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In-Brief: Long-Term Care in Developed Nations: A Brief Overview

Introduction and Purpose

This In-Brief summarizes the findings of the AARP Public Policy Institute Issue Paper, Long-Term Care in Developed Nations: A Brief Overview. As their populations age, all developed nations are tackling issues of access, cost, and quality of long-term care services.

This report provides a brief overview of many of the key long-term care policy trends that cross national boundaries in developed countries. It focuses on examples of nations with much older populations than the U.S., which ranks 29thamong the world's "oldest" countries. The information presented here was derived from an extensive search for cross-national literature and empirical data.

Principal Findings

Many developed nations are encouraging long-term independence among persons with disabilities of all ages by:

Providing "consumer-directed" home care programs to enhance choice and independence. Finding the right balance between providing cash so individuals can select and manage their own services versus having agencies provide home care services directly is an increasingly important issue in many developed nations. European nations with public programs permitting cash benefits for home care include Austria, Germany, the Netherlands, and England.

Encouraging home and community-based services rather than institutional care. Rates of institutionalization have been dropping in most member nations of the Organisation for Economic Cooperation and Development (OECD) since the 1980s. Denmark, for example, has reduced rates of nursing home use while expanding home and community-based services to nearly a quarter of all older persons, with savings in its total public long-term care spending.

Encouraging family support of persons with disabilities. Support for family and other informal caregivers can include respite services to give caregivers a break, payments to informal caregivers, and tax benefits. For example, Japan provides up to one week respite stay per month for care recipients at the highest level of disability; Australia provides a network of adult day centers and in-home respite services. Germany permits up to four weeks of holiday leave per year for family caregivers and provides public pension (social security credits) to caregivers who provide a substantial amount of care.

Providing universal coverage for long-term care services. Whether publicly-funded long-term care services should be available only to the poor, or to the non-poor as well, is a fundamental question. Many developed nations, including Austria, Germany, Japan, the Netherlands, and many Scandinavian nations, have established universal long-term care programs that base eligibility for personal care and other benefits on the need for such services, rather than on an individual's income and/or assets. In contrast, many English-speaking countries, including the United States and England, "means-test" personal care services. However, most developed nations, including most English-speaking nations, provide universal medically-related nursing care in the home.

Insuring individuals against the high costs of long-term care through a mix of public and private financing. Those countries with universal long-term care programs use a mix of financing sources, although public sector spending predominates. Total spending on long-term care remains less than 2 percent of GDP in most developed nations, compared to spending on health care (a median of 8 percent of GDP in 2000 in most OECD nations). As with health care, the United States relies more heavily on private sources of long-term care financing, through out-of-pocket spending by individuals or private insurance, than do most other developed nations.

Improving coordination between chronic medical care and long-term care services. "Home visitation" programs for older persons intended to delay or prevent functional decline and subsequent nursing home admissions are part of national policy in several nations, such as the U.K., Denmark, and Austria.


Many developed countries share similar goals with respect to the delivery and financing of long-term care, including encouraging consumer choice and independence and providing support for family and other informal caregivers. Despite some common goals, there are also differences. For example, in some countries, providing universal coverage for nursing care at home while means-testing in-home personal care services often surprises and confuses individuals who need long-term care. It also can create incentives to providers to shift costs between health and long-term care budgets. Elsewhere, boundaries that divide health and social care are beginning to disappear, such as those between nursing homes/residential homes and community services, including adult day services and in-home services.

The toughest issue is how to pay for an appropriate range of long-term care services in the face of other competing priorities, and how to sustain availability of services in the face of growing demand. Current long-term care spending is a relatively small share of GDP in most developed nations, but it is growing. While uncertainty surrounds all long-range projections about the need for long-term care, a high degree of consensus exists about the need to promote the cost-effectiveness of such care. Such steps include promoting healthy aging and delaying disability for as many years as possible, increasing support for family caregivers, and increasing services in homes and communities. Demography is not destiny, but demographic trends indicate that the time to prepare for the long-term care needs of aging populations is now.


  1. PPI Issue Paper #2003-13, Mary Jo Gibson, Steven R. Gregory, and Sheel M. Pandya, October 2003.

Written by Mary Jo Gibson, AARP Public Policy Institute
October 2003
©2003 AARP
All rights are reserved and content may be reproduced, downloaded, disseminated, or transferred, for single use, or by nonprofit organizations for educational purposes, if correct attribution is made to AARP.
Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049

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