B DaRoit

F Colombo

Organization for Economic Co-operation and Development

RI Stone

S Asiskovitch

WG Weissert

WN Leutz

Israel Journal of Health Policy Research

English

Marsha Gold

Crossref

Israel Journal ofHealth Policy ResearchGold Israel Journal of Health Policy Research 2013, 2:4http://www.ijhpr.org/content/2/1/4COMMENTARY Open AccessHow to provide and pay for long term care of anaging population is an international concernMarsha GoldAbstractAs populations age, most industrialized nations are seeking to review the structure for their long term careprograms with the goal of allocating better limited public resources to meet expanding needs. In this Commentary,I examine critical questions that define the way individual nations provide for the long term care needs of theiraging populations. As examined by Asiskovitch, Israel’s programs appear, in cross-national context, to have abroader reach and rely more heavily on community based services. In the future, the challenge Israel may faceinvolves maintaining aspects of its programs that probably account for its popular support and stability while itidentifies better the extent of potential gaps in care for those with greater needs and how best to meet them.The article by Asiskovitch in this issue of the IJHPR pro-vides a valuable in depth review of Israel’s experience withlong term care [1]. Israel’s program focuses on homebased personal care services, employing a model that hasbeen relatively stable since 1988. As the author describes,the program serves a relatively large and growing share ofelderly beneficiaries with an emphasis on communitybased care. Despite a shift from two to three levels of be-nefits that vary by income and dependency, concerns re-main about the equity of benefit distribution, particularlyfor those with greatest needs. Meanwhile in Israel, as inthe rest of the world, societal changes and an aging popu-lation are creating growing strains on existing institutionsand programs [2]. In Israel, these strains raise issuesregarding appropriate benefit levels, how benefits shouldbe financed, and how the quality of services should beguaranteed.1In this article, I seek to put Israel’s experience in broaderinternational context by posing some critical questionsthat apply to understanding long term care policies of anynation. I then build on them with the goal of placingIsrael’s policies in cross-national context. For simplicity, Ifocus on the elderly though similar and interrelated issuesexist across the age spectrum, particularly for disabledpopulations, raising issues about relative priorities acrossCorrespondence: MGold@Mathematica-MPR.comMathematica Policy Research, 1100 1st Street NE, 12th floor, Washington DC20003, USA© 2013 Gold; licensee BioMed Central Ltd. ThiCommons Attribution License (http://creativecreproduction in any medium, provided the orsubgroups of the population and the extent to which spe-cialized systems should serve the aged.Key policy questionsWhat are the nation’s obligations in meeting the longterm care needs of its population and how, if at all, doesthat obligation vary by income or need?Fundamental beliefs about the role of government arereflected in how nations’ structure programs to meet thelong term care needs of their aging populations. In mostdeveloped nations, public spending on long term careexceeds that of the private sector [3]. However, suchexpenditures fail to reflect unpaid help by family membersand friends providing informal care that may be the main-stay of care, particularly for the broader aged populationeven as socio-demographic trends weaken essential infra-structure to support such care. Programs that seek to paycash benefits to the aged so they can more autonomouslychoose who will provide their care potentially blur theboundaries between the public and private sectors and theformal and informal sources of support [4-6].Ultimately philosophy is translated into reality by eligi-bility policies, program design, and funding levels. Nationsdiffer on whether eligibility is universal or limited byincome or wealth, at what levels such income or wealthlimits apply, and whether benefits are an entitlement ordiscretionary and thus depend on the level of financing orservices authorized and made available. Both the scope ofbenefits provided and the priorities that define whoreceives them also shape the nature of governments is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited.Gold Israel Journal of Health Policy Research 2013, 2:4 Page 2 of 3http://www.ijhpr.org/content/2/1/4commitments. With resources limited, there may be trade-offs in equity between commitments that aim for moreuniversal eligibility versus those that target subgroups withmore extensive needs, however values of a society arereflected in the particular criteria employed.How should long term care services be paid for andfinanced?Public sector financing may be through programs of socialinsurance supported by dedicated taxes that raise revenueto support universal benefits, publicly underwritten insu-rance to eligible populations, grant supported programs,tax incentives, or direct service provision. Private spendingcomes from individuals, private insurance plans that maymediate between individual payments and services, or inkind (and typically uncounted) caregiver support by fa-mily, friends or community, including private charitableorganizations and services. Nations can be categorized bythe total amount of spending on long term care, the gov-ernment (that is public sector) share of that spending, orthe ways in which distribution varies for those at diverseincome levels or needs. The argument for some externalsource of support for long term care rests at least in parton the uncertainties that surround ultimate need for suchservices.2 Nations also differ in how distinctively separatetheir long term services may be from the way they financeand provide acute care. How to better integrate and co-ordinate care that may be provided across acute and longterm sectors is a growing issue as the population ages [7].Where should long term care services be provided?Historically, public spending programs in many nationshave tended to direct a high proportion of their fundstowards those treated in institutional settings of care,reflecting both higher costs for those at risk for needingcare in such institutions and historical patterns that havefavored care in such settings. In 2000, most nations spentthe majority of their public long term care services on in-stitutional care despite variations across nations.3 Therenow is growing interest in maintaining individuals athome or at least in the community to the extent feasible.However it is not clear that community services are neces-sarily less expensive, though that is the hope and commu-nity care tends to be preferred by beneficiaries [8].How can growth in need for care with an agingpopulation be accommodated?This is a critical question that most nations now face asaging populations confront economies that are growingmore slowly than in the post WWII era when the popula-tion was young and societal rebuilding was a priority. Areality of limited resources in the face of growing demandis leading many nations to reconsider both their obliga-tions and the way they structure benefits. While there ishope that program consolidation, reorganization, and ef-ficiency gains can stretch limited resources, ultimatelytrade-offs are likely to be required and the way those tra-deoffs are made will shape future commitments and theway benefits are distributed both by income and need.Israel in cross national contextWhile definitional inconsistencies complicate cross na-tional comparisons, Asiskovitch’s analysis (Table 8) sug-gests that Israel provides publicly financed long term careservices to a larger share of the elderly population thanmany nations, while expending a smaller share of theGNP on such public spending. From the data in the paper,it is not possible to assess fully potential inequities thatmay occur if these patterns reflect failure to allocate suffi-cient resources to those most in need.As a non-Israeli, two aspects of the Israel system appearnoteworthy. First, in contrast to many nations, Israel’s longterm care system appears to encourage community basedsupport, which is important at a time when many nationsare striving to rebalance their own systems. Second, thebreadth of reach behind Israel’s program is striking at atime of limited resources. Arguably such reach contributesto popularity which has helped maintain the stability ofthe program over time. Going forward therefore, the keychallenge is to maintain such positive features while betteridentifying the extent of unmet needs and determininghow best to build on the program to better meet them.Competing interestsThe author declares that she has no competing interests.Authors’ informationMarsha Gold, Sc.D. is a senior fellow at Mathematica Policy Research inWashington DC, an independent nonpartisan organization focused on publicrelevant research and analysis. Dr. Gold is a member of the editorial boardsof Health Affairs and Health Services Research and has published extensivelyon the organization and financing for health care in the United States.Commentary on “The Long Term Care Insurance Program In Israel: Soliditywith the Elderly in a Changing Society (Sharon Asiskovitch).Received: 27 December 2012 Accepted: 3 January 2013Published: 23 January 2013References1. Asiskovitch S: “The long term care insurance program in Israel: solidaritywith the elderly in a changing society”. Isr J of Health Policy Res 2013, 2:3.2. Colombo F, et al: “Help Wanted: Providing and Paying for Long Term Care“.Paris: Organization for Economic Cooperation and Development; 2011.Available at www.oecd.org/health/longtermcare/helpwanted, AccessedDecember 27, 2012.3. Organization for Economic Co-operation and Development: “EnsuringQuality Long-Ter Care for Older People”. Policy Brief; 2005. Available at www.oecd.org/publications/policybriefs. Accessed December 27, 2012.4. Stone RI: Providing long-term care benefits in cash: moving to adisability model. Health Aff 2001, 20(6):96–109.5. DaRoit B, Le Bihan B: Similar and yet so different: cash for care in sixeuropean countries’ long term care policies. Milbank Q 2010,88(3):286–309.6. Lundsgaard J: “Consumer Direction and Choice in Long Term Care for OlderPersons, Including Payments for Informal Care: How Can It Help Improve CareGold Israel Journal of Health Policy Research 2013, 2:4 Page 3 of 3http://www.ijhpr.org/content/2/1/4Outcomes, Employment and Fiscal Sustainability”. Paris: OECD Health WorkingPapers #20; Available at www.oecd.org, Accessed December 27, 2012.7. Leutz WN, Greenlick MR, Capitman JA: Integrating acute and long termcare. Health Aff 1994, 13(4):58–74.8. Weissert WG, Cready CM, Pawelak JE: “The past and future of community-based long term care”. Milbank Q 1988, 66(2):309–88. Reprinted in theMilbank Quarterly 83(4), 2005.doi:10.1186/2045-4015-2-4Cite this article as: Gold: How to provide and pay for long term care ofan aging population is an international concern. Israel Journal of HealthPolicy Research 2013 2:4.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submit

How to provide and pay for long term care of an aging population is an international concern

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How to provide and pay for long term care of an aging population is an international concern

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