Introduction

Public responsibility for long-term care (LTC) – in particular, care for frail older people – has expanded rapidly in most advanced nations in the past two or three decades. A key issue is resource allocation: how much money to spend and on what. But although the LTC field has drawn more and more attention from researchers – we know far more about how various approaches work than ever before – patterns of resource allocation have not been adequately studied. As a recent report indicates, ‘the current available statistics about public LTC programs are somewhat patchy’ (Carrera et al, 2013, p 31). Actually, information is available about LTC expenditure in most individual countries, and recently several admirable surveys of LTC policy across several countries have appeared (see, for example, Colombo et al, 2011; Riedel and Kraus, 2011; Mot et al, 2012; Rodrigues et al, 2012; Genet et al, 2013; OECD, 2013; Ranci and Pavaloni, 2013; Mor et al, 2014). However, systematic comparative analysis of expenditure and coverage of national LTC systems has been lacking.

The objective is simple; the task is quite difficult. Two of us discovered this in trying to compare expenditures in just three countries, Germany, Japan and the US (Campbell et al, 2010). It took far longer than we expected and required many delicate decisions to match up the categories. The present study takes on seven countries, a number small enough to manage the necessary mutual adjusting with our limited time and resources, but large enough to represent significant models of LTC policy.

To draw on quite conventional images in the welfare state literature, we have Sweden in social-democratic Northern Europe, Italy in familial Southern Europe, Germany in corporatist mid-continent, Australia, the US and England as quite different versions of the Anglo-Saxon ‘residual’ model, and Japan as the relatively new entry that shares aspects of all the other models. This chapter presents details of each country's approach to LTC and how their policies have changed over time. This chapter is essentially a ‘snapshot’ cross-sectional analysis of spending and coverage data.

Since our contribution is largely methodological, we begin by explaining how we have tried to deal with the inherent problems of comparing LTC policy. There are four key approaches.

Introduction

A key policy debate in long-term care (LTC) policies across OECD countries today can be summarised by the following question: what measures and strategies can be adopted to optimise resources? New policies are required for balancing finances and access to care, with different options on the table and waiting for governments’ decisions.

This chapter looks at changes over time in public resource allocation among LTC users in the same OECD countries considered in the previous chapter (except for Australia). As in Chapter Four, this chapter focuses exclusively on public care inputs, defined as those inputs that are (at least partially) publicly funded, and looks at users aged 65 and over. Chapter Four led the way to reconsidering how public resources are allocated in different LTC systems through an in-depth analysis of current spending. To complement that analysis, this chapter adopts a long-term perspective, investigating the changes that have occurred over the last 20–25 years in three crucial dimensions of resource allocation: the mix of LTC services for older people, their intensity, and their coverage.

The countries considered are representative of the OECD environment with respect to both the overall welfare models and the models of LTC policies. Concerning the former, as Campbell et al have noted in Chapter Four, ‘we have Sweden in social-democratic Northern Europe, Italy in familial Southern Europe, Germany in corporatist mid-continent, Australia, the US and England as quite different versions of the Anglo-Saxon “residual” model, and Japan as the relatively new entry that shares aspects of all the other models.’ From the point of view of LTC policies, the sample of countries selected represents the different models in the OECD context:

• • Universal coverage within a single programme: this model guarantees people access to formal services without taking into account users’ income or assets as eligibility criteria. It is also organised as a single system, separated or integrated with the overall health system (Germany, Japan and Sweden).

• • Mixed systems: in this case, LTC is provided through a mix of different universal programmes and benefits operating alongside, or a mix of universal and meanstested LTC entitlements (England and Italy).

• • Means-tested systems: under this type of scheme, LTC coverage is provided through safety-net programmes. In countries using this system, income and/ or asset tests are used to define thresholds for eligibility to publicly funded care.