Relative to our international peers, Canada is experiencing alarmingly high fatality and mortality rates due to COVID-19 in long-term care (LTC) facilities. Lessons from other countries are useful in this regard. Japan, South Korea (hereafter Korea) and Germany serve as good examples of countries that have paved different paths by focusing on a continuum of care, a public insurance system and regulations. If Canada had a more universal and better regulated system, it would be able to ensure that more people access a variety of care services at home and avoid a heavy reliance on facility-based LTC.
Japan, Korea and Germany introduced universal, mandatory public long-term care insurance (LTCI) as their populations began to age. LTCI is a social insurance program that covers the cost of care in case people need assistance to manage their daily living activities. In these countries LTCI covers a broad range of activities for daily living associated with aging and disability, from light home-helper services to intensive institutional care. The coverage isavailable for any level of care need, not simply for the most severe cases of disability.
In Japan and Korea, LTCI covers the care needs of everybody over the age of 65, and of those over the age of 40 if they have age-related disabilities such as dementia. In Germany, the insurance covers the care needs of everybody over the age of 18. In all three countries, LTCI functions much like employment insurance in Canada: in Japan and Korea, all working adults aged 40+ must contribute into the insurance fund, mostly through payroll deductions matched by employers; in Germany, the contribution starts from age 18, also through payroll deduction.
While the institutional arrangements and the financial mechanisms of their LTCIs differ from each other, Japan, Korea and Germany have a couple of basic principles in common: 1) a universal public social care system dedicated to LTC; and 2) a continuum of care system, starting from light home-based services all the way to intensive institutional care. In these countries most seniors who need care receive LTC at their homes and/or in the community, and relatively few need to go to LTC homes. This is one reason why these countries, unlike Canada, were able to avoid high numbers of COVID-19 related deaths in LTC homes.
The universality of the LTCI systems is important because it assures that individuals receive at-home care geared toward prevention. Because we don’t have a national LTC system, very few Canadian seniors are receiving LTC. In 2017, according to OECD figures, 8.3 percent of seniors in Korea, 15.6 percent in Germany and 18.0 percent in Japan were receiving LTC, as compared with 4.1 percent in Canada. These countries’ relatively high LTC recipient rates are largely because of their long-term care insurance.
Although in Korea the proportion of the population 65 and over is lower than in Canada, the long-term care recipient rate of Korean seniors is double the Canadian figure. This suggests that Canadian seniors are simply not receiving as much long-term care as seniors in Japan, Germany or Korea: in fact, long-term care recipient rates for Canadian seniors are among the lowest in the OECD.
The continuum of care principle is critical: LTC does not, and should not, begin only after people are severely disabled. When it begins early, it enables older people to live independently and to delay and reduce the need for much more costly institutional care. One reason why Germany and Japan are able to provide long-term care to more seniors than in Canada – and without spending much more for their LTC systems – is that they spend more on home and community-based care than on institutional LTC. In Canada, 82 percent of LTC spending goes to institutional care (versus 11 percent to in-home care and 7 percent in community LTC), whereas in Japan and Germany, institutional LTC takes up 66 percent and 41 percent of the total LTC spending, respectively.
Since the introduction of LTCI, Japan has steadily reduced its LTC beds in institutions and hospitals and shifted more LTC to homes and communities. The number of LTC beds (in both LTC institutions and hospitals) per 1,000 people aged 65+ in Japan is now among the lowest in the OECD, at 33.6, compared with the OECD average of 47.2. In Germany, it is 54.4 beds per 1,000, and in Canada it is 58.
With COVID-19, we see that the benefits of the continuum of care principle extend beyond economics and quality of life: this approach also removes people from the types of multi-residential locations that are most prone to the rapid spread of infection.
In developing LTCI, governments also developed regulations to cover how care needs could be assessed and by whom, who can provide care and under what conditions, the costs of care services, and the training, skills and wages of care workers. Government regulation is also important to ensure good-quality, accessible LTC.
Japan, for example, has strict LTC regulation compared with Germany and Korea, and the lowest fatality and mortality rates in LTC institutions due to COVID-19. In Japan, only government-certified LTC workers and LTC providers (including all the public, private for-profit and not-for profit providers) can provide LTC. The LTCI system in Japan also regulates the education and training of LTC workers, and their wages and employment conditions. In general, LTC workers in Japan receive more formal education than their Canadian counterparts, and more of them are in full-time employment.
Japanese LTC workers must pass a national licensing examination to work in LTC institutions. Thirty-seven percent of Japanese LTC workers have post-secondary education while 59 percent have high school and 4 percent have less than high-school-level education. In Canada the figures are, respectively, 20 percent, 75 percent and 6 percent. The wages of Japanese LTC workers are not particularly high – their average wage is only a little better than that of average industrial workers – but they are still higher than the wages of LTC workers in Canada. Moreover, in 2016, only 17.5 percent of all Japanese long-term care workers were part-timers, whereas in Canada 36 percent worked part-time. The COVID crisis has underscored how Canada’s long-term care workers are poorly paid and their employment insecure.
Many of our international peers have been more active and thoughtful with LTC policies than Canada, and we have lots to learn as we go about reforming our LTC systems. Japan, Germany and Korea’s experience shows Canada that it is possible to develop a universal public long-term care system. This system would help people with activities of daily living where they need it, and it would not cost the government much more than what it is spending now. Further, Canada also needs to develop a better set of regulations if we want to ensure good-quality and accessible LTC for all.
This article is part of the Facing up to Canada’s long-term care policy crisis special feature.