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Table 5 The Challenge of public LTCI

From: Review of evolution of the public long-term care insurance (LTCI) system in different countries: influence and challenge

Rank

Author

Journal

Country

Method

Objective / feature

Key findings

1. challenges from the sustainability of LTCI financing

 1

Schut&van den Berg (2010) [23]

SOCIAL POLICY & ADMINISTRATION

Netherlands

Qualitative research

This paper examined the past experiences, current deficiencies and future prospects of LTC financing in the Netherlands.

The success of the LTCI reforms heavily depends on the definition of entitlements, the accuracy of needs assessment and the feasibility of determining appropriate client-based budgets..

 2

Rothgang (2010) [24]

SOCIAL POLICY & ADMINISTRATION

Germany

Qualitative research

This paper discusses what should be the focus of the second reform of German public LTCI system.

the focus of the second reform of German public LTCI system should concentrated on quality improvements, care management and careful adjustments of benefits. Financing issues are of particular concern such as increasing in the contribution rate.

 3

Nadash et al. (2018) [57]

GERONTOLOGIST

Germany

Qualitative research

The study reviews legislative and programmatic changes of LTCI, using program data, as well as legislative documents and program reports.

1.The program is widely accepted among citizens and has achieved many of its original goals: ensuring access to long term services and supports and reducing reliance on the locally-funded safety-net social assistance program, which can be used to cover nursing home costs. 2.Recent reforms has addressed financing issues by increasing premiums, introducing subsidies for the purchase of private insurance, and creating a “demographic reserve fund.” 3.the program provides evidence for the financial viability of a social insurance model, although longer-term challenges may yet arise..

 4

Tamiya et al. C (2011) [28]

LANCET

Japan

Qualitative research

Lessons from Japan’s long-term care insurance policy

There has been an increase in families’ access to formal care at lower cost, but results for the well-being of caregivers have been mixed. The system’s successful challenges include dissatisfaction with home care, the provision of necessary support to home caregivers, and financial sustainability.

 5

Kato(2018) [59]

JAPAN AND THE WORLD ECONOMY

Japan

Quantitative research

This paper explores the impact of population aging on the Japanese public long-term care insurance (LTCI) within a numerical dynamic general equilibrium model with multiple overlapping generations.

In order to reduce future burdens in the LTCI, an increase in co-payments is most preferable, rather than an earlier starting age of contribution in the longer duration with lower annual burdens, or a shift of the cost to the public sector with a very high consumption tax.

 6

Wang et al. (2018) [55]

INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH

China

Quantitative research

This study collected data from a household survey conducted in Qinghai and Zhejiang on a sample of 1842 households, and explored the determinants of demand for LTCI.

Price, age, education status, and income were significantly associated with demand for LTCI. Most pilot cities were found to mainly rely on Urban Employees Basic Medical Insurance funds as the financing source for LTCI. financing is one of the greatest challenges in the development of China’s LTCI.

 7

Zhang et al. (2020) [68]

SUSTAINABILITY

China

Quantitative research

Based on the International Labor Organization (ILO) financing model from the perspective of fund balance, an overall simulation model and a Monte Carlo simulation are used to estimate the contribution rate of LTCI for disabled elderly from 2020 to 2050 in China.

1.The total financial demands will increase sharply from 538.0 billion yuan in 2020 to 8530.8 billion yuan in 2050. Of that total, 80.2% will be required in urban areas.

2. the per capita financial demands of care in urban and rural areas in 2050 will be approximately six times and 11 times higher than in 2020, respectively.

3.the overall contribution rate of LTCI in China will increase sharply from 1.46% in 2020 to 5.14% in 2050, an increase of about 3.5 times. By comparison, the contribution rate in 2020 will be close to 1.33% in Japan in 2015 and 1.40% in Germany in 2010.

2. challenges from design flaw of LTCI system

 8

Ariizumi, (2008) [15]

JOURNAL OF HEALTH ECONOMICS

USA

Quantitative research

This paper investigate the effects of two common eligibility criteria of LTC programs: means-tested and health-based programs.

1.Publicly provided health-based LTC crowds out the medical spending among low health individuals. 2.Means-tested programs lead to higher initial spending on medical care and consumption goods among middle-wealth individuals.

 9

Zhu& Osterle (2019) [63]

INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT

China

Qualitative research

This paper estimates the prevalence of LTC needs and analyzes the impact of the LTCI pilots on access.

Future policy experimentation on LTCI reform in China needs to address the following pressing policy issues: expanding the coverage of LTCI; narrowing rural-urban disparities in access; improving access for vulnerable subpopulations; and reducing the heavy reliance on institutional care.

 10

Kang et al. (2012) [29]

JOURNAL OF KOREAN MEDICAL SCIENCE

Korea

Qualitative research

This paper discussed LTCI’s eligibility qualifications and the certification process based on functional disability, benefits and coverage of community-based and institutional care in Korea.

The lack of coordination between the health and long-term care sectors, limited consideration of physicians’ assessments in the certification process, inadequate provision of health services in long-term care facilities, and overlapping and inefficient use of care resources act as barriers to providing comprehensive healthcare for older beneficiaries.

 11

Chon (2013) [35]

JOURNAL OF SOCIAL SERVICE RESEARCH

Korea

Qualitative research

This study aims to understand how National Health Insurance Corporation (NHIC) staff and home-visiting service providers experienced and evaluated the new service delivery system.

Korea’s new LTCI service delivery system faces challenges and that a more active role for the Korean government, especially regarding the introduction of a proper care management system, is needed to address the issues.

 12

Chon (2014) [42]

SOCIAL POLICY & ADMINISTRATION

Korea

Qualitative research

This study examined how the Korean welfare state has coped with the increasing LTC needs of older people caused by introducing and implementing a new LTCI system and reforming it.

LTCI was designed to meet limited objectives, such as providing minimal coverage and affording private for-profit market forces a predominant role in the provision of LTCI services.

3. challenges from traditional social concepts or family relationships

 13

Costa-Font (2010) [26]

OXFORD REVIEW OF ECONOMIC POLICY

Europe

Quantitative research

The empirical analysis of the paper exploits cross-country and sub-group variability of a representative database of European Union member states, containing records on LTC coverage and family structure.

A negative association between family ties and expected coverage of LTC for different sub-samples. Policy implications suggest that widespread expansion of LTC coverage might need to accommodate existing familistic cultural norms to avoid insurance crowding out.

 14

Chon (2012) [33]

ASIA PACIFIC JOURNAL OF SOCIAL WORK AND DEVELOPMENT

Korea

Qualitative research

This paper presents an overview of the key issues that were involved in designing and implementing the new Korean system and the lessons that have been learned.

Although the government reformed the long-term care system, a number of new challenges have emerged, such as its limited coverage and the unethical behavior of service providers.

 15

Kim&Choi (2013) [36]

AGEING & SOCIETY

Korea

Qualitative research

This paper aims to analyse the nature of LTCI in South Korea and to examine whether its introduction(2008) could mean a divergence from thepath of both developmentalism and Confucianism.

The regulatory role of the government and concerns about the costs of LTCI are regarded as a developmentalist legacy, whereas Confucian legacies seem to be withering away since LTCI shifts care responsibility from the family to the state. However, the study found that the state has difficulty in regulating the market and costs, and deeply embedded familialism seems difficult to overcome.

 16

Ha et al. (2017) [51]

JOURNAL OF SOCIAL SERVICE RESEARCH

Korea

Quantitative research

This study examined whether the awareness of public long-term care insurance (LTCI) was related to South Koreans’ financial, psychosocial, and physical preparations for later life.

1. being aware of public LTCI increased preparation for later life in financial, psychosocial, and physical domains. 2.participants in the negative status group had higher scores for psychosocial and physical preparation than individuals who perceived themselves as being in relatively better situations. 3.the policy makers and practitioners should include education on LTCI and the risks it targets across various preparation domains as well as account for differences in perception and preparation among sub-populations of middle-aged adults in order to ensure effective social policies for the elderly population.

 17

Ayalon (2018) [58]

HEALTH & SOCIAL CARE IN THE COMMUNITY

Israel

Qualitative research

The present study aimed to evaluate the perspectives of older adults, their family members and home care workers regarding the LTCI.

How even though the NII workers are engaged with various stakeholders, they often lack direct contact with older adults, their family members and paid home care workers: those most directly influenced by the LTCI.

4. challenge of balancing fairness and efficiency

 18

Bakx&Schut& van Doorslaer (2015) [47]

INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT

Dutch

Qualitative research

This paper examined the feasibility of appropriate risk adjustment in LTC insurance.

Prior health care expenditures are also important in reducing predicted losses for subgroups of health care users. Nevertheless, incentives for risk selection against some easily identifiable subgroups persist. Moreover, using prior utilization and expenditure as risk adjusters reduces incentives for efficiency, creating a trade-off between equity and efficiency.

 19

Park (2015) [49]

INTERNATIONAL JOURNAL FOR EQUITY IN HEALTH

Korea

Quantitative research

The Aday-Andersen model was used as a conceptual model to examine the extent to which equity in the use of long-term care has been achieved in Korea.

1.those who rated his or her health to be fair, good, and very good, had no limited activities, were disabled, and had insurance coverage were more likely to use long-term care services, respectively. 2.the introduction of a national long term care insurance program did not yield a fully equitable distribution of services. 3. Long-term care reforms in Korea should continue to concentrate on expanding insurance coverage and reducing the inequities reflected in disparities in consumer cost sharing and associated patterns of utilization across plans.

 20

Saito et al. (2018) [56]

PLOS ONE

Japan

Quantitative research

This study examined income-based inequalities in caregiving time and depressive symptoms in Japanese older family caregivers under a public, universal long-term care insurance (LTCI) system.

1.A Poisson regression model revealed that caregivers in lower income groups (compared to those in the highest) were 1.32 to 1.95 and 1.63 to 2.68 times more likely to engage in > = 36 and > = 72 h/week of caregiving, respectively. 2.an interaction effect of income by caregiving role indicated no significant difference in inequality between caregivers and non-caregivers (p = .603).

 21

Yang et al. (2020) [67]

RESEARCH ON AGING

China

Quantitative research

This paper discussed the effects of piloted LTCI on equity and efficiency in financing in Qingdao city.

There remain sizable disparities in financial burden among insurance participants, despite an emphasis on ensuring equitable access to care. Although the insurance brought cost savings to the health care sector, the LTC providers are incentivized to provide care at the least cost, even when such care is deemed inadequate due to the fixed payment for their services.