program is financed
through a 1.7% levy on wages shared equally by employers and employees.
Japan’s challenge of providing for their elderly is magnified by changing family
roles, with more women entering the workforce and unavailable to care for the frail
elderly. Japan’s “New Gold Plan” of 1994 laid the foundation for a long-term care
insurance system that was enacted into law in December 1997 and was implemented
in April 2000.
In Canada, there is no national system for providing or insuring long-term care.
Instead, provinces are responsible for providing services resulting in variability in
eligibility criteria and services across the country. The federal government provides
a block grant for health care, social programs and post-secondary education.
Provinces may use a portion of the federal contribution for home and community-
In 1990, the National Health Service (NHS) and Community Care Act was
enacted in the United Kingdom. Its goal was to control growth in spending for
institutional care, consolidate accountability for services at the local level, and lessen
the bias toward institutional care through greater incentives for home and community-
based care. A Royal Commission on Long-Term Care was appointed in 1997 to
examine the current system and make recommendations for improvement. It reported
far-reaching recommendations in 1999.
Introduction ................................................... 1
Germany ...................................................... 4
Summary .................................................. 4
Background ................................................ 4
Eligibility .............................................. 7
Financing .............................................. 9
Administration .......................................... 9
Japan ........................................................ 10
Summary ................................................. 10
Background ............................................... 10
Eligibility ............................................. 14
Financing ............................................. 15
Administration ......................................... 16
Canada ...................................................... 17
Summary ................................................. 17
Background ............................................... 17
Eligibility ............................................. 21
Financing ............................................. 22
Administration ......................................... 23
Summary ................................................. 23
Background ............................................... 24
Eligibility ............................................. 27
Financing ............................................. 28
Administration ......................................... 29
Germany ..................................................... 30
Japan ........................................................ 31
Canada ...................................................... 32
List of Tables
Table 1. Comparison of Selected Country Characteristics and
Long-Term Care Systems.....................................3
Table 2. Population Projections for Germany, 2010-2050.................6
Table 3. Population Projections for Japan, and Percentage by Age Group,
2000-2050 ................................................ 12
Table 4. Japanese Population by Age Group, 1980-1997
Table 5. Canadian Population aged 65 and over, 1971-1998..............19
Table 6. Population Projections for Canada, aged 65 and over, 2001-2041 ..19
Table 7. UK Population aged 65 and over, 1971-1998...................25
Table 8. Population Projections for the United Kingdom,
aged 65 and over, 2000-2040..................................26
Table 10. Expenditures on Long-Term Care Services, 1995...............29
Long-Term Care for the Elderly:
The Experience of Four Nations
As the U.S. prepares for an aging society and the retirement of the baby-boom
generation beginning in 2008, policy makers will increasingly be called upon to focus
on issues related to providing and financing long-term care. Other industrialized
countries face similar challenges and are planning or already taking steps to change
their long-term care systems. This report provides a description and comparison of
approaches taken by Canada, Germany, Japan, and the United Kingdom.
The programs in all four nations seek to enhance the quality of life for the frail
elderly population. During the 1990s, three countries, Germany, Japan, and the
United Kingdom, each enacted major legislation to redesign their systems of long-
term care for the frail elderly. In 1994, Germany created an employer mandated
insurance program where employer and employee share equally in a 1.7% levy on
wages to pay for long-term care services. Japan enacted major legislation to establish
a public long-term care insurance system which was implemented in April 2000.
In 1990, the United Kingdom enacted major legislation to transfer funds from
the central government to local governmental authorities to be used for home and
community-based services and to correct a financial bias that favors institutional care.
More recently, in 1999, the Royal Commission on Long-Term Care made far reaching
recommendations to the British Parliament regarding changes in the current system.
In Canada, there is no national system of long-term care. The provincial and
territorial governments have the primary responsibility for both health and social
services as they affect long-term care. They have individually taken measures to
reorganize and refinance their systems. The federal government’s role in these areas
is through its constitutional spending power, its ability to generate revenues and to
spend such money in ways that do not infringe on provincial powers.
Similarities in the four countries include the following:
!Projections of the increasing share that the elderly will represent in
the coming decades have spurred policymakers to review and revise
existing financing and service delivery systems.
!Each of the countries is striving to create greater incentives for home
and community-based care, and in some cases, to correct incentives
that favor institutional care. In some cases, the desire to control
costs of institutional care has propelled policymakers to expand home
and community-based care.
!Each of the countries recognizes the important role of unpaid care
provided by family and friends to assist older persons with functional
and/or cognitive disabilities. The role of women in providing unpaid
care in each country is especially salient. In Japan, particularly,
which has traditionally relied almost exclusively on family care, the
increased participation of women in the workforce is expected to
have a profound effect on family care. The United Kingdom’s Royal
Commission on Long-Term care has proposed a major national
initiative to assist caregivers.
!Responsibilities for administration are generally decentralized , either
divided among federal and local (or provincial) authorities. Local
governmental agencies or, in the case of Germany, insurance plans,
are responsible for assessment of an individual’s need for service and
development of a care plan according to services available.
!Each of the countries requires individuals to pay for a portion of the
cost of their care and in the case of Germany, a deduction is made
from employee’s income to pay for long-term care insurance.
!Each of the countries, except Germany which has a mandated
employer-based insurance plan, relies on public funding to finance
long-term care in varying degrees.
Table 1 compares major components of each system.
Table 1. Comparison of Selected Country Characteristics and
Long-Term Care Systems
population Germany Japan Canada U.K.
% of 65+
12.7% (1998)15.8% (1997)15.7% (1997)12.3% (1998)15.7% (1998)
13.2% (2010)20.5% (2010)22.0% (2010)14.1% (2011)16.5% (2010)
20.3% (2040)34.6% (2040)31.0% (2040)22.6% (2041)26.6% (2040)
Financingemployerpublic long-termfederal transferpay as you go
mandatedcare insurancepayments; taxtaxation;
insurance; 1.7% ofplan; publiccredits andindividual
wages, sharedsubsidies;deductions forcontributions
equally byinsuranceindividuals; clienttoward cost of
employer andpremiums andfees for somecare; tax credits
employees copayments paidservices imposedfor caregivers
by beneficiariesby provinces
Eligibility assessment ofassessment ofassessment ofassessment of
need for care byneed for care byunmet needs byneed by local
medical servicemunicipalitiescase managers;authorities;
department ofeach province hasrequires
health insuranceown long-termindividuals to
fund; benefitscare plan, nowcontribute toward
granted on basis ofcommonly calledthe cost of care
care requirementcontinuing care;based on a fee
and not financialformal incomeschedule (called a
resourcestesting exists in“means test”)
Services &pre-determined12 at-home carewide range ofwide range of
benefitsbenefits accordingprograms toinstitutional andinstitutional and
to three levels ofchoose from, threehome care benefitshome care services
care/need;institutional carein varyingin varying
beneficiaries ableservices;amounts set byamounts
to choose a mix ofmaximum benefitsprovinces
cash or servicesat fixed yen
amounts based on
Problemslow fertility raterapid growth instrained resources;bias toward
and growingelderly populationlack of uniforminstitutional care;
elderly populationand decrease inservices andlack of uniform
number ofeligibility criteriaapplication of
potentialacross provinceseligibility criteria;
caregivers; declineuneven quality and
in family careaccess
!In 1997, almost 13 million people, 16% of Germany’s population,
was 65 years of age or older. By 2050, this group will represent
36.0% of the total population. An estimated 1.75 million people, or
!In 1995, Germany established a mandatory, universal, employer-
based long-term care insurance system. The system is financed
through a 1.7% wage contribution, split equally between the
employer and employee. The system provides both cash and services
to the eligible population. As of January 1997, insured persons
totaled 71.7 million, or 87% of the total population. At the end of
!Each of over 1,200 individual “sickness funds” (or health insurers)
has a medical service department that assesses individuals to
determine eligibility and extent of need for long-term care.
Individuals in need of care are assigned to 1 of 3 levels of care which
establishes the extent of benefits and/or cash allowances that a person
!While the mandatory long-term care insurance system is financed
through employer-employee contributions, each German state
(Länder) is responsible for providing and arranging care.
The national health care system in Germany has century old beginnings. The
year 1876 marks the foundation of the Health Office of the German Reich in Berlin.
In 1883, statutory health insurance was enacted by the first chancellor of the German
state, Otto von Bismarck. From those early beginnings, social welfare legislation was
enacted throughout the next century contributing to the evolution of what was
considered by many as a model social insurance health care system. What originally
began as an insurance scheme for wage-earning laborers and their families, expanded
to include other groups of workers.
Today, Germany’s social insurance program for health covers more than 90%
of a population totaling over 82 million. Germany’s statutory health insurance
automatically insures employees with income below a specified annual level,1 and its
coverage extends to the dependents of the insured at no extra cost. Additionally,
health coverage is extended to the unemployed. Self-employed persons and state
employees with an income above the specified annual level are not automatically
insured by the social insurance program. They are required to join a state health
insurance system or purchase private health insurance.
1 The 1999 income limit was DM 76,500 a year in western Germany (US $41,500), and DM
Over 1,200 individual sickness funds (health insurance plans) provide health
insurance coverage in the form of both cash and in-kind benefits at a high level of
service for those insured.2 The sickness funds are financed through pay-as-you-go3
contributions, ranging from 12% to 15% of employment income. Typically, half of
the contribution to the sickness fund is paid by the employer while the other half is
paid by the employee. Though regulated by federal legislation, the health care system
is administered by the states. Persons with statutory health insurance may choose
their sickness fund.
Demographic Trends. Changing demographics were an influential factor in
establishing a long-term care insurance system for Germany’s aging population. In
1980, 9.4 million people in the Federal Republic of Germany were 65 years of age or
older.4 In 1997, the number of 65+ in Germany grew by 38% to almost 13 million.
This growth is partially attributed to the reunification of the German Democratic
Republic (East Germany) and the Federal Republic of Germany (West Germany).
The younger generation in Germany is decreasing both in absolute terms and as
a proportion of the total population. In 1997, the number of people under 15 years
of age totaled 13.1 million (16% of the total population), a slight decrease compared
to prior years.5 The Federal Statistical Office of Germany calculates that in a few
years there will be more people aged 65 years and over than those 15 years and under.
The United States Bureau of the Census population projections for Germany confirms
The total German population is projected to fall to 57 million people in the year
2050, a 30% decrease from the 1997 total population. It is estimated that 5.3 million
people, or 9.2% of the population, will be 14 years of age or younger while 20.7
million people, or 36% of the population, will be 65 years of age or older. This
represents a 59% increase over the number of people 65 years of age or older in
1997.6 With life expectancies at birth estimated at 74 years for men and 80 years for
women, and a total fertility rate of 1.25 children born per woman, these projections
are likely to significantly affect the demand for long term care services in the future.7
2 Sickness funds are quasi-public, not-for-profit insurance organizations that operate under
statutory requirements but vary in the extent to which they provide services, pay health care
providers, and how much they charge in contributions. In January 1996, employees in a local,
company, guild, or other statutory health insurance fund were given the freedom to choose the
fund that would cover their needs.
3 The average health insurance contribution rate in May 1998 was about 13.6% of the non-
exempt employee income in western Germany and about 13.9% in eastern Germany. (Federal
Ministry of Labour and Social Affairs.)
4 Schwab, Teresa. Caring for an Aging World. New York, 1989.
5 Federal Statistical Office Germany. Population. June 24, 1999.
7 CIA, The World Factbook 1998.
Table 2. Population Projections for Germany, 2010-2050
Percentage by age group
YearTotal population(in thousands)0-1415-6465 and over
Source: Table prepared by the Congressional Research Service (CRS) based on data from the U.S.
Bureau of the Census, International Data Base.
Projections about the growing older population and a desire to expand home and
community-based care led to a major redesign of the German long-term care system.
The redesign was enacted into law in 1994. The law established a mandatory
universal social insurance program for long-term care (Pflegeversicherung) financed8
through equal employer and employee contributions. The program is separate from
the general health insurance program.
Before the enactment of a social insurance approach, long-term care services for
the chronically ill were covered under the federal welfare law, and financed at the
local level. Under the welfare program, eligibility for services was means-tested and
determined by assessing a person’s income and assets. Services received included
cash support and/or in-kind benefits.
The long-term care social insurance program is considered a capped entitlement
program with maximum per-person benefits. It provides nearly universal coverage
and, unlike the prior welfare program, eligibility is not related to a person’s income9
and assets. For persons covered by the statutory health insurance program
administered through the sickness funds, long-term care insurance is compulsory and
is also administered by the sickness funds. Privately insured persons, i.e., self-
employed persons, are required under the new legislation to purchase private long-
term care insurance. While the long-term care insurance program covers institutional
care, the new insurance system favors home care over institutional care. Non-
8 The German Bundestag (Lower House) approved a draft bill addressing social provisions
for long term care on April 22, 1994. One week later, the Bundesrat (Upper House) consented
to the bill. On January 1, 1995, long term care insurance was established as an independent
branch of the social insurance system and gradually phased in. The long-term care insurance
program has provided benefits for home care since April 1, 1995, and for long-term
institutional care since July 1, 1996.
9 Cuellar, Alison Evans and Joshua M. Weiner. Structuring a Universal Long-Term Care
Program: The Experience in Germany. Generations, v. XXIII, no. 2, summer 1999. p. 45ff.
(Hereafter cited as Cuellar and Wiener, Structuring a Universal Long-Term Care Program.)
professional caregivers receive training and compensation for their caregiving efforts
under the new law, and providers of institutional care are compensated on a per
resident, per month basis.
In January 1997, the number of persons with long-term care insurance totaled
71.7 million or 87% of the total population. Of that number, 51.1 million were
contributing members while 20.6 million were insured non-contributing family
members. At the end of 1997, 1.7 million, or 2.3% of the total insured population,
had been beneficiaries of the insurance with 72% requiring out-patient care and 28%
requiring in-patient care.10
Eligibility. The long term care insurance program provides benefits and services
to anyone requiring assistance with the “regular tasks” of daily life on a long term
basis (estimated at 6 months or longer).11 Under the public long-term care insurance
program, the medical service department of each health insurance fund is responsible
for assessment of individuals in their own homes to determine eligibility and the extent12
of need for long-term care services. Each person in need of assistance is assigned
to one of three levels of care, ranging from a need for 90 minutes of care per day for
Level I to at least 5 hours of care per day for Level III. Each level of care is
associated with a maximum insurance allowance, i.e., level of cash and services a
person may receive. The entitlements provide for both home care services and
nursing home costs. National guidelines and pre-determined benefits ensure
uniformity of assessment and equality of treatment.
While the long-term care insurance program is focused on the elderly, it also
provides for the younger disabled population in need of nursing care. These persons
receive a flat rate allowance to help cover treatment costs. The goal is to help
disabled people live in the community rather than residing in nursing homes. German
law emphasizes integration of persons with disabilities into the community and the
workplace by promoting employment of such persons. The law requires that at least
6% of the workforce of government and private employers (with more than 16
employees) be persons with disabilities. If the employment quota for the disabled is
not met, the employers must pay a fee which ultimately subsidizes costs for those who
do employ disabled persons.
Services Provided. Germany began phasing in its long-term care insurance
program in 1995. Home care benefits were provided beginning April 1, 1995. In July
10 “In-patient” care refers to care requiring hospitalization “for the purpose of observation,
care diagnosis, or treatment.” “Out-patient” care is same-day services in which the person
is not hospitalized. (On health Medical Dictionary, [http://onhealth.com])
11 Section 14(4) of Volume 11 of the Code of Social Law defines regular tasks as personal
hygiene – washing, bathing, cleaning teeth, combing hair, shaving, emptying bowels and
bladder; food – preparing or administering food; mobility – getting in and our of bed, dressing
and undressing, walking, standing, climbing stairs, leaving and returning to one’s home; and
household tasks – shopping, cooking, cleaning the home or apartment, washing-up, changing
and washing bed linen and clothing or heating of the home.
12 Section 18 of the Code of Social Law XI.
1996, the second phase began, providing for institutional care. Anyone paying into
the long-term care insurance fund can immediately receive full benefits.
The insurance plan in Germany provides both cash and services so that
beneficiaries may receive a nursing allowance, a home care allowance, and/or payment
of full institutional care. There are no restrictions as to the combination of cash and
services received so that anyone may benefit from comprehensive services and
minimal amounts of cash, or may choose to receive all benefits in the form of cash and
buy privately delivered services. Although cash has been a major choice of long-term
care clients, recent trends show the number of people choosing only cash is declining.
One reason may be because the majority of people in need of long-term care desire
to live at home or in familiar surroundings for as long as possible. More people seem
to prefer tailored individual home care services or combination packages that provide
both in kind and cash benefits.
Long-term care cash allowances determined by a person’s care requirement level
are paid as flat-rate reimbursements for costs assumed to have been incurred. No
proof of costs is required from individuals providing home care. However,
monitoring by a professional caregiver (similar to a case manager) takes place every
3 to 6 months. The professional caregiver must assess the quality of the home care
situation and suggest possible improvements.
Care in residential homes is generally restricted to cases in which proper care
cannot be provided in the home. If the individual requires institutional care, long-term
care insurance will pay expenses for basic care, social services, and treatment
according to the level of care required. However, the insured person is responsible
for paying the costs for room and board and must pay at least 25% of the nursing
home charges if the home is relatively low in cost. A person’s benefit rate may not
be granted in full if it is more than 75% of the nursing home charges.13
Home care services may be provided by friends or family members. This policy
was designed to provide financial security for the caregivers of recipients residing at
home, and to assist spouses of persons with disabilities who had no pension income.
Additionally, the policy reinforced support for home care rather than institutional
care. Although the policy has shifted towards providing increased home care, there
are still approximately 490,000 people in nursing homes. This represents 28% of the
Long-term care insurance also provides respite care for caregivers so that
persons providing home care for at least 12 months may take up to 4 weeks of holiday
leave per year. Similarly, a caregiver providing at least 14 hours of unpaid care per
week, and is unemployed or works no more than 30 hours, is covered by statutory
pension insurance and accident insurance. Contributions for pension coverage for
caregivers is paid by the long-term care insurance program.
13 “For example, the DM 2,000 monthly rate cannot be granted in full if a nursing home
charges less than DM 2,660 a month.” (Federal Ministry of Labour and Social Affairs, p.60)
14 Federal Ministry of Labour and Social Affairs, Social Security at a Glance. p. 56.
Financing. The public long-term care insurance plan is financed entirely
through equal employer and employee contributions. Assistance received, however,
is not related to amount paid in to the insurance fund or to a person’s financial
situation. What began as a 1% contribution rate in 1995 rose to a rate of 1.7% of
wages income with the enactment of the second phase of the program. Contributions
are split evenly between the employer and employee.15 Contributions are subject to
a ceiling of DM 6,375 (US $3450) a month in western Germany and DM 5,400 (US
$2920) a month in eastern Germany in 1999.16 They are directly deducted from
wages and transferred to the health insurance fund. When costs of care exceed benefit
levels, the difference must be paid by the person requiring care.
Because long-term care insurance is mandatory under law, those self-employed
in Germany have an obligation to pay for their own private long-term care insurance.
Those privately insured typically have higher incomes than federal insurance
contributors. Premiums (private contributions) for compulsory private long-term care
insurance are determined by the individual’s age, with premiums not to exceed the17
maximum contribution of DM 108.38 (US $59) a month as of January 1, 1999.
Only cash benefits and reimbursements of covered long-term care expenses are
offered by compulsory private long-term care insurance.
In 1997, benefit expenditures totaled DM 27.9 billion (US $15.6 billion). Since
the inception of the long-term care insurance program, mandatory contributions and
premiums have accumulated reserves amounting to DM 5.5 billion (US $3 billion) at
the end of 1997. It is anticipated that these funds will help stabilize the contribution18
rate in the future.
Administration. Cost containment played an important role in the development
and introduction of long-term care insurance. The legislative objective was to
significantly reduce the number of people dependent on social assistance (welfare) and
increase the relative share of home care.19 Prior to implementation of the long-term
care insurance program, responsibility fell on each Länder (state) to provide efficient
administration and services to persons in need of long-term care.
Under the long-term care insurance program, the health insurance plans have an
important role. The medical service department of each health insurance fund is
15 To compensate one day of employers for bearing half the contributions to long-term care
insurance, one day of holiday pay was eliminated and became an extra working day except
in the state of Saxony. In Saxony employees contribute 1.35% of their income and employers
contribute 0.35% of wage towards the insurance fund. This contribution is assumed to be in
addition to the 12-15% contribution made to state health insurance funds.
16 Federal Ministry of Labor and Social Affairs, Social Security at a Glance. p. 60.
17 Ibid., p. 61.
18 Answers from the Federal Ministry for Labor and Social Affairs to Questions submitted by
the Royal Commission on Long Term Care for the Elderly during its visit to Germany on June
responsible for determination of eligibility and need for care.20 Similarly, personnel
of the medical section of the health insurance plan must determine if adequate
rehabilitation measures are available for the insured individual. Some observers have
pointed out, however, little formal case management takes place and individuals are
not assessed on a regular basis.21
!In 1998, about 20.5 million people, 15.7% of the population, was 65
years of age or older. By the year 2050, the elderly are expected to
represent one-third of the total population.
!Family care has historically characterized care for the elderly in
Japanese society. Lower fertility rates, decreasing youth population,
high life expectancy, and the fading tradition of family care have
altered the system of elder care. Women, the primary caregivers, are
entering the labor force at a greater pace than in previous years.
!In April 2000, a new public long term care insurance system was
implemented. Public subsidies will pay one half of the total benefit
expenditures. Elderly beneficiaries pay insurance premiums based on
their income, as well as a coinsurance amount on the services they
!Eligibility for the new long-term care insurance system is determined
by assessment of an individual’s cognitive and functional condition.
Individual service plans are developed and consumers will select
services from 12 types of home care and three institutional care
levels, based on need. Municipalities are responsible for assessment
and administration of services.
Health insurance coverage has been available in Japan since enactment of the
Health Insurance Law of 1922. In 1947, the Japanese constitution established the
goal of holding the government responsible for providing health care to its citizens,
but universal health coverage was actually achieved 14 years later in 1961. There are
several insurance systems in Japan. A government-managed health insurance plan
covers employees of small businesses; mutual aid associations insure public employees
and teachers and agricultural workers; the self-employed are insured under another
system.22 Japan’s current health program for the elderly is part of this multi-part
national health insurance system.
20 Section 18 of the Code of Social Law XI
21 Cuellar and Wiener, Structuring a Universal Long-Term Care Program, p. 48.
22 Japan Pharmaceutical Manufacturers Association, National Health Insurance Systems,
July 15, 1999.
In 1963, the Welfare Law for the Elderly provided coverage for all elderly in
need of services and financial support, regardless of income. An amendment to this
law in 1973 established free medical care services for those 70 years of age or older
who met certain income tests. Subsequent high medical costs for this population led
to the enactment of the Health and Medical Service Law for the Elderly in 1982
which required the elderly to make co-payments. This law also provided for more
comprehensive services, including rehabilitation and prevention services.
Amendments to the law established health care facilities for the bedridden and senile
elderly in 1986 and a home-visit nursing care system in 1991.
Overlapping goals of health care and welfare services led to their unification in
1989. A 10-year Gold Plan was established by the Ministry of Health and Welfare
as a strategy to promote health care and welfare for the elderly including the
enhancement of in-home and institutional services. In 1994, higher goals were set to
build the foundation for elderly long-term care services with more rapid
implementation, called the New Gold Plan.
In 1996, the Japanese government reevaluated its programs and began structural
reform of its social security system. The primary objective of the reform was to
improve overall efficiency. The second objective was to promote self- sufficiency to
enable individuals to live in their homes as long as possible. As part of this reform,
a public long-term care insurance system was enacted in April 1997 and was
implemented in April 2000. The system is designed to provide comprehensive and
high quality long-term care services, including home care and institutional services.
It builds upon the existing health care program.
Demographic Trends. The Japanese tradition that stresses filial duty has
characterized the country’s system of care for many years. While most elderly remain
in their own homes, many reside with their eldest son. In 1998, approximately half
of elderly persons lived with their children. Once a Japanese older person begins to
live with his/her child, the daughter-in-law becomes the main provider of care, often
spending years tending to the nursing and daily needs of her “patient.”
While children of aging parents carry the responsibility of providing care for the
senior population, this Japanese tradition is being affected by a number of social and
demographic factors. These include: a rapidly growing elderly population, lower
fertility rates, decreasing youth population, and high life expectancy. In addition,
modern Japanese women are entering the labor force in larger numbers and are
increasingly leaving behind the role of housewife and caregiver.
In 1980, 10.6 million people were 65 years of age or older, representing 9.1%
of the total population. By 1998, this number had increased dramatically – by 93%
to 20.5 million people, or 16.2% of the total population. The large growth has been
partially due to a baby boom that occurred in Japan around 1930. The large
expansion in the older population, coupled with high life expectancy rates (averaging
77.2 years for men and 84 years for women in 1998) have heightened concern about
the need for long-term care.23
The total population of Japan is expected to peak in 2007 with 127.8 million
people, and then begin to decline in absolute numbers falling to 100.5 million by the
year 2050. Population projections indicate continued growth of the older population
coupled with a decline in the number and proportion of younger persons. Persons
aged 65 years of age or older are expected to increase from 17.2% of the total
population in 2000 to 32.3% by the year 2050, as shown in Table 3. The working
age population (age 15-64) is expected to decline from 68% of the total population
in 2000, to 54.6% in 2050.
Table 3. Population Projections for Japan, and Percentage by Age
Total population Percentage by age group
Year(in thousands)Under 15 years15 to 6465 and over
Source: Table prepared by the Congressional Research Service (CRS) based on data from Ministry
of Health and Welfare, 1998. Medium-variant projections as of January 1997.
The population under age 65 has been decreasing in number and as a share of the
total population since 1985. This means that potential caregivers have not grown as
rapidly as the elderly population. The decreasing number of potential caregivers is
expected to affect the dynamics of family care that has historically characterized
In 1980, there were 78.8 million people (67.4% of the total population) between
the ages of 15-64. By 1998, this number grew only 10% to 87 million (69% of the
total population) while the share of future caregivers under 15 years of age decreased
by 31% to 19.1 million (15.1% of the total population). Caregivers, however, are
typically older persons themselves. Almost half of Japan’s caregivers were 60 years24
of age or older in 1998.
In addition, it is not clear that the future working generation will be able to
support the elderly to the same extent it has in past generations. The labor force is
23 CIA, The World Factbook 1998.
24 Ministry of Health and Welfare of Japan, Outline of Long-Term Care Insurance in Japan,
expected to decrease as indicated by Japan’s low fertility rate of 1.38 children born
per women (1988).25
Table 4. Japanese Population by Age Group, 1980-1997
YearTotalUnder 15 years15-6465 and over
1980116,98927,507 78,835 10,647
(23.5%) (67.4%) (9.1%)
1990123,26722,468 18% decline85,904 9% growth14,895 40% growth
(18.2%) 1980-1990 (69.7%) 1980-1990 (12.1%) 1980-1990
1995125,44020,01427% decline87,165 1980-199518,261 72% growth
(16%) 1980-1995 (69.5%) (14.6%) 1980-1995
1997126,16619,366 30% decline87,042 1980-199719,758 86% growth
(15.3%) 1980-1997 (69%) (15.7%) 1980-1997
Source: Table prepared by the Congressional Research Service (CRS) based on data from the
Statistics Bureau, Management and Coordination Agency, [www.stats.go.jp].
Japan’s public long-term care insurance system was implemented beginning in
April 2000. It will provide comprehensive in-home and institutional benefits for
persons aged 40 and over who need long-term care services. Its purpose is to provide
comprehensive and high-quality long-term care services, including in-home care and
institutional services. The goals of this new system are to:
!allow users to choose freely from diversified services;
!offer integrated welfare and medical services; and
!provide more efficient medical services for long-term care.
It is anticipated that services offered through the insurance system will rectify the
over use of expensive long-term stays in hospitals, or the practice referred to as
“social hospitalization.” “Social hospitalization” (or “social admissions”) refers to
hospitalizing those in need of long-term care due to the shortage of community care
and nursing homes. In Japan, almost 6% of the elderly population are institutionalized
(compared to about 5% in the United States). However, some analysts still point to
an insufficient number of nursing homes (as well as home care providers) for the tens
of thousands in need of care. Some Japanese reports find 47,000 people are currently
25 CIA, The World Factbook 1998.
on waiting lists for the 3,942 nursing homes in existence.26 Only those who are
bedridden or have senile dementia are accommodated because of the high demand.
One half of all bedridden persons are bedridden for 3 years or more. Two-thirds of
Japan’s institutionalized elderly are cared for in private hospitals, mostly owned by
doctors. Of the elderly in hospitals, one-third remain there for more than a year.
Eligibility. A “certification”or assessment process administered by the Long-
Term Care Certification Committee in each municipality will assess a person’s
eligibility based on his/her mental and physical condition. Standards for certification
will be objectively determined nationwide. Each municipal committee will determine
whether long-term care or support is required and certify a need for care based upon
a doctor’s opinions.27
Under this system, people age 65 and older will be the “primary insured.” This
group is expected to total 22 million in FY2000. The “secondary insured” will be
those between the ages of 40 and 64, expected to be almost twice the size of the 65+
group with 43 million people in FY2000. These two age groups are categorized as
“primary” and “secondary” because of differences in the method of assessment and
collection of premiums for each.
People between the ages of 40 and 64 may receive in-home and institutional care
based on age-related factors leading to early onset of senility, cerebrovascular
disorders, and other illnesses associated with aging. Those 65 and over who require
long-term care or support because they are bedridden, physically weak, or have
dementia may receive care under this system. Those who require support because of
physical weakness will be provided with in-home services to prevent the necessity of28
institutional care. The degree of family support available will not be a factor in
eligibility determinations. Those disabled under age 40 will be cared for under the
existing welfare system.
Services Provided. After determination of an individual’s needs, a care planning
organization will then allow the insured to select his/her preferred services from 12
types of at-home care programs, creating a service plan. The goal is to allow users
to choose the services they want.
With the new insurance system, frail persons in need of physical support may
receive approximately ¥60,000 (US $520) per month in home benefits while those
26 Personal communication from the Ministry of Health and Welfare, Bureau of Social
Welfare and Labor Division.
27 There is no indication that Japan uses the equivalent of limitations in activities of daily
living (ADLs) or instrumental activities of daily living (IADLs) in determining need for care.
ADLs refer to basic human functions, including bathing, eating, dressing, getting around
inside, toileting, and transferring from a bed to a chair. IADLs are tasks necessary for
independent community living including shopping, light housework, telephoning, money
management, and meal preparation. Those who are bedridden, with dementia, feeble, or
suffering from age-induced illnesses are eligible for care under the plan.
28 Ministry of Health and Welfare. Annual Report on Health and Welfare 1996-1997. p.
requiring more intensive care (for example, those who are bedridden or have
dementia) may receive an amount between two and a half to about six times that
amount per month depending on the level of care needed.29 Benefits for institutional
care will be fixed for each type of institution. The amount of financial support for
institutional benefits will be fixed depending on the level of care required.
In-home services include:
!Home-visit care (home help),
!Home-visit bathing services,
!Commuting assistance for rehabilitation,
!In-home medical care management guidance,
!Commuting assistance for care (day service),
!Short stays in facilities,
!Communal living facilities with care-takers (group homes),
!Long-term care at fee-charging homes for the elderly,
!Rental service for welfare equipment, and30
!Funds for home improvement.
Institutional care services include:
!Special nursing homes for the elderly,
!Health services facilities for the elderly, and
!Sanatorium-type wards, etc.
SMedical care wards for dementia, and
SMedical care wards with enhanced nursing staff31
Financing. The current health program for the elderly, under the 1982 law, is
financed through an insurance pool in which health plans, EHI and Kokuho, originally
contributed 70%, and national government and local governments contributed 30%.
In 1991, a reform raised, in part, the share of combined contributions made by the
national and local governments from 30% to 50% keeping a 70%/30% share in
principle. Although insurance premiums vary, generally employers and employees32
contribute equal shares of 8.5% of the employee’s salary for health insurance. In
FY1996, medical expenditures for the elderly totaled 34% of the total national
29 Ministry of Health and Welfare of Japan. Outline of Long-term Care Insurance in Japan.
Chapter 3 and personal communication from the Social Welfare and Labor Division of the
30 Ministry of Health and Welfare. Annual Report on Health and Welfare 1996-1997. p.
31 Ibid., p. 179.
32 Japan Pharmaceutical Manufacturers Association, National Health Insurance Systems.
Financial support for the long-term care insurance program will come from the
national government, prefectures,33 medical care insurers, and pension insurers.
Public subsidies will pay one half of the total benefit expenditures, with the national,
prefectural and municipal governments contributing 25%, 12.5%, and 12.5%,
respectively. To keep a balance between service users and non-users, and to raise
awareness of service costs, beneficiaries will pay a 10% coinsurance amount for long
term care services. Moreover, recipients will be responsible for their own meal costs
at long-term care facilities.
“Primary” insured users (age 65 and older) will pay fixed insurance premiums
based on income, as determined by each municipality. Premiums will be deducted
from pensions. The medical insurance systems of the “secondary” insured users (aged
A portion of these premiums for this group will be paid by employers. These
premiums will be collected together with the medical insurance premium by the34
In FY1995, total expenses for long-term care amounted to ¥2.2 trillion (US
$21.3 billion35). Most of these funds were spent on the elderly, while a small amount
(an estimated ¥0.1 trillion (US $968 million, or about 4.5%) was spent on long-term
care for people 40 to 64 years old. Projected FY2000 expenditures for long-term
care under the new insurance program for the elderly alone are expected to reach ¥4.3
trillion (US $41 billion), with an approximate monthly insurance premium of ¥263036
to 2910 (US $25-$28). One source projected expenses for 2010 at approximately
$53 billion. It is anticipated that premium amounts will increase in succeeding years
as total expenses increase.
Administration. Since 1990, municipalities have been responsible for the
administration and provision of the long-term care insurance system. Under the new
public long-term care system, they will continue to be involved. They will be
responsible for “certification” and assessment of individuals in need of long-term care,
collection of long-term care insurance premiums from the primary insured group, and
administration of benefits and services. The national government will be responsible
for provision of public subsidies and establishment of assessment standards.
33 Japan is divided into 47 prefectures, which are administered by governors and assemblies.
A prefecture is further subdivided into minor civil divisions, including the city, town, and
village, which have their own mayors, or chiefs, and assemblies. [www.eb.com]
34 Ministry of Health and Welfare. Annual Report on Health and Welfare 1996-1997. p.
35 FY1995 currency values are converted with December 31, 1995 rates.
36 Ihara, Kazuhito. Japan’s Policies on Long-Term Care for the Aged: The Gold Plan and
the Long-Term Care Insurance Program. International Longevity Center. New York, 2000.
!In 1998, 3.7 million people, 12.3% of the Canadian population, was
65 years of age or older. By the year 2041, the elderly will represent
!Canada provides universal, publically-financed health care insurance
coverage for all its citizens. The program, Medicare, enforced by the
Canada Health Act (CHA), is described as an interlocking set of 10
provincial and three territorial health insurance plans which provide
hospital, in-patient, and out-patient services, physician services, and
dental surgical services performed in a hospital.
!The Canada Health Act is focused on hospital and physician services
and as such, does not encourage the development of extended care
services in the provinces or territories. As part of the annual
reporting conditions under the Canada Health Act, provinces and
territories are only required to provide information on extended
health care services. They do report a range of institutional, home
and community-based options. The types and levels of services, as
well as access, vary widely. In addition to provincial funds, these
services may be financed by client fees and portions of a federal
!Generally, provision of long-term care in provinces relies on a case
management system where case managers assess an individual’s
functional disability and need for long-term care services, develop a
plan of care, monitor and review client needs, and adjust plans
accordingly. While physicians control access to hospital-based
rehabilitations or chronic care beds, they may not authorize eligibility
for long-term care benefits in nursing homes or for at-home care.
Health care in Canada was a private service until 1947 when a public insurance
plan for hospital services was introduced by the province of Saskatchewan. Nine
years later, the federal government offered to pay for roughly half of hospital and
diagnostic services in all provinces if acceptable hospital insurance programs were
developed in each. Public insurance plans were established by 1961 with all ten
provinces and the two territories providing universal coverage for at least in-patient
hospital care that qualified for federal cost-sharing. Comprehensive medical care
legislation with cost-sharing provisions was enacted by the federal government in
1968. By 1972, all provincial and territorial health insurance plans included
physicians’ services, establishing a more comprehensive health care insurance system.
The government’s vision was to provide health insurance for everyone regardless of
income, age, or residency.
Today, Canada provides universal, publically-financed health insurance coverage
for all its citizens. The program, Medicare, is described as an interlocking set of ten
provincial and territorial health insurance plans which provide hospital, in-patient, and
out-patient physician services. The Canada Health Act (CHA) of 1984 stipulates five
criteria that provincial health plans must meet in order to receive federal funds. These
!Public Administration: each health insurance plan must be
administered and operated on a non-profit basis by a public authority
responsible to the provincial government.
!Comprehensiveness: each health insurance plan must insure all
medically necessary services provided by hospitals and physicians,
and where permitted, by other health care practitioners.
!Universality: all insured persons (that is, eligible residents) are
entitled to insured health services on uniform terms and conditions;
!Portability: residents are entitled to coverage when they move to
another province or abroad.
!Accessibility: each health insurance plan must provide reasonable
access to insured hospital and physician services without barriers.
Charges, such as extra billing by physicians and user fees by
hospitals, to insured persons for health care services are not generally
These five criteria do not however apply to long-term care services in home and
In accordance with these criteria, each province and territory administers its own
health care plan. Although the federal government contributes to health care costs,
each province has primary funding responsibility. Under provisions of the Canada
Health and Social Transfer (CHST), implemented in 1996-97, the federal contribution
for health care services was wrapped into a block grant program with other social
program funds. The formula for distribution of funds to provinces varies according
to regional differences. Each province receives a per capita amount for health care
services based on the formula.
Demographic Trends. The elderly population of Canada has been growing
rapidly in number and percentage, with a current life expectancy at birth of 76 years
for men and 83 years for women. In 1971, 1.8 million people or 8% of the Canadian
population was 65 years of age or older. By 1998, the number of people aged 65
more than doubled to 3.7 million, or 12.3% of the total population. This is an
increase of almost 2 million people aged 65 and over from the 1971 total. This
represents a 112% growth over a span of 27 years. Table 5 below presents the rate
of growth from 1971 to 1998.
37 If it is determined that either “extra-billing” or user charges are being used by a province,
then the federal government makes a mandatory dollar-for-dollar deduction from the federal
cash contribution. A few provinces have charged minimal amounts in the past.
Table 5. Canadian Population aged 65 and over, 1971-1998
TotalAs % of Canadian
Source: Table prepared by the Congressional Research Service (CRS) based on data from Statistics
Current projections for the year 2011 estimate that Canada will have close to 5
million people aged 65 and over, representing 14.1% of the Canadian population.
The number of people 65 years of age or older is expected to total almost 10 million
by the year 2041. Many Canadian policymakers point to the growing elderly
population to highlight the importance of and need for comprehensive long-term care
services. They emphasize the need to change the way that health and social services
for the elderly are organized and delivered.
Table 6. Population Projections for Canada,
aged 65 and over, 2001-2041
TotalAs % of Canadian
Source: Table prepared by the Congressional Research Service (CRS) based on data from Statistics
Each province has an extended health care services (EHCS) benefit program,38
sometimes referred to as “continuing care.” Benefits provided include a range of
institutional and home and community-based services programs. The types and
amount of services and eligibility criteria for long-term care services vary widely by
province. Provinces receive federal funds for EHCS as part of the per capita amount
they receive for their health services plans. However, because the full range of long-
term care services are not insured services under the CHA, provinces are responsible
for financing some part of the long-term care services they provide.
To understand long-term care in Canada, it is necessary to look at the activities
of individual provinces. The provinces, not the federal government, are responsible
for the organization of long-term care services. Currently the provinces receive block
grant funding for health, social and post-secondary education programs under the
CHST and can use any portion of this block fund for long-term care. Up to 1996
when the CHST replaced the Established Programs Financing (EPF) and the Canada
Assistance Plan (CAP), the provinces received a separate small per capita amount for
extended health care services. Because many of the services offered as continuing or
long-term care are not insured services under the Canada Health Act (CHA), the five
criteria and other conditions such as user fee prohibitions do not apply. Thus
individuals who receive care outside of a hospital in their communities or homes may
be required to pay the full or partial cost of certain services.
Canada faces the challenge of providing appropriate and affordable long-term
care services for its aging population. In planning for the future, policymakers have
favored home and community based services over institutional care. Many programs
and agencies, recognizing the need for improvement, have initiated changes in care
models and services for seniors, contributing to a widespread move towards better
and more integrated methods of service delivery for the elderly requiring a broader39
range of services. A recent Canadian study has found a number of common goals
that have been adopted or are in the process of implementation by agencies and
programs to better serve community needs. These goals include improved client
choice of and access to services, better coordination of services, and increased
education of long-term care services staff.
The same study pointed out that Canada needs to address a number of issues in
program development and delivery of long-term care. These include a lack of public
understanding of the need for “continuing care” for older persons that addresses both
health and social needs over a long period of time. Other challenges include a lack
38 Extended health care services are defined in the Canada Health Act as nursing home
intermediate care, adult residential care, home care, and ambulatory health care. These
services are part of a broader range of health and social services to residents of a province.
Canada Health Act Annual Report, 1997-98. See: [http://www.hc-sc.ca/medicare].
39 Innovations in Best-Practice Models of Continuing Care for Seniors. Report prepared on
behalf of the Federal/Provincial/Territorial Committee (Seniors) for the Ministers Responsible
for Seniors, March 1999. p. 2.
of resources, high public expectations for quality services, and geographic dispersion
Eligibility. Eligibility for long-term care services varies widely by province.
However, eligibility for services is frequently determined through a “single entry
system” that is a single central source in local communities for individuals to obtain
comprehensive information and access to the “continuing care” system available in the
community.41 Through this system, case mangers screen and assess people in need
of long-term care services, determine the level of care that is needed, establish an
initial individual care plan with a specified amount and type of services to be
delivered, regularly monitor and review client needs, and adjust plans accordingly.
Need is determined by an individual’s functional disabilities.
Case managers are professional coordinators who determine the need for care
and function independently of the delivery of medical care. Most case managers are
public employees. Case managers work mainly in community care centers, hospitals,
housing units (through community support agencies, insurance companies, and
different care programs), and in independent practices, with growing occurrences of42
the latter sector. Physicians control access to hospital-based rehabilitation or
chronic care beds, but cannot authorize eligibility for long-term care benefits in
nursing homes or for at-home care.
Services Provided. Long-term care services range from various types of
institutional care, including nursing homes, adult care homes, and a range of home and
community-based services. Provincial home care programs may include the
following services, among others:
!assessment and case management,
!nursing and health care treatment services,
!personal care and homemaker services,
!minor home repair and maintenance,
!social assistance services, social contact, and security services (i.e.,
friendly visiting and telephone reassurance), and
!drugs and medical supplies.43
Though service delivery mechanisms vary among provinces and territories, nursing,
personal care, and homemaking services are available in all provinces and territories.
In 1997-1998, 3% of the population, or 1 million Canadians received home care
services.44 In addition, many provinces include adult day care as part of their long-
term care system.
40 Ibid., p. 56.
41 Hollander, M. J., and E. R. Walker. Report of Continuing Care Organization and
42 As reported by the Ontario Case Managers’ Association to Ms. Sonia Ménard, Reference
Librarian, Library of Parliament (Canada).
43 Health Canada, Home Care: Definition and Methodology.
44 Provincial and Territorial Home Care Programs: A Synthesis for Canada. p. 33.
Family and friends continue to serve as caregivers though it is becoming
increasingly difficult. The most common family provider of care is the woman, either
the wife, daughter, or daughter-in-law. Women providing care experience low pay-
rates when providing formal, professional service, or compromise their own job
promotions or forego earning opportunities when providing informal family service.
A few corporations provide leave to care for the elderly, and professional, formal
caregivers have begun to unionize to achieve better pay and regular employment.45
Studies have indicated that the elderly who cannot be maintained safely and
economically at home by paid services, and have minimal family caregiving services,
generally enter long term care institutional facilities at greater cost than home care.46
Financing. Canadian health care expenditures are primarily publicly financed.
About 70% of total health expenditures is funded through the public sector, from tax
revenues. The remaining 30% is privately financed through supplementary insurance,47
employer-sponsored benefits or directly out-of-pocket by the consumer.
Under the Canada Assistance Plan (CAP) of 1966, the provinces and the federal
government shared much of the cost of long-term care for the chronically ill, disabled,
and frail. CAP funding was provided by the federal government in the form of a
transfer payment to the provinces, and was conditional on administration of needs
tests, absence of residency requirements, and establishment of an appeal system. CAP
provided open-ended social assistance and social services to needy Canadians through
In fiscal year 1996-1997, a new single block transfer, the Canada Health and
Social Transfer (CHST), was created by the federal government. This consolidated
the government’s contribution to provincial health and social programs, replacing
CAP and EPF with its provisions for extended health care services. Through the
CHST system of block funding, the federal government transfers are provided through
cash payments and tax points with movement to a per capita amount calculated for
each province. However, the federal CHST addresses health, social and post-
secondary education and while any portion of the block transfer may be used for long-
term care, the provinces are the primary financers of long-term services.
Recently, the federal government has attempted to provide assistance to home
care consumers through tax credits and deductions. Some of these tax credits48
!Disability Tax Credit – a federal and provincial income tax reduction
of up to $1,020 for taxpayers with a serious physical or mental
45 Shapiro, E. Community and Long-Term Health Care in Canada. p. 347. Blomquist, T.
and D. M. Brown, eds. Limits to Care: Reforming Canada’s Health System in an Age of
46 Ibid., p. 355.
47 Health Canada, Canada’s Health System: Health Spending.
48 In Canadian dollars.
!Caregiver Tax Credit – a maximum savings of $400 in federal taxes
for those providing care at home for an elderly parent or a disabled
child over age 18.
Federal government contributions and support for home care services are also
provided through direct programs, such as Veterans Affairs Canada and Department
of Indian and Northern Affairs Canada, targeting specific clients. Co-payments for
services are made by consumers, and vary by province.
Administration. The Canadian constitution grants the provinces jurisdiction
over health and social policy. The CHA requires that each province comply with the
five fundamental principles and the extra-billing and user fee requirements mentioned
above, but does not establish further guidelines. Consequently, each province has the
freedom of designing and providing its own system of care, and administering its own
plan. As a result, long-term care in Canada has evolved into complex, but not
uniform, systems across and within provinces.
Community, home-based, and institutional long-term care programs are
administered by the public, private, and voluntary sectors. Home care programs are
usually administered by the health and social service departments of each province or
territory, or by the community health board. Estimates for 1994 indicated that
publicly funded home care programs provided 90% of all home care services. Private
services cater to those not eligible under the public system and those wishing to
augment the public services they receive.49
!In 1998, almost 9.3 million people, 15.7% of the population, was 65
years of age or older. By the year 2040, the elderly will represent
!Prior to 1990, the National Health Service (NHS), the United
Kingdom’s (U.K.) national health insurance program, financed long-
term care services, primarily residential services, without charge to
long-term care recipients. Long-term care services were substantially
changed in 1990 by the Health Service and Community Care Act,
enacted partially in response to growing costs of institutional care
services and to create financial incentives for home and community-
!In December of 1997, a Royal Commission on Long-Term Care was
appointed by the Secretary of State for Health. The Royal
Commission was responsible for examining options for funding long-
term care for the elderly and recommended a number of policy
changes regarding the financing and delivery of long-term care.
49 Canadian Home Care Association. Portrait of Canada: An Overview of Public Home Care
These included recommendations for more public support for home
and community-based services and for families and others who
provide unpaid, informal care. It also recommended a major
restructuring of financial eligibility criteria for personal care services
at home and in institutions, and more consistency in service financing
and delivery provided by local governmental authorities. Major
decisions regarding the Commission’s recommendations will take
place in summer 2000, but some action by the U.K. government is
The expectation of family care in the United Kingdom dates back to the
Elizabethan Poor Law of 1601 in which adult children were assumed responsible for
the relief of elderly parents. Over three centuries later, in 1946, the National Health
Service (NHS) Act established a system of publically financed health care, including
hospital and specialist services, general medical and pharmaceutical services, and local
health services. From this arose a comprehensive service established in 1948 by the50
NHS, providing universal coverage and free medical care.
Various changes to the NHS were adopted in the 1970s to respond to increasing
public demands and expectations about health service, advances in medical
technology, and issues regarding planning and coordination of services. Despite these
reforms, by the 1980s, the NHS was being criticized as being inefficient and non-
responsive to the needs of patients. As a result, the National Health Service and
Community Care Act of 1990 was enacted to increase local authority, decentralize
administration over health care, and encourage competition among health care
providers.51 Some provisions of the Act affected long-term care services.
The goals of the Act’s long-term care reforms were to: (1) control growth in52
public spending for residential (institutional) long-term care; (2) consolidate
responsibility for providing and funding services at the local level of government; (3)
allow older persons with disabilities to remain in their own homes to the maximum
extent practicable; and (4) increase consumer choice by creating a market of private53
providers. Prior to the 1990 law, financial incentives were oriented toward support
of residential care which was a means-tested, open-ended entitlement funded through
the NHS. In many cases, the costs for residential and nursing homes for individuals
50 U.S. Library of Congress. Congressional Law Library. Health Care under International
Law and the Laws of Selected Foreign Nations: Great Britain. p. 85. (Hereafter cited as
U.S. Library of Congress, Health Care under International Law.)
51 Ibid., p. 85.
52 Residential care is care in institutions, but excludes nursing care. It is distinguished from
nursing home care where nursing and personal care services are provided.
53 Wiener, Joshua M. and Alison Evans Cuellar. Moving Responsibility for Long-Term Care
to Local Governments: the Experience in the U.K. Generations, v. XXIII, no. 2, summer
were fully covered by the NHS. Home and community-based care was funded at the
discretion of local authorities to the extent funds were available.
Under the 1990 law, automatic entitlement to residential long-term care ceased
under the NHS, and funds were transferred to local authorities to be used for long-
term care services. Payment of costs then changed from a open-ended entitlement
system to one where total costs were capped. These funds, similar to a block grant,54
could be used for home and community-based care or residential care. These and
other associated changes went into effect in April 1993.
In addition to the aim of changing the bias toward institutional care in favor of
more home and community-based care, the 1990 law was designed to consolidate the
administration of long-term care services at the local level by making local social
service departments responsible for “care management” of persons needing care.
Thus, social service departments could tailor long-term care services to meet client55
needs and preferences, as well as improve coordination of services for clients.
Demographic Trends. The number of people aged 65 years or over increased
from 7.3 million people (13.2% of the total UK population) in 1971, to 9.3 million
(15.7% of the total) in 1998, a 27% growth. Table 7 below includes the percentage
growth from 1971 to 1998.
Table 7. UK Population aged 65 and over, 1971-1998
Year (in thousands)As % of United Kingdom population
Source: Table prepared by Congressional Research Service (CRS) based on data from the U.S.
Bureau of the Census, International Data Base.
It is believed, however, that the UK population will stop growing after the year
2030, with an estimated total population of 59.4 million people, and will actually
decline in the future. The projection for 2040 is 57.3 million. However, the
54 Ibid., and Barbara Coleman. European Models of Long-Term Care in the Home and
Community. American Association of Retired Persons. Public Policy Institute. September
55 Filinson, Rachel. Legislating Community Care: The British Experience, with U.S.
Comparisons. The Gerontologist, v. 37, no. 3. p. 333.
percentage of people aged 65 years and over is expected to increase from 23.5% in
2030 to 26.6% by 2040. The UK therefore faces a challenge in providing for an aging
population with a smaller labor force in the future. This projected population
composition will result from low fertility rates, presently at 1.7 children born per
woman, coupled with growing rates of life expectancy at birth. In 1998, the life
expectancy averaged 75 years for males and 80 years for females. This has been an
increase since 1984, when life expectancy at birth was 72 and 74 years, respectively.
Table 8. Population Projections for the United Kingdom,
aged 65 and over, 2000-2040
TotalAs % of United Kingdom
Year (in thousands)population
Source: Table prepared by the Congressional Research Service (CRS) based on data from the U.S.
Bureau of the Census, International Data Base.
Recognition of the demographic trends and dissatisfaction voiced by many U.K.
policymakers with the current long-term care system led to a recent major policy
review. In 1997, the Royal Commission on Long-Term Care was appointed by the
Secretary of State for Health to analyze the current system and to make
recommendations for improvement. The Commission was to examine options “for a
sustainable system of funding of Long-Term Care for the elderly, both in their own
homes and in other settings.” The Royal Commission presented its findings and
recommendations in a report to Parliament in March of 1999 (With Respect to Old
Age, A Report by the Royal Commission on Long Term Care).
While the 1990 Act was designed to improve the system of care, the Royal
Commission concluded that the “current system is failing.” Reasons for this included
insufficient home care and assistance to caregivers, lack of progress in correcting the
institutional care bias, poor quality of institutional care, and lack of a client-based
focus, among other things. Among the Commission’s conclusions were the following:
!“Long-term care is a risk that is best covered by some kind of risk
pooling–to rely on income or savings, as most people effectively have
to do now, is not efficient or fair due to the nature of the risk and the
size of the sums required;
!Private insurance will not deliver what is required at an acceptable
cost, nor does the industry want to provide that degree of coverage;
!The most efficient way of pooling risk ... across all generations, is
through services underwritten by general taxation, based on need
rather than wealth [with some cost sharing];
!... more care (should be given) to people in their own homes.
Therefore the role of housing will be increasingly important in the
provision of long-term care.
!More services should be offered to people who have an informal carer56
The following presents information on the current long-term care system in the
United Kingdom. It also presents selected findings and/or recommendations made by
the Royal Commission to improve or change the current system.
Eligibility. “Local (governmental) authorities” in the United Kingdom, through
social service departments, are required to assess an individual’s need for long-term
care and develop a plan to meet needs. Public services may be received once care
managers in local authorities have determined that an individual needs services.
For residential and nursing home care, income and assets, based on a national
standard, are assessed to determine the extent of contributions individuals must make
toward the cost of care. This contribution schedule is called a “means test.” Presently,
people with assets above £16,000 (US $25,900)57 do not receive financial assistance
and must pay the full cost of residential or nursing homes. Persons with assets of less
than £16,000 must contribute toward the costs of care. For home care services, local
authorities have discretion as to the application of financial eligibility standards. Some
authorities charge a small flat rate, some charge full costs, and some apply a variety of58
The Royal Commission stated that the present system “leads to the
impoverishment of people with moderate assets before they get any help.”59 Its report
recommended a radical restructuring of the means testing system, so that personal care
services, that is, tasks involved with assistance with daily living, be exempt from means
testing. The Commission analysis was based on the following rationale. Persons
needing long-term care incur three types of costs: living costs (food, clothing, etc.),
housing costs (rent, mortgage), and personal care costs. According to the
Commission, personal care costs reflect the true risk, or “catastrophic costs”of long-
term care. Therefore, public funding should finance all of these costs, with no charges
levied on individuals. Instead, means testing limits and contribution schedules would
be applied to the income a person uses to finance living and housing costs. The
56 A Report by the Royal Commission on Long Term Care. With Respect to Old Age: Long
Term Care–Rights and Responsibilities. Presented to Parliament by Command of Her
Majesty. March 1999. p. xviii-xix. See also, Roll, Jo. Social Policy Section. House of
Commons. Royal Commission on Long-Term Care, February 17, 2000.
57 This includes the value of one’s home. In their report, the Royal Commission recommends
disregarding the value of the home when determining an individual’s contribution.
58 Royal Commission, p. 34.
59 Royal Commission on Long-Term Care, p. xviii.
exemption of means testing for personal care services would apply to personal care
provided in both residential and nursing homes as well as to care provided at home.
Services Provided. The public, private, and voluntary sectors provide care in a
range of settings including care at home, day care, sheltered housing, and residential
care. The NHS provides continuing care in nursing homes, hospices and hospitals, and
community nurse services. In 1999, there were about 600,000 people aged 65 and
older in the UK receiving home care services, and close to 500,000 receiving60
Unpaid care provided by family and friends provides substantial long-term care
support. The Royal Commission estimated that 5.7 million people, about 10% of the
total population, provide some form of informal care. Of these, about 800,000 people
provide unpaid care for 50 hours a week or more. In 1995, 60% of all caregivers were
women and 48% of all caregivers were between 45 and 64 years of age. Twenty
percent were over 65 years old and 32% were between the ages of 16 and 24. Forty-
three percent of the individuals receiving informal care were the parent or parent-in-
law of the caregiver. Unlike the recent trends in Japan, the Royal Commission found
no evidence in the UK of women being less willing or available to provide unpaid
The Royal Commission found that, despite attempts to lessen the bias toward
institutional care in favor of home care envisioned by the 1990 Health and Community
Care Act, more effort is needed. The Commission indicated that its proposals to
provide personal care services, free of charge, would lead to expansion of home care
services. It also recommended that more support be given to families and others who
provide unpaid, informal care, and proposed that a national caregiver support program
Financing. The current system of care is financed on a pay-as-you-go basis, with
current taxation paying for the benefits delivered at the present time. In addition,
persons receiving long-term care contribute toward costs of their care. Table 10
shows public and private expenditures for long-term care in 1995. Total long-term
care expenditures were estimated to be £11.1 billion (US $17.7 billion), with 64% from
public sources, and 36% from recipients.
Only about one quarter of total funds was for home and community-based care,
with the remainder for care in institutions. Of the amount spent on institutional care,
about half was paid by fees from residents, and half from public sources. Expenditures
for long-term care are expected to rise to £14.7 billion (US $23.8 billion) in 2010 and
£19.9 billion (US $32.2 billion) in 2021.
60 Royal Commission on Long Term Care, p. 8.
61 Ibid., p. 15-16.
Table 10. Expenditures on Long-Term
Care Services, 1995
Total: £11.1 billion (US $ 17.7 billion)
Paid by the state (via NHS and Social
services)£7.1 billion (US $11.3 billion)
Paid by older persons£4 billion (US $6.4 billion)
Total: £11.1 billion (US $ 17.7 billion)
Spent on home and community-based care£2.7 billion (US$ 4.3 billion)
Spent on nursing homes, and residential care,62
and long-stay hospitals£8.3 billion (US $ 13.3 billion)
Source: Table prepared by the Congressional Research Service (CRS) based on data from the Royal
Commission on Long-Term Care, p. 10.
Current expenditures on long-term care in people’s homes and in residential
settings amount to 2.2% of taxes from pensions, investments, and earnings. However,
tax credits have also been introduced for caregivers so that wives providing care may
The Royal Commission recommended continuation of the current pay-as-you- go
model to finance long-term care. While the Commission considered other methods,
it recommended no major changes in taxation. As discussed above, the Commission
did recommend changes so that individuals would be required to contribute toward the
cost of their care.
Administration. Local authorities are responsible for administration and
management of funds on behalf of persons in need of long-term care services. This
was a result of legislative changes in the 1980s and by the 1990 Act to decentralize
administration of health and social services. After consultation with Local Authority
Associations, the central government allocates funds to local authorities based on a
formula. Local governments are responsible for assessment of individuals and for
administration of most institutional and home and community-based care services.
The Royal Commission found that there is inconsistency among local authorities
in their application of means testing and determination of an individual’s long-term care
needs. While it supported local autonomy in administration, it also recommended that
the financing and delivery system be revised so that individuals can have clear
expectations of what services they may expect from the public sector, and that there
be more consistency across jurisdictions regarding services provided and eligibility
62 Residential care, as defined by the Royal Commission, does not include nursing care.
Evashwick, Connie J. The Continuum of Long-Term Care. Albany: Delmar Publishers,
Hoskins, Irene. Combining Work and Elder Care. Geneva: International Labor Office,
Kalisch, David W., Tetsuya Aman, and Libbie A. Buchele. “Social and Health Policies
in OECD Countries: A Survey of Current Programmes and Recent
Developments.” Organization for Economic Co-operation and Development,
U.S. Library of Congress. Law Library. Report for Congress: Health Care Under
International Law and the Laws of Selected Foreign Nations. Washington D.C.,
Scharf, Thomas and G. Clare Wenger. International Perspectives on Community Care
For Older People. Brookfield, VT: Avebury, 1995.
Schwab, Teresa. Caring For An Aging World. New York: McGraw-Hill, 1989.
Stopp, G. Harry. International Perspectives for the Elderly. New York: Peter Lang
The World Factbook 1998. CIA.
Answers from the Federal Ministry for Labour and Social Affairs to Questions
submitted by the Royal Commission on Long Term Care for the Elderly during
their visit to Germany on June 17, 18 1998. Bundesministerium für Arbeit und
Claudia Nolte, MdB. CRS meeting. July 8, 1999.
CRS Report No. 92-543, The German Health Care System, by Celinda Franco. 1992.
CRS Report No. 93-609, Health Care Fact Sheet: Recent Reforms of the German
Health Care System, by Celinda Franco. 1993.
Federal Ministry of Labour and Social Affairs. Social Security at a Glance. Bonn:
Federal Ministry of Labour and Social Affairs, 1999.
Health. Federal Statistical Office Germany. June 24, 1999.
Long-Term Care Insurance. Federal Ministry of Labour and Social Affairs.
July 12, 1999. [http://www.bma.bund.de]
Population. Federal Statistical Office Germany. June 24, 1999.
Population by Age Groups, Marital Status and Religious Affiliation. Federal
Statistical Office Germany. June 24, 1999.
Annual Report on Health and Welfare 1996-1997. Ministry of Health and Welfare.
Tokyo: Japan International Corporation, 1998.
Ikegami, Naoki. Growing Old in Japan. Age and Ageing, v. 27, 1998. p. 277-278.
Japan: Age Stratification and the Elderly. Library of Congress. July 15, 1999.
Japan: Age Structure. Library of Congress. July 15, 1999.
National Health Insurance Systems. Japan Pharmaceutical Manufacturers Association.
July 15, 1999.
National Medical Expenditure. Japan Pharmaceutical Manufacturers Association. July
Office for Long-term Care Insurance. Health and Welfare Bureau for the Elderly.
Ministry of Health and Welfare of Japan. Outline of Long-term Care Insurance
in Japan, Chapter 3. 1998.
Oshima, Sumiko. Japan: Feeling the Strains of an Aging Population. SCIENCE, v.
Statistics Bureau. Management and Coordination Agency. Population by Age Group
and Dependency Ratio. June 24, 1999. [http://www.stat.go.jp/1602.htm]
Structural Reform of the Social Security Programs for an Aged Society With Fewer
Children: 1990-present. Ministry of Health and Welfare. July 15, 1999.
Aronson, Jane, and Sheila M. Neysmith. The Retreat of the State and Long-Term Care
Provision: Implications for Frail Elderly People, Unpaid Family Carers and Paid
Home Care Workers. Studies in Political Economy, v. 53, summer 1997. p. 37-
Canada Assistance Plan. 1989 Report of the Auditor General of Canada: Department
of National Health and Welfare. August 18, 1999.
Canada Health Act Annual Report 1997-1998. Health Canada.
Canada’s Health System. Health Canada: Health System and Policy Division. June
Canada’s Seniors...At a Glance. Health Canada. June 28, 1999.
CAP. Carleton University. August 18, 1999.
CHST. Carleton University. August 18, 1999.
Community-Based Services in Health Care: The Advantages. February 7-9, 1995.
National Advisory Council on Aging. June 28, 1999.
Daw, James. Medical Tax Credit, Estate Plans Boosted. The Toronto Star. February
Deber, R. et al. Summary of The Public/Private Mix in Health Care. National Forum
on Health. July 30, 1999.
Federal-Provincial Transfers. Finance Canada. August 18, 1999.
Fletcher, Susan. Cost and Financing of Long-Term Care in Canada. Department of
National Health and Welfare.
Greb, Janet, Larry W. Chambers, Amiram Gafni, Ron Goeree, and Roberta Labelle.
Interprovincial Comparisons of Public and Private Sector Long-Term Care
Facilities for the Elderly in Canada. Canadian Public Policy. p. 278-296.
Health Expenditures by Type. Statistics Canada. July 19, 1999.
Hollander, Marcus J. Assessing the Impacts on Health Reforms on Seniors.
December 1997. Canadian Policy Research Networks. June 28, 1999.
Hollander, Marcus J. and Elizabeth R. Walker. Report of Continuing Care
Organization and Terminology. December 1998. June 28, 1999.
Innovations in Best-Practice Models of Continuing Care for Seniors. March 1999.
Health Canada. June 28, 1999.
National Framework on Aging. Health Canada. June 28, 1999.
Nymark, Alan. A Federal Perspective on Health Care Reform-Pulse ‘98, Toronto,
Ontario, May 11, 1998: Speaking Notes. Health Canada. August 18, 1999.
Overview of the National Evaluation of the Cost-Effectiveness of Home Care.
February 1999. Centre on Aging, University of Victoria. June 28, 1999.
Population By Sex and Age. Statistics Canada. June 24, 1999.
Population Projections for 1996,2001,2006,2011, and 2016. Statistics Canada.
July 19, 1999.
Portrait of Canada: An Overview of Public Home Care Programs. Canadian Home
Care Association, 1998.
Principles of the National Framework on Aging: a Policy Guide. Health Canada.
August 18, 1999.
Provincial and Territorial Home Care Programs: A Synthesis for Canada - May
The Public and Private Financing of Canada’s Health System. National Forum on
Health. August 18, 1999.
Public Home Care Expenditures in Canada, 1975-1976 to 1997-1998. Health
Canada: Health System and Policy Division: Home Care. June 28, 1999.
Shapiro, Evelyn. Community and Long-Term Health Care in Canada. Limits to Care.
p. 327-362. C.D. Howe Institute.
Social Security. Finance Canada Glossary of Frequently-Used Terms. August 18,
What’s New For 1998. Intuit Canada Limited-QuickTax Tax News. August 18, 1999.
About The Department of Social Security. The Department of Social Security.
August 12, 1999. [http://www.dss.gov.uk/about.htm]
Alan Davey. CRS meeting. July 28, 1999.
Building a Better Britain for Older People: Care and Carers. Department of Social
Security. July 6, 1999. [http://www.dss.gov.uk/hq/pubs/older/care.htm]
Building a Better Britain for Older People: Consultation. Department of Social
Security. July 6, 1999. [http://www.dss.gov.uk/hq/pubs/older/consult.htm]
Building a Better Britain for Older People: Income. Department of Social Security.
July 6, 1999. [http://www.dss.gov.uk/hq/pubs/older/income.htm]
Building a Better Britain for Older People: Conclusion. Department of Social
Security. July 6, 1999. [http://www.dss.gov.uk/hq/pubs/older/conclude.htm]
DSS Benefits List: Residential Care, Nursing Homes, Community Care. The
Department of Social Security. August 12, 1999.
Filinson, Rachel. Legislating Community Care: The British Experience, With U.S.
Comparisons. The Gerontologist, v. 37, no. 3, 1997.
Government Acts Decisively to Protect Vulnerable People in Supported Housing.
Department of Social Security Press Releases. July 6, 1999.
Modernizing Social Services: Services for Adults. The Stationery Office. Secretary
of State for Health. July 1, 1999.
New Deal for People with a Disability or Long-term Illness: A Programme for Action.
Department of Social Security. July 6, 1999.
The Royal Commission on Long Term Care. With Respect to Old Age. London: The
Stationery Office Limited, 1999.
Social Security Departmental Report: The Government’s Expenditure Plans
Supporting People: A New Policy and Funding Framework for Support Services.
Department of Social Security. July 6, 1999.
The UK in Figures: Health. Government Statistical Service. August 3, 1999.