Choices, Policy Logics and Problems in the Design of Long–term Care Systems

Establishing a public, comprehensive, independent, mainly community–based long–term care system, separate from medical care and social services, can lead to the provision of more effective and consumer–oriented services, and also to a more appropriate mix of public/private financing. Of the two main approaches to financing long–term care (LTC), a tax–based model is more flexible in providing benefits according to the individual’s need, since income levels and the family’s ability to provide care will be taken into consideration, while a social insurance model is more rigid because the individual’s rights are more explicitly defined. The latter system is likely to provide more opportunities for choice, including decisions about the mix of health and social services. Policy–makers must decide which approach to take after weighing the positive and negative aspects of each, and the existing organizational infrastructure. Decisions must also be made on the practical issues of coverage, fairness, form of benefits, service delivery patterns, relationship with medical and social services, and controlling costs. With increasing pressure to contain public sector expenditures and improve efficiency, the focus of care will gradually shift from medical care to LTC, and within LTC, from institutions to housing. How to make this process proactive and planned, instead of ad hoc and reactive, is the challenge for public policy.