Aiming Higher: Advancing Public Social Insurance for Long-term Care to Meet the Global Aging Challenge; Comment on “Financing Long-term Care: Lessons From Japan”

Document Type : Commentary


1 Aging, Disability, and Long-Term Care Program, RTI International, Waltham, MA, USA

2 Social Protection and Jobs, The World Bank, Washington, DC, USA


Globally, aging populations are driving the demand for long-term care (LTC) services for a growing number of older people with disabilities or chronic illnesses. A key challenge for policy-makers in all countries is to find a comprehensive solution to financing LTC services to make them widely accessible, affordable, and equitable for all in need. In this commentary, we make a case for LTC policy-makers and reformers across countries to take a long-term vision toward establishing a public, mandatory social insurance model of LTC financing. We first take a hard look at the LTC financing problems and the limitations of existing financing options. We then argue for a public social insurance approach to LTC financing and offer insights into several top-level insurance design features that are key to successful implementation of a public social insurance model, building on the experiences and lessons learned from Japan and other countries that have already “gotten there.” We conclude with additional thoughts on the future of public LTC insurance in a global context, including the prospect of spreading this model to middle-income countries.


Main Subjects

  1. Feng Z. Global convergence: aging and long-term care policy challenges in the developing world. J Aging Soc Policy. 2019;31(4):291-297. doi:10.1080/08959420.2019.1626205
  2. Spasova S, Baeten R, Coster S, Ghailani D, Peña-Casas R, Vanhercke B. Challenges in long-term care in Europe: A study of national policies. Brussels: European Social Policy Network (ESPN), European Commission; 2018.
  3. Colombo F, Llena-Nozal A, Mercier J, Tjadens F. Help Wanted? Providing and Paying for Long-Term Care. OECD Publishing; 2011.
  4. Ikegami N. Financing long-term care: lessons from Japan. Int J Health Policy Manag. 2019;8(8):462-466. doi:10.15171/ijhpm.2019.35
  5. Wiener JM. After CLASS: the long-term care commission’s search for a solution. Health Aff (Millwood). 2013;32(5):831-834. doi:10.1377/hlthaff.2013.0373
  6. Wiener JM, Feng Z, Zheng NT, Song J. Long-Term Care Financing: Issues, Options, and Implications for China. In: Glinskaya E, Feng Z, eds. Options for Aged Care in China: Building an Efficient and Sustainable Aged Care System. Washington, DC: World Bank; 2018:191-213.
  7. Wiener JM, Lepore M, Jones J. What policymakers need to know about long-term services and supports. Public Policy Aging Rep. 2018;28(1):29-34. doi:10.1093/ppar/pry001
  8. Gusmano MK, Grafova IB. Financing Long-Term Care. American Affairs. 2018;11(3):32-40.
  9. Allaire BT, Brown DS, Wiener JM. Who wants long-term care insurance? a stated preference survey of attitudes, beliefs, and characteristics. Inquiry. 2016;53. doi:10.1177/0046958016663728
  10. Khatutsky G, Wiener JM, Greene AM, Thach NT. Experience, knowledge, and concerns about long-term services and supports: Implications for financing reform. J Aging Soc Policy. 2017;29(1):51-69. doi:10.1080/08959420.2016.1199192
  11. Applebaum R, Bardo A, Robbins E. International approaches to long-term services and supports. Generations. 2013;37(1):59-65.
  12. Sitaraman G, Alstott AL. The Public Option: How to Expand Freedom, Increase Opportunity, and Promote Equality. Cambridge, MA: Harvard University Press; 2019.
  13. Rhee JC, Done N, Anderson GF. Considering long-term care insurance for middle-income countries: comparing South Korea with Japan and Germany. Health Policy. 2015;119(10):1319-1329. doi:10.1016/j.healthpol.2015.06.001
  14. American Academy of Actuaries (AAA). Issue Brief: International Perspective on Long-term Care. Washington, DC: AAA; 2015.
  15. Campbell JC, Ikegami N. Long-term care insurance comes to Japan. Health Aff (Millwood). 2000;19(3):26-39. doi:10.1377/hlthaff.19.3.26
  16. Koller CF, Fulmer T. A new fix for long-term care. POLITICO; 2019.
  17. Glinskaya E, Feng Z. Options for Aged Care in China: Building an Efficient and Sustainable Aged Care System. Washington, DC: World Bank; 2018.
  18. Ministry of Human Resources and Social Security. Guiding Opinions on Initiating Long-Term Care Insurance Demonstrations. Beijing, China: Ministry of Human Resources and Social Security; 2016.
Volume 9, Issue 8
August 2020
Pages 356-359
  • Receive Date: 05 October 2019
  • Revise Date: 13 November 2019
  • Accept Date: 23 November 2019
  • First Publish Date: 01 August 2020