Sigma5 2014 en

No 5/2014
How will we care?

Finding sustainable
long-term care solutions
for an ageing world
01 Executive summary
02 Introduction
04 The ageing population
and its care needs
08 Long-term care today
16 The economics of
private insurance
solutions
21 Creating a better care
market for older lives
29 Conclusion
30 Appendix: LTC solutions
in select countries
Executive summary
By 2030, there will be more than 1billion
people aged 65 and over.
The world is getting older. Over the next 20 years the number of people aged 65
and above will increase by 80% to nearly 1 billion. This major demographic shift
will generate increased demand for care services in all parts of the world.
The provision and funding of care services

for the elderly will be one of the most
pressing issues facing society, driven by
various demographic and societal trends.
The financing and provision of effective care services for the elderly will be one of the
most challenging issues facing society, driven by various demographic and societal
trends. Public spending on long-term care (LTC) will increase significantly in the
coming decades, straining government budgets in advanced economies. In emerging
markets, public finances are less stressed but the low starting point of LTC spending
and the immense growth of funds needed will still be a huge challenge.
Care needs for the elderly progress with

age from assistance for an active life to,
potentially, 24-hour care.
In the past, care for the elderly has tended to be thought of only in terms of advancedstage institutional care. Today, a fundamental premise of care services is to help
people live at home for as long as they can. The care services continuum begins with
providing the required assistance to help the recent retiree maintain an active and
independent life. The services then progress to additional support (sometimes
institutional) to manage the increasing mental and physical incapacities that come
with age, and may culminate in 24-hour care.
The burden of care will increasingly

fall on private individuals.
Private individuals in both advanced and emerging markets will increasingly need
to shoulder the burden of providing care services for the elderly. Already today,
where public provisions are not comprehensive (many advanced markets), or are
unavailable (most emerging markets), care is mostly financed out-of-pocket.
To date, various supply- and demand-side

issues have held back the development of
a large-scale private LTC insurance sector.
The contribution of private insurance is typically less than 2% of total LTC spending,
and the experience so far has been mixed. Various issues influence the lack of
success of a private insurance market. For example, on the supply side a dearth of
experience data makes provision of insurance solutions difficult. Traditional LTC
insurance is very long-term and requires a number of forward-looking assumptions
which, due to changing market and social policy conditions, complicate the provision
of LTC insurance. Adverse selection can also be an issue. On the demand side, there
is a general lack of consumer awareness of complex and difficult-to-understand LTC
risks. Behavioural and cognitive biases also play a role in directing consumers to
sometimes make non-optimal LTC choices.
This can change. Private insurance

can be part of an integrated, multistakeholder
However, private insurance can and should play a role in future LTC solutions by being
part of an integrated, multiple stakeholder (insurers, governments, healthcare
institutions, care providers and consumers), and financially sustainable solution. This
sigma reviews various options to meet the challenge of the ageing populations care
needs. These include private insurers becoming investors in care infrastructure and
services, and more involvement of employers in raising awareness of LTC risks. There
also needs to be stronger coordination of the different agents involved in care
delivery and a promotion of healthy-ageing initiatives. Other options could be state
incentives to encourage and support family members to become home carers, and
more investment in technological innovation to enable better health monitoring, care
coordination and a longer period of living at home.
and financially sustainable LTC solution.
There is also scope for private insurance solutions to better meet consumers needs.
To take advantage of this business opportunity, some insurers are reconsidering
product design, developing new products and introducing hybrid-type solutions that
combine LTC insurance with life, retirement/pension and critical illness products.
Swiss Re sigma No 5/2014 1
Introduction
Ageing is not lost youth but a new stage of opportunity and strength. Betty
Friedan
The coming silver tsunami

Population ageing presents challenges
and opportunities for societies and
insurers.
Population greying is a near universal issue which doomsayers foretell will bring
about widespread global economic and social disruption over this century. While
such gloomy predictions are more the subject of dystopia movies than insurance
industry debates, population ageing is a global reality. The expanding pool of elderly
will require more care, something for which society should and, in partnership with
insurers, can prepare. But what exactly are the health and ageing developments that
will lead to care needs over the next 1015 years? Where are the greatest threats
hidden in caring for an older population? What (long-term) care solutions and related
opportunities are available for insurers amid the challenge, and why has the market
not already jumped at the prospect? This sigma explores the topic in detail.1
The number of people aged 65 and

over will nearly double in several
regions between 2010 and 2030
The era of most-rapid ageing will in many countries take place over the next 20 years.
Birth rates have declined significantly over the past several decades, and life
expectancy has risen. These developments are not solely an advanced world
phenomenon. Emerging countries are ageing too and at a much faster pace, a
challenge given that many of these countries are growing old before getting rich.
with Latin America and Asia seeing

the most dramatic increases.
The worlds old-age population is set to increase dramatically (see Figure 1). By 2030,
the number of people in the 6579 and 80+ age groups will increase to nearly
1 billion (from around 530 million in 2010). The oldest regions today Europe and
Japan will see the smallest percentage increase, while in Latin America and Asia
the number of people aged 65 and over will nearly double. The absolute rise in the
number of elderly and the speed of the change present severe challenges.
Figure 1:
Population growth by age group and
region, 2010 to 2030
140%
120%
100%
80%
60%
40%
20%
0%
20%
Europe
019
Northern Oceania
America
2064
Asia
6579
Latin
Africa
America
and the
Caribbean
World
80+
Source: United Nations, Department of Economic and Social Affairs, Population Division (2013),
medium-fertility scenario.
1 This sigma will focus on the care needs of the ageing. It will not cover the topic of retirement income
which was discussed extensively in sigma 4/2008: Innovative ways of financing retirement, Swiss Re
(2008). Other Swiss Re reports on related topics include A short guide to longer lives (2010), A window
into the future (2011), and A mature market (2012).
2 Swiss Re sigma No 5/2014
A growing need for (long-term) care solutions

In both advanced and emerging markets,
the funding needs for ageing populations
will stress budgets.
As the number of elderly rises, so does the need for funding and provision of longterm care (LTC) services. Advanced and emerging markets will need to manage
the costs of caring for the elderly as their health deteriorates due to chronic disease,
disability and cognitive impairments. According to a study by the Bank of International
Settlements, advanced market governments are already constrained by their public
debt burdens. Future promises of age-related spending (retirement and retiree
healthcare costs) are often huge, amounting to a multiple of the explicit government
debt.2 A 2010 report concluded that without sweeping changes to age-related
public spending, sovereign debt will soon become unsustainable.3 In emerging
markets, a sharp rise in public spending on LTC is expected even though formal
social protection systems do not yet exist or cover only a small proportion of the
older population.4
Other demographic trends are

compounding the overall care
solutions challenge.
Other demographic trends are compounding the overall care solutions challenge.
Even in advanced countries, unpaid informal care by families is currently often the
largest contributor to care solutions. Meanwhile, the availability and accessibility
of informal care is increasingly constrained, particularly in emerging markets, where
the family has traditionally provided care outside of acute care settings. In India and
China, the percentage of older people living in multi-generational households with
their adult children is 82% and 69%, respectively, compared with fewer than 10%
in parts of Western Europe.5 However, urbanisation, higher female labour force
participation and lower fertility rates do not bode well for the future of informal care
in emerging markets. For example, in China a 4-2-1 family structure, where one child
may have to care for two parents and four grandparents, is increasingly common.
Similarly, in India, the migration of the younger generations from rural to urban areas
is weakening older persons traditional support systems.6 Additionally, in a global
Swiss Re survey of more than 22000 respondents, individuals from emerging
markets showed a relatively low willingness to provide care for their parents or
partners, presenting another challenge to the family care model.7 The shrinking of
working-age populations in many advanced and emerging countries also begs the
question of who should provide care in the future.
2 S. G. Cecchetti, M. S. Mohanty and F. Zampolli, The future of public debt: prospects and implications,
BIS Working Papers No 300, (2010) and Developing Future Social Protection Systems. Retirement
Income, World Economic Forum publication, (2013). See also C. de la Maisonneuve and J. O. Martins,
Public spending on health and long-term care: a new set of projections, OECD Economic Policy
Papers, No. 06, (2013).
3 Global Aging 2010: an irreversible truth, Standard and Poors, (2010).
4 Social Security Programs Throughout the World, International Social Security Association, (2009).
5 R. Jackson, N. Howe, and T. Peter, The Global Aging Preparedness Index, Second Edition, Centre for
Strategic and International Studies, (2013).
6 J. Anita, Emerging Health Insurance in India An overview, 10 th Global Conference of Actuaries,
(2008).
7 See Swiss Res Risk perception survey, April to May 2013, http://riskwindow.swissre.com/riskwindow#qst=17;cnt=1;age=1 (accessed 1 September 2014).
The ageing population and its care needs

The level of overall care needs will
depend on whether increased longevity
comes with added healthy life years.
If increasing longevity comes with added healthy life years known as compression
of morbidity the level of overall care needs might be lower in the future, despite a
larger older population. However, if the same number of years is spent in ill health,
just at a later age (postponement of morbidity), or if more years are spent in ill health
(expansion of morbidity), then the overall care needs outlook is more challenging.
Morbidity varies from country to

country
The debate between the compression, postponement and expansion of morbidity

is far from resolved. Advanced world evidence points to compression in at least some
cases.8 However, large variations exist from country to country,9 and populationwide studies may mask significant trends through time and in sub-groups of
societies.10 For example, a recent study in New York City found that limitations to
cope with daily self-care were associated with lower income.11 Other studies have
found that the higher the level of education, a proxy for socioeconomic status, the
lower the disability rates.12
and even among sub-groups of

societies within the same country.
For low- and middle-income countries, data is harder to come by. A study in the city
of So Paulo showed that from 2000 to 2010, persons aged 6064 gained two
years of life but lost three years of life expectancy in good health.13 Additionally,
World Health Organization surveys in five emerging markets found that bettereducated and wealthier people in each country have a significantly lower decline
in health condition from one survey period to the next.14 Another complication is the
difficulty in predicting the effect of conflicting population health trends, such as
increasing obesity and a declining number of smokers.
Care needs assessment what triggers dependency?

Generally speaking it is the oldest of
the old who experience a high rate
of disability and dependency.
Importantly, older lives are not defined by calendar age, but rather by the level of
health or disability. The variance of health and disability conditions among the elderly
can be huge, with some already old at age 60 while others remain active and fit
beyond 80+. For example, the oldest competitor to date to finish an Ironman race
was a youthful 82!15 Generally speaking, however, it is the oldest-of-the-old who
experience the highest incidence of disease and co-morbidity, and a high rate of
disability.16 These conditions are linked to functional dependency and needing help
with a range of self-care activities.
8 See, eg, J. F. Fries, B. Bruce, and E. Chakravarty, Compression of Morbidity 19802011: A Focused
Review of Paradigms and Progress, Journal of Ageing Research, (2011); and G. Payne et al., Counting
Backward to Health Cares Future: Using Time-to-Death Modeling to Identify Changes in End-of-Life
Morbidity and the Impact of Aging on Health Care Expenditures, The Milbank Quarterly, vol 85 no 2,
(2007).
9 AHP Luijben, H. Galenkamp and DJH Deeg, Mobilising the Potential of Active Ageing in Europe,
MoPAct, (2012).
10 Theories of the future course of mortality and morbidity, New Zealands Long-term Fiscal Position, The
New Zealand Treasury, (2006).
11 Health of Older Adults in New York City Public Housing, New York City Housing Authority Senior
Survey, (2010).
12 G. Lafortune et al., Trends in Severe Disability Among Elderly People: Assessing the Evidence in
12 OECD Countries and the Future Implications, OECD Health Working Papers, (2007).
13 L. Plouffe, The Future of Health and Health Care in an Ageing World: A Focus on Brazil, the Dominican
Republic and the United States of America, International Longevity Centre, Brazil, (2013).
14 P. Kowal et al., Data Resource Profile: The World Health Organization Study on global AGEing and adult
health (SAGE), International Journal of Epidemiology, (2012).
15 R. Fauteux, Sister Madonna Buder Ironman Triathlon finisher at 82-years-old: A world record,
The Examiner, 28 August 2012. The Ironman is a triathlon race including a 2.4-mile swim, 111-mile bike
ride and a 26.2-mile run.
16 J. Coughlin and J. Pope, Innovations in Health, Wellness, and Aging-in-Place, IEEE Engineering in
Medicine and Biology Magazine, (2008); Population Ageing in East and South-East Asia: Current
Situation and Emerging Challenges, UNFPA, (2006).
Care services refer to the support

provided to people as they lose the
ability to care for themselves.
The support provided to people as they lose the ability to care for themselves due
to chronic disease, disability or cognitive impairments can be categorised as care
services. These encompass a broad range of health and health-related services,
combining medical, social and community aspects, alongside traditional LTC in
institutional settings. The various components are not clearly delineated and often
overlap. As care needs vary in setting, level and scope, the services to address them
need to be diverse and dynamic.
Historically, care services and solutions

have focused on advanced needs only,
and care needs have been addressed in
isolation.
Traditionally, care services and solutions17 have focused on advanced care needs
in institutions. But the funding and service delivery for advanced care has not been
aligned with other stages of care needs, nor is it coordinated with the general
healthcare and social services that are an integral part of addressing overall care
needs. It would be better if care for the elderly was seen as an integral part of
broader health. Also, consumer and care-system preferences are shifting to providing
care closer to home, which will likely require a wider range of care solutions to suit
the diverse needs of older individuals.
Figure 2:
The continuum of care
Costs
Advanced care need

due to multiple ADL*
failures, with need for
significant home care
or institutional care
End of life palliative

care or catastrophic
institutional care
Early care need

due to comorbid*
conditions but able
to live at home with
home care assistance
or day care
Healthy
Very early care need

due to eg some IADL*
failures; focus on
adaptation and
prevention
Level of care services provided
*IADL=instrumental activities of daily living; ADL=activities of daily living; comorbid=medical condition(s)

existing simultaneously but independently with another or a related medical condition.
Source: Swiss Re Economic Research&Consulting.
17 Care solutions refer to care insurance products that help address care needs of the elderly.
The ageing population and its care needs
ADL/IADL are commonly-used

advanced-care-needs classifications of
an individuals ability to manage his/her
daily life.
The early care needs are typically linked to chronic disease management, or to early
treatment of well-controlled conditions (see Figure 2). At a more advanced stage,
dependency, and thus a need for care, is often measured using a classification
system that assesses an individuals ability to do daily activities. More specifically,
the classification distinguishes between activities essential for independent living
(activities of daily living, or ADL) and those that are instrumental activities of daily
living (IADL). These are more complex activities requiring a higher level of personal
autonomy (see Figure 3).18
The fewer ADL/IADL an individual can

perform, the higher his/her dependency.
Normally, the ability to peform IADL declines before ADL incapacities occur and
these IADL limitations are considered representative of early care needs. The degree
of dependency on ADL/IADL scales is determined by qualified/certified staff and
in some cases, the list of ADL evaluated far exceeds the sample list in Figure 3. For
example, in Korea 52 separate components in five categories are evaluated under
ADL.19 The fewer ADL/IADL an individual can perform, the higher his/her
dependency.
Other criteria for determining

dependency, including ones based on
cognitive impairments, are used also.
Other criteria for determining dependency, such as hours of help required per week,
are also used in some countries. Cognitive impairments can also lead to dependency
and are in fact becoming a leading cause of dependency, although not all
classifications systems recognize these as a trigger.
Figure 3:
The ADL/IADL measures for assessing
dependency
ADL
I ADL
Bathing
Housework
Dressing
Money management
Walking /moving
unassisted from
bed to wheelchair
Medication adherence
Feeding
Getting around
outside the house
Mobility
Shopping
Continence
Source: Swiss Re Economic Research&Consulting.
18 For a further discussion, see J. C. Milln-Calenti, et al., Prevalence of functional disability in activities of
daily living (ADL), instrumental activities of daily living (IADL) and associated factors, as predictors of
morbidity and mortality, Archives of Gerontology and Geriatrics, vol 50, (2010); and K. J. Colello, J.
Mulvey and S. R. Talaga, Long-Term Services and Supports: Overview and Financing, Congressional
Research Service Report for Congress, (2013).
19 R. S. Jones, Health-care reform in Korea, OECD Economics Department Working Papers, no 797,
(2010).
There are several key risk factors

for old-age disability.
Key risk factors associated with old-age disability20

The underlying causes of old-age disability vary across individuals and populations.
The most commonly identified risk factors for old-age disability are: demographics,
health conditions, behaviour and lifestyle choices, and social support, along with
the already-mentioned socio-economic status.
Dependency is strongly linked to age

and gender.
Demographics: Age has been found to be the most important risk factor for old-age
disability. Advanced ageing causes changes in bodily structures and functions and
is a strong and consistent predictor of functional disability. Gender differences in oldage disability are substantial, with women facing a higher risk of becoming disabled
and facing disability for longer durations.
Chronic diseases, cognitive impairments,

self-reported health status and chronic
pain are associated with higher disability.
Health conditions: Chronic diseases, such as hypertension, diabetes and arthritis

are linked to disability and dependency globally, along with cancer and strokes. In
emerging markets, where assistive devices and treatment are less readily available,
vision, hearing and mobility are also considered to be key ageing issues. Cognitive
impairments can also result in dependency and are expected to contribute
significantly to future LTC needs growth. Cognitive impairments may arise due to
Alzheimers and similar forms of irreversible dementia and require substantial
supervision to protect the dependant from threats to health and safety. Poor selfrated health is also found to be associated with functional impairment. Similarly,
chronic pain strongly increases the likelihood of ADL and IADL limitations.
Behaviour and lifestyle choices are also

relevant determinants of disability at old
age.
Behaviour and lifestyle choices contribute to the development of disability in old

age. For example, smoking and low levels of physical activity increase the risk for
functional status decline, as has been shown in many studies.21
Married and socially active people are

at lower risk of becoming disabled.
Social support: Both the quantity and quality of social support significantly affect the
development of old-age disability. As a measure of social support, marital status has
been found to be an important factor associated with disability in western countries,
with the unmarried having a higher risk of disability. Similarly, a low frequency of
social contact has been associated with poor physical functioning.
The care needs of the elderly increase

as health and behavioural conditions
decline.
Care needs for the elderly range from supporting independent living to providing
24-hour care. The starting point is a relatively independent and active retiree with
an early diagnosis of minor conditions. Here the focus is on preventing health from
declining and providing additional social care. Both are crucial. The next stage is
when the retiree begins to need help with a few of the IADL. Thus, some home
support is required, for example with cooking or cleaning. After failing multiple ADL,
additional help is needed. Finally, round-the-clock care and even formal institutional
care may be necessary. The health, social and behavioural conditions of a person are
all factors in determining an individuals needs and should be considered as part of
the entire scope of assistance provided during all stages of the care continuum.
Overall, (long-term) care solutions will

be one of the biggest challenges facing
society in the coming decades.
Effective (long-term) care solutions will be one of the biggest challenges facing
society in the coming decades, and policymakers will need to find balanced
solutions that are equitable, fair and sustainable. Private insurance can and should
play a role in funding and managing LTC risks. However, private LTC insurance has
had a limited impact in the past, which raises the question of how exactly insurers
can increase their support to societies in managing LTC-related risks and costs.
20 A detailed overview including original sources is presented in J. Hu, Old-Age Disability in China
Implications for Long-Term Care Policies in the Coming Decades, RAND Corporation, (2012). See
also H. Gilmour and J. Park, Dependency, chronic conditions and pain in seniors, Statistics Canada,
Supplement to Health Reports, vol 16, (2003); M. Prince, Dementia and chronic diseases a global
view, Centre for Global Mental Health, Kings College London, (2011); R. Nugent, Chronic Diseases in
Developing Countries, Center for Global Development, (2008).
21 For an overview see A. Stuck et al., Risk factors for functional status decline in community-living
elderly people: a systematic literature review, Social Science and Medicine, vol 48, no 4, (1999), pp
445469.
Long-term care today

Financing of long-term care today
Traditionally, care services and solutions have focused only on the more advanced
care needs stages or LTC. In 2008, total public and private expenditure on LTC
in OECD countries averaged 1.5% of gross domestic product (GDP).22 There was
significant cross-country variation in spending ranging from a low of around 0.2%
of GDP to a high of 4%. This reflects differences in care needs and their definition,
in the comprehensiveness of formal LTC systems, and in the culture of care and the
associated role of the family in specific societies.
The sources of LTC financing vary across

countries.
The sources of LTC financing also vary significantly across countries (see Figure 4).
For example in the Nordic European countries, LTC is an integral part of the welfare
systems that provide universal coverage and most LTC needs are publicly financed
(through taxes or social insurance). In other OECD countries like the US and the UK,
access to public financing for LTC is means-tested to ensure that only the neediest in
society have access. Mixed systems that combine universal and means-tested LTC
entitlements are also common in OECD countries (eg, France, Italy, Portugal and
New Zealand).
Figure 4:
LTC expenditures by sources of funding,
select OECD countries, 2007
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Switzerland
Portugal
Germany
Spain
Slovenia
US
Korea
Austria
Canada
Finland
Estonia
Norway
Denmark
Australia
Japan
New Zealand
Hungary
Sweden
France
Poland
Belgium
Iceland
Czech Republic
Netherlands
Total expenditure on LTC in OECD

countries ranges from 0.2% to more
than 4% of GDP.
Government
revenue
Social
security
Private
insurance
Out-of-pocket
Other
Note: Data on out-of-pocket spending for some of the countries are underestimated. For example, in the
Netherlands, cost sharing on long-term care services is estimated to account for 8% of the total LTC
expenditure. The share of out-of-pocket spending for Switzerland is overestimated as cash benefits granted
for care in care facilities are not considered.
Source: OECD Health System Accounts (2010), US Congressional Budget Office (2013).
In most OECD countries, LTC is financed

largely through government programs
or social security.
In most OECD countries, LTC is largely financed through government programs.

Where public schemes are not comprehensive or are unavailable, LTC is financed
mostly by out-of-pocket payments and private insurance. Out-of-pocket payments in
some countries are substantial.23 The contribution of private insurance, on the other
hand, is typically less than 2% of total LTC spending.
22 Total expenditure includes both public and private expenditure for home and institutional LTC. The study
did not cover all OECD countries. See F. Colombo et al., Help Wanted? Providing and Paying for
Long-Term Care, OECD Publishing, (2011).
23 Although out-of-pocket payments may include co-payments of public LTC schemes.
The value of informal care is significant

but often not included in LTC expenditure
statistics.
Official statistics and public data tend to omit a huge chunk of LTC costs. In many
countries, the majority of care is provided informally by unpaid family members,
often dwarfing formal expenditure. In the US, for instance, the economic value of
such informal care was estimated to be some USD 234 billion in 2011, which was
about 55% of the total spending on LTC of USD 426 billion that year, and equivalent
to 1.5% of GDP.24 In the UK, the economic value of the unpaid informal care provided
by family, friends and neighbours is estimated to be GBP 119 billion per year (USD
184 billion),25 or 8% of GDP and well in excess of the entire National Health Service
(NHS) budget of GBP 98.8 billion for the year 20092010.26 In Canada, informal
caregivers provide about 80% of the care for people with chronic health issues,
contributing an estimated economic value of CAD 25 billion (1.4% of GDP).27
In emerging markets, informal/family

care plays an even more important role.
In emerging markets formal government-financed LTC schemes are rare. According

to the OECD, average spending for public LTC was 0.1% of GDP in the BRIICS (Brazil,
Russia, India, Indonesia, China and South Africa 48% of global population)
compared to 0.8% in OECD countries.28 The informal/family care sector is often the
only option for those in need of care. The lack of a formal sector is partly rooted in
cultural differences such as the established role and responsibilities of the family and
the state: in many emerging markets, the state has rarely provided a safety net of any
kind. Another reason is that the rapid demographic and economic developments in
emerging markets in recent years have outpaced the implementation and funding of
formal LTC schemes and infrastructure.
In all markets, private individuals face

a growing financing obligation for LTC
over the next 15 years.
Spending on public plans in the advanced world will increase from 0.8% of GDP in
2010 to between 1.2% and 1.4% of GDP by 2030, the OECD says. Given strained
public finances and competing needs, policymakers will have to make difficult
decisions. In emerging markets, public finances are less strained but the low starting
point of LTC spending (0.1% of GDP) and the immense growth of the funds required
(between 0.5 and 0.6% of GDP by 2030) will be a huge challenge. Ultimately, the
burden on individuals will increase in both the advanced and emerging markets. They
already pay for a large chunk of their own LTC needs. They will need to pay more.
Provision of long-term care

Most care today is provided at home by
family members.
Funding is not the only area of concern. So too is availability of LTC infrastructure and
formal and informal care providers. Today, around 70% to 90% of those who provide
care are family members, and 90% of all home care is provided informally without
compensation.29/30 For example, in Europe children, children-in-law and spouses
make up more than 75% of carers.31 Similarly, in Japan informal care by adult children
or children-in-law is the most common source of care for the elderly, in accordance
with the traditional Japanese social norms. In Singapore, more than 75% of caregivers
are spouses and children, and about 14% of caregivers are maids.32 Semi-trained
domestic workers or maids from developing countries are also common home
helpers for the elderly in countries such as Hong Kong and parts of Europe.
24 See Rising Demand for Long-Term Services and Supports for Elderly People, Congressional Budget
Office, (2013), http://www.cbo.gov/publication/44363 (accessed 1 September 2014).
25 In this and all other cases in this report, unless otherwise specified, the exchange rate used is the
year-average for the year of the data point.
26 Valuing Carers 2011 Calculating the value of carers support, Centre for International research on
Care, Labour and Equalities, University of Leeds, (2011).
27 CLHIA Report on Long-Term Care Policy. Improving the Accessibility, Quality and Sustainability of
Long-Term Care in Canada, Canadian Life and Health Insurance Association, (2012).
28 OECD, no 6, (2013), op. cit. The data refers to the period 20062010.
29 R. B. Saltman, H. F. W. Dubois and M. Chawla, The impact of aging on long-term care in Europe and
some potential policy responses, International Journal of Health Services, vol 36, no 4, (2006).
30 Informal care-givers may still receive social transfers conditional on providing care and possibly, in
practice, some informal payment from the person receiving care.
31 Informal care in the long-term care system, European Overview Paper, Interlinks (2010).
32 K. S. Hock, T. E. Ser and Y. M. Teng, National Survey of Senior Citizen 2011, IPS Report, commissioned
by Ministry of Social and Family Development, (2013).
Often this is the preferred form of

receiving care, and in many cases
also the only one available.
The widespread use of informal care is due to many reasons. First, from the
dependants point of view, care at home is often the preferred means of receiving
support.33 But admittedly, in many countries it is also the only source of care
available. Meanwhile in some countries for example in France, Germany, Korea,
China, India, many states in the US, Ontario in Canada, and Brazil adult children,
children-in-law or families are by law responsible for their dependent parents.34
This is called filial piety, a value ingrained in many societies and a law in others.
Demographic trends point to a growing

scarcity of informal carers.
However, demographic trends point to a decline in the pool of potential caregivers.

The informal care sector will likely not be able to keep pace with growing care needs.
This shortage of supply may result in a shift towards the more expensive formal sector.
However, in many advanced countries the number of nursing home beds and qualified
caregivers is already scarce today. In emerging markets the situation is often worse.
Increasing the formal LTC supply will require significant investment from alreadystrained government budgets.
Capacity of residential care homes is also

limited and there is a shortage of
qualified carers.
For example, in China there were 39904 residential care homes in 2010,35 providing
a total of 3.2 million beds,36 capacity for just 1.5% of the 180 million persons above
age 65. Moreover, it is estimated that China requires at least 10 million trained elder
care workers and that currently, only a small proportion of caregivers are suitably
qualified.37 Elsewhere, in Brazil nursing homes exist almost only in major metropolitan
areas and are mainly supported by religious institutions. The state of So Paulo, for
example, with more than 3.5 million old-aged people, has only 4500 registered
nursing home beds.38 In Malaysia, a country of 28 million people, currently just
three public and one private hospital offer care for older patients, and there are only
11 geriatricians in the country, most in Kuala Lumpur.39 In India, where the number of
elderly amounts to approximately 90 million, there were an estimated 1444 old-age
homes with a total of about 73000 available beds in 2009.40 Capacity is also an
issue in advanced markets, though to a lesser degree.
Financial sustainability is the most

important priority for LTC systems.
Given these challenges, policymakers around the globe need to assess how to fund
and provide LTC efficiently and effectively. Ensuring fiscal and financial sustainability
is widely considered to be the most important policy priority for LTC systems in
OECD countries.41 This involves decisions about whether LTC should be financed
publicly or privately (or a mix of both).
33 Eurobarometer Special 283, Health and long-term care in the European Union, Survey conducted by
TNS Opinion&Social upon the request of the European Commission, Directorate General
Communication, Public Opinion and Media Monitoring, (2007).
34 P. Hope et al., Creating Sustainable Health and Care Systems in Ageing Societies, Report of the Ageing
Societies Working Group (2012), P. Knebel, Brazil: The young country is aging, Infosurhoy.com, (2011).
35 Y. C. Wong and J. Leung, Long-term Care in China: Issues and Prospects, Journal of Gerontological
Social Work, vol 55 no 7, (2012), pp 570586.
36 As a result of a government initiative (Views on Speeding up the Development of Elderly Services) the
capacity of residential care homes increased strongly between 2006 and 2009 with on average
additional 227000 beds per year.
37 Y. C. Wong et al. (2012), op. cit., J. Hu, (2012), op. cit.
38 L. E. Garcez-Leme, M. Deckers Leme, and D. V. Espino, Geriatrics in Brazil: A Big Country with Big
Opportunities, International Health Affairs, (2005).
39 K. S. Ambigga et al., Bridging the gap in ageing: Translating policies into practice in Malaysian Primary
Care, Asia Pacific Family Medicine, (2011).
40 S. K. Gulati and S. K. Jain, Best practices in managing LTC of elderly in developed European nations:
evolving strategies for India, presentation at the London School of Economics, 7 September 2012.
41 F. Colombo et al., Help Wanted? Providing and Paying for Long-Term Care, OECD Publishing, (2011).
The role of private insurance

Although LTC insurance is a tiny fraction
of total L&H premium income, ...
That LTC is rarely financed through private insurance is mirrored in very low levels
of LTC insurance premium income. Of the estimated USD 2670 billion of premiums
written by life and health (L&H) insurers globally in 2014, less than 1% stems from
LTC insurance, despite the huge LTC protection gap that people face.
it can help cover dependency costs.
Private LTC insurance traditionally covers the costs associated with dependency. It is
ideally bought before retirement. Premium payments are accumulated and then used
to pay the care costs (reimbursement-type insurance) of the insured or a fixed benefit
(annuity/indemnity/income type insurance). Private LTC insurance if available at all
coexists with countries public LTC systems, either to complement, supplement or
substitute any available public plans (see Table 1 and the Appendix for a discussion
of the major LTC insurance markets).
The role of LTC insurance is largely

determined by the existing social
security setting.
For instance, in Germany the mandatory private LTC insurance offers substitute
cover to those who opt out of the social LTC insurance scheme. In the US, only the
poor are eligible for Medicaid, while all others are responsible for their own LTC
cover. Private LTC insurance is thus a primary means for LTC risk sharing. Voluntary
private LTC insurance can also offer complementary/supplementary coverage for the
portion of the LTC costs not covered under universal public plans, such as in France,
Japan and Germany.
Voluntary LTC insurance has not been

able to close the LTC protection gap.
In practice, voluntary LTC insurance as a primary source for LTC risk sharing and
financing has turned out to be far from ideal. In the US and the UK, the limitations of
public plans and tough means-tests should give consumers a strong incentive to buy
private LTC cover. In both countries, however, LTC insurance has not been successful
and has only been purchased by a small fraction of the population. In addition, in the
US, policies turned out to be incorrectly priced and resulted in major financial and
reputational damages for insurers.
Insurers have been relatively successful

in providing supplementary LTC insurance.
By contrast, insurers have been relatively more successful in selling supplementary

LTC insurance like, for example, in Germany, France, Israel, and Singapore, although
benefit levels are usually quite small and insufficient to cover care costs. There have
been no major issues in these markets thus far but here too, traditional LTC products
have also not been a runaway success and market participants continue to explore
alternatives.
However, these successful LTC markets

are mostly younger than the US, and the
real test may be yet to come.
Note too, that the sales successes in some of these markets are not necessarily proof
of concept. The first decades of deferred LTC insurance products are usually not
problematic as claims are low, unless there is large selection bias. The acid test
begins after the first policyholder generation reaches the age when dependency
quickly rises. In this respect, it may be that the US is simply the most senior market.
Generous public systems limit the

development of private markets.
Insurers have also been less successful in markets with very generous public systems,
such as Japan and Korea. With the government covering a majority of the care costs,
there is little incentive for consumers to purchase additional private coverage. On the
other hand, subsidies for supplementary LTC insurance can incentivize consumers to
buy LTC insurance and reduce their LTC protection gap (eg, in Germany).
Singapore has adopted an interesting

voluntary system.
Singapore has adopted an interesting approach, based on insights from behavioral

science and aided by massive promotional campaigns, to increase participation in
its ElderShield program, a private-public-partnership LTC insurance plan. At age 40
citizens by default participate in ElderShield, but have the right to opt-out. Moreover,
premiums for ElderShield can be paid out of medical savings accounts, which are
funded by salary deductions and for which young healthy people often find few
other ways to spend the money as it is not available for non-medical purposes.
95 Universal social LTC insurance for those

40 and older
NA Long-Term Care Insurance Program (LTCIP)

is a universal LTC scheme with loose means
test
NA LTC costs are financed through: (1)

government subsidies; (2) ElderShield (a
government-designed, privately insured
scheme); (3) ElderShield supplements
(top-up policies offered by private insurers
on top of ElderShield); and (4) Medifund for
remaining LTC costs for the needy.
45 Currently: means-tested safety net

NA
(assets<USD 3740000)
To be introduced: lifetime LTC cost cap,
LTC cost in excess of cap born by
government (room and board not included in
cap)
27 Mix of universal (for home care) and

NA
means-tested benefits (often for institutional
care)
Japan*
Israel
Singapore
UK*/**
Canada*
7.9%
(only life
insurers)
19.0%
5.5%
99
220
160 (ElderShield)
710 (total)
240 (individual)
470 (group)
13.6%
1.3%
NA
22.5%
Primary risk
sharing
mechanism
ElderShield is the
part of the
healthcare system
designed to meet
LTC needs.
Supplements
public LTC
insurance
Supplements
public LTC
insurance
Supplements
public LTC
Pre-funded,
deferred
Supplements
public LTC
Pre-funded,
Primary risk
long-term care sharing
bonds, and
mechanism
immediate
needs annuities
Pre-funded,
deferred
Pre-funded,
deferred
Nursing care
expenses
(P&C), Critical
illness (L&H)
Pre-funded,
deferred
Pre-funded,
Supplements
deferred, stand mandatory LTC
alone and rider insurance
to L&H
Pre-funded,
deferred
USD 1920 for a 60-year old

for a benefit of USD 45/day
(based on insurance table
DAV 2008P)
USD 3300 for a 60-year old

(range: USD 1500
and 5800)
Typical annual
premium rate
Level premiums from age

65, under specific
conditions rates can be
adjusted with the Insurance
Commissioners approval
NA
NA
Fixed benefit and

For same conditions, most
reimbursement, typically
likely similar to the US
with a waiting period of 30
to 90 days, limited period
or lifetime coverage
NA
Fixed benefit up to
Fixed, but entry age and
USD 3 840 per annum, for gender specific, for a
up to six years
40-year old male/female
USD 1680/2100.
ElderShield and ElderShield
supplements premiums can
be paid from Medisave, a
mandatory individual
medical savings account
scheme.
Fixed benefit, typically

with a waiting period of
30 days, limited period of
coverage
Fixed and/or lump sum

benefits
Mainly fixed benefit,

USD 475 (on average, age
typically USD 2025/day, at inception also 60)
waiting period 90 days
(lump sum also available,
premiums and benefits
can be inflation protected)
Reimbursement and fixed

benefits
Mainly reimbursement,
usually capped at USD
150/day for 3 years,
waiting period 90 days,
often inflation protected.
Role of insurance Benefit type
Private LTC insurance

Nominal
LTC products
CAGR
(20032012
in LC)
LTC insurance data is not

NA
separately reported, may be
included in private health
insurance written by L&H
and P&C companies
826 (total)
599 (life insurers)
192 (Mutual 45)
35 (Institutions de
Prvoyance)
1095 (voluntary LTC

insurance)
11645 (total)
9550 (individual)
2095 (group)
Premium volume (2012,

USD million)
Note: *Total LTC costs are based on 2008 LTC/GDP ratios; **Public expenditure on LTC only; LC = local currecny; NA=not available.
Source: Total LTC: OECD (2011), CBO (2013); private LTC insurance: Supervisory Authorities, Insurance Associations, Singapore Ministry of Health.
NA
NA
90% (45%
taxes, 45%
social
contributions,
10% copay)
70%
47 Universal LTC consisting of social health

insurance and a specific, means-tested LTC
scheme called Allocation Personalisee
dAutonomie (APA)
France*
67%
71%
47 Universal LTC insurance, dual system with

social LTC and private LTC insurance
191 Means-tested safety net (Medicaid, assets

<USD 2 000)
% of total
LTC
Germany*
US
Total paid LTC

Public LTC
costs (2011, Type of public LTC scheme
USD billion)
Table 1:
Market size and private/voluntary LTC insurance in countries with significant private LTC insurance
In most emerging markets there are

hardly any social or government schemes
for LTC funding.
In most emerging markets, few if any private products are available, even though
there is little in the way of public LTC insurance. In China, large insurance companies
sell savings-type insurance marketed as solutions to finance LTC costs. In India, there
is no market for LTC insurance. Here the backstop is the culture of mutually supportive
and self-reliant families. In Latin America, a 2005 survey of 13 countries found that
only Brazil had a voluntary private LTC insurance market.42
A novel approach with a cap on lifetime

LTC costs paid out of pocket by the
consumer has been proposed in the UK.
A novel approach is working its way through the legislative system in the UK. The
proposal is to set a limit on the lifetime LTC costs that a person pays out of pocket.
Once the limit is reached, the government takes over, eliminating the tail risk. The
caveats to the system are that room and board costs are not included in the cap,
nor will they be paid by the government after the cap is reached. Moreover, already
strained local governments have to verify the coverage and payments for care in
fulfilling the cap. Nevertheless, this set-up with no tail risk would make it easier for
insurers to offer private solutions to help cover the early risks and may help broaden
the types of private solutions available to help consumers with care costs.
The risks and costs of becoming dependent

A starting point for estimating the
expected costs of care would be
accurate data about LTC risk.
Figures on incidence rates by level of

dependency are only available for a few
countries.
Dependency increases with age, with

only about 10% of cases classified at
the most severe level.
Three types of information are needed to estimate the expected cost of LTC. The first
deals with the probability of becoming dependent (the incidence rate), including
its severity and any transitions between levels of disability. Next, the duration of
dependency would ideally be available. And finally, information on the cost of care is
necessary to allow insurers to calculate the expected LTC costs (ie, the average costs
per insured). However, such data is not universally available.
The probability of becoming dependent
Probabilities of dependency are important for future care planning and for assessing
the cost of LTC. But figures on incidence rates for the various levels of dependency
on the ADL or IADL scales or other metrics are available in a few countries only,
usually those with well-developed LTC insurance markets. In the US, for example,
it is estimated that around 20% of the residual life expectancy at age 65 for males
and 30% for females will be in a state of chronic disability.43
Dependency increases with age, and females have a higher probability of becoming
dependent (see Figure 5). At advanced ages and for both genders, mild dependency
is common, but only about 10% of cases across all age groups are classified as
severe. The exception is women older than 90, of whom 15% are severely
dependent.
42 N. Aguilera, and J. Huerta-Muoz, CISS-CIESS Survey on LTC in Latin America and the Caribbean,
Working paper CISS/WP/05012, Inter-American Conference on Social Security (CISS), Inter-American
Center for Social Security Studies (CIESS), (2005).
43 E. Stallard, Estimates of the Incidence, Prevalence, Duration, Intensity and Cost of Chronic Disability
among the U.S. Elderly, Society of Actuaries, Long-Term Care Insurance Section, Issue 22 (2009); and
E. Stallard, Joint Dependence of Cognitive Impairment and ADL Disability in the U.S. Elderly Population:
Estimates from the 2004 National Long Term Care Survey, (2013).
Figure 5:
German LTC insurance beneficiaries by
age group and dependency levels, 2011
60%
60%
Females
50%
50%
40%
40%
30%
30%
20%
20%
10%
10%
Males
seve
med
mild
0%
0%
60 to
65
65 to
70
70 to
75
75 to
80
80 to
85
85 to
90
Mild
90 and
older
Medium
60 to
65
65 to
70
70 to
75
75 to
80
80 to
85
85 to
90
90 and
older
Severe
Source: Bundesministerium fr Gesundheit (Germanys Federal Ministry of Health).
Prevalence rates also differ considerably

according to the definition of dependency.
A key driver for the total cost of care is

the duration of care in nursing homes,
which varies significantly among
individuals.
Unit costs of care vary significantly

for different levels of dependency.
Informal care costs are comparatively low.
Prevalence rates also vary significantly according to the definition of dependency as

well as its interpretation. Large variations in dependency data can occur depending
on whether the ability to perform ADL is defined as with or without the use of assistive
devices such as canes or walking frames. Similarly, the assessment can be based
on a requirement for total or partial failure of ADL, thus impacting the experience
rates. Moreover, differing experience levels are possible depending on whether or
not the disability definition includes a trigger based on cognitive impairment without
necessarily failing any ADL.
Duration of dependency
The second key driver for the total cost of care is duration of care. Again, comparative
cross-country data are sparse but according to a report commissioned by UK private
health insurer BUPA,44 the average length of stay in nursing and residential homes in
the UK is around 800 days (2.2 years). However, the range is immense: about 50%
of dependants die within the first 15 months after admission, while 10% are resident
for more than six years. Length of stay does show some general patterns. It declines
with the age at admission, and on average women stay more than one year longer
than men. Those with dementia have significantly shorter lives in nursing and
residential homes.
Unit costs of care
The third driver of care costs are the unit costs of care. The range of costs varies
widely, both within and across countries.
Most dependants suffer relatively low levels of dependency, requiring a few hours
of help per week, and the cost of this type of care is comparatively low. In the case
of informal care provided by relatives, which is the most prevalent form, the care is
often unpaid. Formal home care costs amount to the average hourly wage of a home
health aide (a typical long-term care worker), multiplied by the hours of care needed.
For example, in the US caregivers are paid around USD 21 per hour.45 In Germany,
44 Based on a close to population representative sample of 11565 observations in the UK, see J. Forder
and J. L. Fernandez, Length of stay in care homes, PSSRU Discussion Paper 2769, Canterbury:
PSSRU, (2011).
45 Congressional Budget Office, (2011), op. cit.
professional caregivers in nursing homes have a gross wage of between USD 17 and
USD 21, which is probably a good proxy for formal homecare costs.46
The bulk of LTC costs are related to the most severe cases, where institutional care is
required. In the US, on average around 92% of the lifetime LTC costs are incurred
during episodes of severe disability which account for about 50% of disabled
years.47 Nursing home costs are hence an important factor for expected lifetime LTC
costs. As shown in Table 2, annual nursing home costs are high relative to median
income and wealth. A median income in an advanced country would cover just
0.3 to 0.7 years of institutional care. In many countries, median wealth would need
to be fully spent to cover nursing home costs, and in many cases it would run short.
Severe cases involving institutional

care make up the bulk of lifetime LTC
expenses.
Table 2:
Income and wealth compared to the cost of
nursing homes
Retiree income+
couple/male/female
Median
income++
Median
wealth+++
Nursing home costs

by degree of dependency
Severe
US
UK
Germany
France
Canada**
Australia***
Switzerland
Japan
Italy
Spain
China
Mexico****
32821
28045
40600 /26000/21500
NA/24 383/16990
39886
30783
46286
29916
29056
25237
27213
27835
34929
38570
47237
26671
44911
111524
49370
141850
90252
219505
95916
110294
25385
19844
NA
NA
23451
18531
5645
3086
138653
63306
8023
9718
Medium
85000
54400
54300
116800
62200
26400
22000
Number of months nursing

home can be financed ...
Low
42 600*
43 000
46700
44 600
36 000
47200
77900
49300
24600
26600
15400
39550
40100
38900
36400
22800
6500
by median
income++++
by median
wealth++++
4
7
6
7
12
9
5
5
6
31
13
38
30
56
15
27
11
8
4
2
68
29
6
5
Note: all income, wealth and cost data in USD. Latest data as available between 2008 and 2013; * Assisted Living; ** In Canada Nursing home costs refers
to copayments, which are means tested; the value shown here is the maximum copayment. Copayments vary significantly by province; *** For an individual
exceeding the means-test (severe: dependent reaches cap of AUD 25000 for care fees, mild assuming AUD 25/day care fees); **** Annual costs do not include
possible registration fees of close to USD 9 000 or more.
Source: USA: Metlife (2012); UK: Office of National Statistics; Germany: www.pflegekostet.de; France: Maisons-de-retraite.fr; Canada: senioropolis.com; Australia:
CPSA; Switzerland: Federal Office for Statistics; Japan: P. Olivares-Tirado and N. Tamiya, Trends and Factors in Japans Long-Term Care Insurance System, Japans
10-year Experience, SpringerBriefs in Aging, (2014); Italy: Auser (2012); Spain (2012): Infopenta; China: AXCO; Mexico: Emprendedores a bimonthly journal of
Facultad de Contadura y Administracin de la UNAM; +OECD (2013); ++ OECD (2010), +++Credit Suisse (2013); ++++Annual costs refer to the costs of severe
dependency (nursing home stay) where available.
Cases of severe care are expensive and

insurance for severe LTC offers significant
welfare gains.
The experience data, where available, show that severe disability has a comparatively
low probability, but very high cost. In contrast to low levels of dependency (which
have a high probability but low cost), a simple system of individual savings accounts
is inappropriate to finance cases of severe dependency, because saving will in
retrospect turn out to have been unnecessary due to the low probability of occurrence.
Moreover, only a few people are that rich to be able to save enough to cover the cost
of an average episode of severe LTC. This suggests LTC insurance offers significant
welfare gains.
46 http://www.lohnspiegel.de/main/zusatzinformationen/pflegeberufe (accessed 1 September 2014).

47 Stallard (2009), op. cit.
The economics of private insurance solutions

The private LTC insurance market is small
due to various supply- and demand-side
issues.
In spite of a seemingly large market opportunity for LTC insurance, the reality is that
the private solutions sector is small. Private premiums are expected to be less than
1% of global life and health premiums in 2014, amounting to at most USD 20 billion.
There are supply- and demand-side reasons for this.
Supply-side issues
Lack of data can be an impediment
to improving overall care solutions.
Lack of appropriate data can impede overall care solutions and the wider development
of an insurance market. In markets without notable LTC insurance sales and this is
the case in many advanced and nearly all emerging markets the limited availability
of experience data makes it harder to design and price care solution products. It is a
chicken-and-egg problem: without a large market there is little experience data and
without experience data, there is no market.
LTC insurance is typically deferred

and far forward-looking, making it
sensitive to assumption changes...
But even where data exists, it is not obvious how the key parameters will develop in
the future. Where there have been private markets, LTC insurance has traditionally
been deferred, involving many years or even decades between the design and
pricing of the contract and payment of benefit. However, fixed benefit contracts
require long-term assumptions about dependency incidence rates, mortality rates
for healthy and disabled, lapse rates and investment income. Reimbursement-type
policies require even more assumptions such as future care cost escalations and the
cost implications of innovations in future care technology. In the case of a 50-year
old purchasing LTC insurance, these projections must hold for 30 to 40 years, or
more. It is virtually impossible to make such assumptions accurately, and any errors
in doing so can cause significant losses to the insurer.
which makes it challenging to price

the policies.
Insurers can include a safety margin in pricing to guard against assumption sensitivity,
but that makes policies more expensive. Also, consumers can be put off by contractual
clauses that allow insurers to raise prices on blocks of business that have not met
assumptions. Finally, these long-term systematic risks are not easy to hedge and
require a lot of solvency capital, another cost in providing these products.
The US experience illustrates

why deferred LTC insurance with
reimbursement is particularly
challenging.
There is no easy work-around for the unknown future. In the US, assumptions made
for past products proved inadequate, especially when it came to investment income
and lapse rates. When significant losses from these contracts as a group became
apparent, regulators gave insurers permission to adjust premium rates several times.
However, the rate increases upset policyholders, understandably, and in many cases
made the premiums unaffordable. These challenges generated ongoing financial
losses and reputational damage to the US life insurance industry overall, so much so
that most players eventually withdrew from the LTC market.
An imbalance of premium payments and

expected benefits can result in market
failures.
Insurance markets can fail in scenarios of asymmetric information and adverse

selection.48 Where adverse selection is suspected, insurers may need to charge
higher prices to make up for the potential crowding out of demand from healthy
individuals. This again makes products more expensive. Brown and Finkelstein
(2007) find some evidence for an imbalance between premium payments and
expected benefits of LTC insurance.49 However, they conclude that this alone cannot
explain the low levels of coverage and that demand side effects must also play a role
in preventing wider uptake of LTC products.50
48 Asymmetric information occurs when one party has more or better information than the other, creating
an imbalance of power and undesirable market outcomes. Adverse selection is a consequence of
information asymmetries. It occurs when higher-risk people tend to buy more insurance but the insurer
is unable or not allowed to account for this in the price.
49 The imbalance between premium and benefit may also be rooted in the long-term nature of insurance
products which basically requires inclusion of safety margins, which again elevates the cost of
insurance, see J. R. Brown, and A. Finkelstein, Why is the market for long-term care insurance so
small?, Journal of Public Economics, vol 91 no 10, (2007), pp 196791.
50 J. R. Brown, et al. (2007), op. cit.
Inadequate care infrastructure and a

shortage of claims assessors stand in the
way of development of the LTC insurance
market.
Other supply-side issues include inadequate care infrastructure and a shortage of

healthcare professionals. Both undermine the value proposition of LTC insurance,
since one may not be able to easily purchase the care services needed. The market
also needs people with sufficient expertise to act as claims assessors. For example,
when ElderShield in Singapore was set up, a panel of expert assessors and a set of
guidelines were needed to ensure consistency in the assessment of dependency.
Volatile government social policies can

undermine the development of a private
market.
Developing and providing solutions for LTC also requires a consistent regulatory and
social policy landscape over a long period. If government-provided social insurance
policies affecting the elderly are subject to frequent changes, insurers will be more
hesitant to make the required investments into care solutions.
Finally, LTC insurance is sold, not

bought, and it can be a tough sell.
Finally, LTC insurance belongs to a class of products that are in general sold, not
bought. Many companies have struggled with the challenges of training a sales
force for LTC solutions. Younger sales people are generally less able to sell LTC
products than older agents. Moreover, LTC insurance competes with other off-theshelf products in the L&H sector. In an environment of large protection gaps,51 life,
disability, critical illness and/or medical insurance products are generally easier to
sell than LTC insurance.
Demand-side issues
A key demand-side issue is the lack
of awareness.
Demand-side issues also hinder the uptake of private LTC insurance. A main issue is
lack of awareness around the risks and costs of LTC. People of working age rarely
think about their end-of-life needs, since challenges 50 years in the future are too
remote and rank very low on their list of priorities. A study from the UK demonstrates
that even older-aged couples do not discuss their end-of-life care and how to pay for
it.52 People tend to procrastinate on solutions. Discussion on the retirement of the
baby-boomers was only fully underway in the 1990s, about 20 years before they
were to retire. If the same lead time is applied, the baby-boomers will be seriously
talking about LTC when they are 20 years away from needing care, or over the next
5 to 10 years. But it is already late since available solutions are mostly pay-as-you-go
programs. Thus, the burden of caring for the baby-boomers may have already shifted
to their children.
In emerging markets, awareness for

LTC risks has not yet developed.
Lack of awareness is also a likely reason for low LTC insurance demand in emerging
markets. These countries have seen fundamental economic, demographic and societal
shifts in the last few decades, changes that happened over a period of 150 years in
advanced markets. The needs awareness in the emerging markets has not kept
pace.
LTC risks are complex and difficult

to assess.
LTC risks are complex. For consumers it is hard to assess the magnitude of their risks
and hence to judge the value proposition of LTC products. When presented with
complex financial choices, consumers often fail to act, or make simple short-cut
decisions, which is often the decision to not buy insurance at all.
51 For more detail on mortality protection gap estimates by region see Swiss Res publications The
Mortality Protection Gap in the US, Mortality Protection Gap: Asia-Pacific 2011, Customers for Life
European Insurance Report 2010, Term&Health Watch 2012, and The Mortality Protection Gap in
Latin America 2013.
52 D. Price et al., Financial planning for social care in later life: the shadow of fourth age dependency,
Ageing and Society, vol 34 no 3, (2014).
Estimates of the need for LTC often provide

conflicting information, creating confusion
and possibly inhibiting advance planning.
The lack of understanding is not helped by the availability of a wide and sometimes
conflicting range of estimates of the need for LTC. For example, one US study
predicts that at least 70% of baby boomers are expected to need some LTC service
at some point, and that 40% are projected to require nursing home care.53 Another
report, however, says among people age 65 or over, only 14% need long-term care,
rising to half after age 85.54 In Europe, a comparative projection is that in the
Netherlands, there is a 20% probability of males incurring costs for nursing home
care over their lifetime.55 In many emerging markets, meanwhile, there are no
estimates at all. Such variety of benchmark reference points can be very confusing
for a person considering his/her future LTC needs.
The expectation that government will

provide a solution crowds out private
savings and insurance solutions.
Even if people are aware of the risks, many mistakenly believe a government or some
sort of public LTC scheme is available, which takes away any incentive to make
private provisions. This is the case in the many advanced markets which do have
public or social security provisions of some sort. However, these provisions may not
be universal LTC schemes and the benefits far from comprehensive. It may even be
that individuals speculate that once the baby boomers start needing care, public
schemes will be introduced (a negative social norm). This perception crowds out
individual responsibility around the need to arrange for private LTC.
For example, close to 70% of consumers

in Europe believe the provision and
funding of LTC is a public responsibility.
In a Swiss Re survey of more than 15000 consumers in 14 European countries,

close to 70% said the government is responsible for the provision and funding of
LTC.56 This perception was most widespread in the Nordic countries with universal
tax-based LTC systems. In countries where LTC is means-tested, financed out-of
pocket or by insurance, the responsibility was seen to lie more with the individual
than the government. Nevertheless, in all but one country, at least half of survey
respondents put the onus for nursing care for the very old on the government (see
Figure 6). Interestingly, in all countries, consumers expect the role of the
governments to decline over time.
In North America, misperceptions

of government involvement with
LTC similarly abound.
Misperceptions regarding what social security and governments will provide in

terms of LTC are evident in North America also. In the US, 86% of the baby boomers
under the age of 65 do not know if Medicare covers LTC, or they overestimate the
coverage. This lack of awareness is prevalent even though middle-income US
citizens with Medicare (ie, those 65 and over) cite long-term care in a facility and
long-term care at home as the top healthcare expense that they feel will threaten
their financial security in retirement.57 In Canada, many mistakenly believe that all of
their long-term care needs will be met by governments. In reality, however, they will
largely be responsible for the cost of their own care needs.58
53 D. R. Calmus, The Long-Term Care Financing Crisis, Center for Policy Innovation Discussion Paper No.
07, (2013); P. Kemper, H. L. Komisar and L. Alecxih, Long-Term Care Over an Uncertain Future: What
Can Current Retirees Expect?, Inquiry, Winter 2005/2006.
54 S. Rogers and H. Komisar, Who needs long-term care? Fact Sheet, Georgetown University Long-Term
Care Financing Project, (2003).
55 L. Spoor, Towards Multi-Pillar Financing of Dutch Long-term Care for the Elderly?, in the Geneva
Association Health and Ageing Newsletter, (2013).
56 European Insurance Report 2012, Customers for Life, Swiss Re (2012).
57 Retirement Healthcare for Middle-Income Americans, Bankers Life and Casualty Company, Center for a
Secure Retirement, (2012).
58 Canadian Life and Health Insurance Association, (2012), op. cit.
Figure 6:
Proportion of survey respondents who
believe the government is responsible for
provision of nursing care for the very old
now and in 10 years time
Finland
Denmark
Sweden
Norway
Netherlands
Turkey
France
Spain
Belgium
Italy
Switzerland
Austria
Poland
Germany
Total
0%
20%
Today
40%
60%
80%
100%
In 10 years
Source: European Insurance Report 2012, Customers for Life, Swiss Re.
Private insurance solutions are also

crowded out by the expectation that
offspring will care for their dependent
parents.
The expectation that children will take care of their parents further crowds out private
responsibility for LTC insurance. In many emerging markets, traditionally one of
the children or a child in-law takes the role of the caregiver. However, the transition
towards smaller families, increasing labour force participation by women and higher
mobility of the workforce (increasing distance to the dependant) challenge these
traditional arrangements and brings their sustainability into question.
LTC insurance can be expensive or

even unaffordable,
For many consumers, LTC insurance is deemed too expensive or even unaffordable.
Thus, the development of the market may be hindered because low- and middleincome groups cannot afford the coverage, while high income groups do not need it.
Nevertheless, given the generally limited median incomes of the elderly and low
accumulated assets, the cost of the actual services of LTC is even more unaffordable
for most people than LTC insurance.59 In the US, around 27% of consumers among
the wealthiest 20% had a LTC policy in 2008 while among the poorest 20%, only
about 4% owned LTC insurance.60
especially if bought after retirement.
Affordability is related to the age at which a policy is bought. If individuals purchase

LTC insurance at a young age, the premiums are much lower. According to one study,
an individual buying LTC insurance at age 60 will pay almost double the annual
premium rate an individual buying the same coverage at age 45 does.61 At younger
ages though, incomes are lower and there are many competing and more immediate
spending needs (raising a family, buying a car or house, etc). End-of-life issues far in
the future do not feature prominently in peoples thinking. The upshot is that many
only start to think about their LTC needs when they approach retirement age, when
the risk is already relatively close and the premiums, therefore, high.
59 F. Colombo et al. (2011), op. cit.

60 J. R. Brown et al. (2011), op. cit.
61 See Herleitung der Rechnungsgrundlagen DAV 2008 P fr die Pflegerenten(zusatz)versicherung,
German Actuary Society.
Figure 7:
Annual premiums for LTC insurance in
the US and Germany, in USD, 2010
18 000
16 000
14 000
12 000
10 000
8 000
6 000
4 000
2 000
0
Men
Women
Germany
Comprehensive LTC, USD 50/day
Age
45
50
55
Constant benefit 5% benefit escalation

US
30-day waiting period, USD 150/day
60
65
70
75
Source: J.R. Brown and A. Finkelstein, Insuring Long-Term Care in the United States, Journal of Economic
Perspectives, vol 25 no 4, (2011), pp 119142, Herleitung der Rechnungsgrundlagen DAV 2008 P fr die
Pflegerenten(zusatz)versicherung, German Actuary Society.
Affordability is a severe issue for

the elderly.
In Germany, in 2012 those between 50 and 65 had a median income of EUR 20688.62
For a 65-year old man, an LTC premium would have taken up 7% of his income and
for a woman of the same age, 11%. By comparison at age 45, the LTC premium
would have taken 3% and 4.3%, respectively, of the male and female median
income. In the US, the premiums similarly get more expensive with age (see Figure
7). Further, as there is no mandatory basic LTC insurance in the US (in contrast to
Germany), the benefits of private cover and hence premium payments are typically
much higher, and therefore more unaffordable, particularly for the elderly.
Behavioural economics and cognitive

biases such as procrastination,...
Finally, behavioural economics and cognitive biases play an important role in

consumer thinking around buying insurance.63 People often postpone making tough
decisions about the future because they can involve unpleasant discussions and/or
thoughts. Procrastination is very much part of the decision-making process when it
comes to buying LTC insurance. Procrastination and affordability are interrelated:
with every year of postponement, premiums become more expensive and potentially
unaffordable.
overconfidence and loss aversion also

play a role in limiting the uptake of LTC
insurance.
Another well-established bias is overconfidence. Many people think good things

are more likely to happen to them than to others and bad events such as becoming
dependent less likely than to others. Loss aversion is also important: paying for
decades into a policy with the risk (actually rather the luck) of not receiving anything
back is a big hurdle for consumers to cross when it comes to making a decision
about buying LTC insurance.
62 Source EUROSTAT.
63 For a discussion of how behavioural economics impacts insurance buying see
sigma 6/2013 Life insurance: focusing on the consumer, Swiss Re, (2013).
Creating a better care market for older lives

Youll never walk alone a multi-stakeholder approach
The solution to providing care to the
ageing population involves multiple
stakeholders.
The challenge of providing care for the ageing population requires a comprehensive
solution, including all stakeholders: insurers, governments, healthcare institutions,
current and potential care providers, and current and future potential consumers of
care. Starting from different points, most countries will have to reform their systems
to find sustainable solutions for growing care demands.64 This chapter looks at
possible policy and other responses.
Governments can help raise awareness

by being clear about the extent of state
provisions.
As a starting point, governments could help raise consumer awareness of the risks
and costs of care solutions by clearly communicating what care is provided by the
state. This would help individuals make more informed decisions about how best to
provide for their old-age care needs. It would also give insurers a better-defined
backdrop from which to develop care products.
They could also partner with insurance

companies as potential investors in care
infrastructure
Governments could partner with insurance companies as potential investors in care

facilities. At present, governments often house patients inappropriately and very
expensively in hospitals, and do not have the financial capacity to invest in care
infrastructure. By partnering with insurers, governments would benefit from lower
costs and funding needs. For insurers care infrastructure could be an interesting
asset class because their returns are positively related to the development of care
needs. Therefore, care infrastructure would be a good asset match for care risks on
insurers liability side.
and reconsider those regulations that

impede the development of a private
LTC market.
Policymakers also need to be mindful of regulations which may hinder the development
of a private market. For example, excessive capital requirements on very long-term
products can create impediments to insurers willingness to participate in the
market, and also make products more expensive.65
Tax incentives and more employer

involvement could help with future
funding needs.
Another approach would be to work with employers to institute programs similar to

voluntary pensions, such as the 401(k) in the US. Employer involvement can also
help raise awareness of LTC risks. Group LTC insurance does exist in certain markets
such as the US and France, but employers typically do not contribute towards the
cost of premiums. With the right design (for example opt out instead of opt in) and
tax or other financial incentives, it may be possible to make some people start paying
for policies early when it is still affordable, as in Singapore. It is along these lines that
the Taiwanese government is expected to launch a LTC insurance system in 2016,
financed collectively by the state, private employers and the insured.66 Similarly, in
the UK there is discussion about a ring-fenced pension system dedicated to care
solutions and with additional tax incentives. The idea is that this Care Pension Fund
is to be used only to fund care expenses. Further, if the fund is not used, it can be
passed on to family descendants without inheritance tax.
Any solution needs to consider

promoting longer working lives.
The care solutions challenge is also about social behaviour. Many people have the
mind-set that retirement begins at a certain age, say 60 or 65, with no flexibility.
They also expect that any available government programs in retirement will also
begin at this age and cover their care needs. These attitudes could be encouraged to
shift towards the possibility of working longer through incentives and labour market
flexibility and by removing any structural and legal barriers or other disincentives to
working longer. The work could be on a full- or part-time basis and would give
individuals more time to save for future care needs.
64 P. Hope et al., (2012), op. cit.

65 R. L. Lumsdaine, Why Systemic Risk Considerations Affect the Market for Long-Term Care Insurance,
The Economists Voice, (2011).
66 Distribution Debrief: Insurance Market Update. Asia-Pacific, Towers Watson, Issue 28, (2012).
An integrated approach
Better coordination is needed across all
the aspects of the financing and delivery
of care solutions.
There needs to be stronger coordination across the different agents involved in the
delivery of care services and solutions. Currently the financing and delivery of care
is highly fragmented, and in most cases it is separate from healthcare provision.
Moreover, there is often no coordination between social services and home-care
providers, which generates extra costs and inefficiencies, and does not deliver
the best outcome to the patient.67 An example of a well-coordinated system is
LifeChoices in Michigan. This is a membership program with an upfront fee (USD
3000050000) and a monthly fee (about USD 400) to cover all core services and
assists people to age at home.68
Demonstration programs for such

care have been set up in the US,
and discussed elsewhere.
Managed long-term care, which coordinates the provision of care across various
services from health to social care and across the multiple dimensions of care from
informal to formal, is another example. In the US, demonstration programs that
coordinate all care in this manner have been established. In exchange for a lump sum
per person paid by the government,69 the health plan agrees to provide all aspects
of care services for persons in the program. Discussions to set up similar programs
have occurred in Asia but no plan is actually in place yet. In the UK, the Better Care
Fund is an analogous idea.
In the future, a wider market for such

managed care plans is possible.
In the future, employers who provide health insurance through the group market
could perhaps include managed care coverage as part of the employee benefits
package. But it will be some years before this can happen as there are still many
unanswered questions about the cost-effectiveness of the managed care program.
Also, the market would need a rule to deal with employees who switch jobs and/or
retire.
Encouraging mechanisms that allow

people to remain at home longer can
help reduce the costs of care.
Tax incentives can ameliorate the already

heavy burden faced by families who
provide care.
Home is where the heart is and where care could be?

Many people want to stay at home when they need care.70 And, given the large cost
differentials between hospitals, long-term care facilities and home care, significant
savings can be achieved by implementing structural changes that help them do so.
Existing insurance products often include home-care coverage. Even so, in many
cases a reliance on medical models of care and a lack of community-based support
services has led to the continued inappropriate placement of older people to
residential care facilities.71 For example before reforms in 2000, in Japan the elderly
were admitted to hospitals because there were no nursing homes (so-called social
admissions). The reforms were implemented specifically to cut the number of
inappropriate long-term admissions into general hospitals.72
Care provided by family members is an integral part of the current care delivery
system, and will remain so if the aim is to keep people at home for longer. However,
demographic and societal trends are putting pressure on family-provided care and
the availability of family care will not keep up with the increasing care needs of the
elderly. One option to incentivise more family care could be to offer state payments
for care services, although this is difficult when government budgets are already
stretched. In some countries, dependants living at home can choose a cash
benefit in lieu of receiving care in an institutional setting to pay informal caregivers.
67 Americas Long-Term Care Crisis, Bipartisan Policy Center (2014).

68 G. Mitchell, Technology for Missions Sake, LeadingAge magazine March/April (2012).
69 The demonstration programs are initially undertaken for a portion of the dual eligibles who qualify for
means-tested public LTC under Medicaid and are also old enough to qualify for public healthcare under
Medicare.
70 For example, see R. Tarricone and A. D. Tsouros, The Solid Facts. Home Care in Europe, World Health
Organization, (2008); and, Smart Technology for Healthy Longevity, Australian Academy of
Technological Sciences and Engineering (2010).
71 Long Term Care and Technology. Senior Officials Meeting Final Report, International Federation on
Ageing, (2012).
72 Fact sheet on Japan, Help Wanted? Providing and Paying for Long-Term Care, OECD, (2011).
The aim is to keep people at home and contain overall care services costs. In the
Netherlands and Germany, these cash benefits are very popular, even though their
value is lower than the equivalent services in-kind.73
Additionally, family carers may be a
target market for care solution products.
Families could also be a target market for care solutions. Such solutions could range
from traditional LTC insurance, to a product that covers some parts of the care
provided by the family member to alleviate the burden on that caregiver and also
give him/her an opportunity to continue to work. And, as in many countries already
today, care solutions could include respite care riders, giving a caregiver a chance to
go on holiday while a nurse takes care of the family member at home.
Actually finding people to look after

the elderly is likely to become an added
challenge.
With the demographic shifts taking place in many parts of the world, the issue is also
about finding and training people to care for the elderly. One solution could be to have
the young old (people just retired) take care of the old olds, an idea that challenges
traditional models of retirement. Likewise, initiatives to engage younger retirees in the
community, for instance re-employment in urban gardens, community nurseries and
in community restaurants, can reduce the burden on pay-as-you go systems. Such
ideas have been piloted in Japan and have increased the community workforce and
helped contain medical and nursing cost. Importantly, they also help the elderly feel
less socially isolated and maintain their physical and mental functions.
In several countries, an important step

is integrating migrant workers employed
informally into the formal system.
In some countries such as Austria, Germany, Switzerland and Italy, but also in many
Asian markets, migrant workers are significant providers of informal care. Often
these carers operate in a grey market. For instance, in Italy less than half the
2 million-plus home care assistants are formally employed.74 In implementing
changes to better integrate the informal and formal care sectors, lawmakers may
need to consider migrant worker rights. Additionally, issues arising in the home
countries from the outflow of potential carers need to be addressed. In some cases,
going abroad may be an option for the elderly themselves: seeking less expensive
care in a market with good care infrastructure.
Many major risk factors leading to ADL

limitations
are preventable.
An ounce of prevention
Health prevention initiatives can generate significant cost savings.75 Lifestyle-related
chronic diseases such as coronary artery disease, stroke, diabetes and some cancers
are a growing burden on individuals and national health systems. Yet many of the
major risk factors for non-communicable diseases like these, and thus the resultant
ADL limitations, are preventable.
Obesity and smoking, for example, are key contributors to chronic disease trends. In
the US, estimates attribute 12% of type 2 diabetes and 22% of coronary heart disease,
as well as other conditions, to lack of physical activity.76 Meanwhile, several studies
have concluded that improved diets and increased levels of physical activity reduce
the risk of chronic conditions and associated disability, and that appropriate
management of the conditions can limit or reverse ADL limitations.77 A study in
France found that intellectual and physical activity could even help hold back mental
deterioration. Specifically, the report cites a 15% reduction in Alzheimers detection
in workers who retired at age 65 over those who retired at age 60.78
73 These schemes raise the issues of moral hazard and fraud, but this is true for all government social
programs and insurance products.
74 R. Tarricone et al. (2008), op. cit.
75 See for example F. Colombo and J. Hurst, Revisiting the OECD Review of the Korean Health System,
Osaka Economic Papers, vol 58 no 2, (2008).
76 R. Nugent, Chronic Diseases in Developing Countries, Center for Global Development, (2008).
77 G. Lafortune et al. (2007), op. cit.; C. Malhotra et al., Prevalence, correlates and perceived causes of
limitations in activities of daily living among older Singaporeans, Aging Clinical and Experimental
Research, vol 24 no 1, (2011); and R. Nugent, Chronic Diseases in Developing Countries, Center for
Global Development, (2008).
78 C. Courbage, Editorial to the Geneva Association Health and Ageing Newsletter no 29, (2013).
Insurers can incentivise healthy living

with rewards programs.
A portion of future (expensive) care needs can be avoided by smaller, but earlier
investments in preventative measures. Insurers and other care services funding
providers may be able to benefit from initiatives that keep people well and active,
rather than just focus on extreme acute care. To incentivise people who, for instance,
do not want to stop smoking, premiums could be differentiated accordingly, and
there could be other rewards for those who do take preventive actions. Such rewards
programs have already been introduced by L&H insurers in South Africa, who use
telematics and other types of data collection to monitor the insureds actions.79
Several countries have made a start

with healthy ageing initiatives.
Several countries have made a start with healthy ageing initiatives. For example,
Taiwans Healthy People 2020 is a health-promotion program for older people
with a focus on the prevention and management of chronic conditions including
diabetes, hypertension and asthma. In Japan, the government has mandated wellness
programs. In Singapore, initiatives include regular health screenings for early detection
of illness, and a focus on social integration of seniors and inter-generational cohesion.
Such undertakings can all be part of care services and solutions.
Insurers and public payers for care

solutions should encourage the
application of new technologies,...
Service innovation through technology

Just as health insurers have realized the value of subsidising gym memberships, care
solutions insurers and public payers for care services may benefit from subsidies that
encourage the application of technologies and devices that help older people live
alone longer.80 Or, insurers could provide the distribution channels for these types of
technologies.81
which can provide scope for innovation

and efficiency in the care solutions arena.
Technological innovation can enable better health monitoring, care coordination and
a longer period of living unassisted/alone. For example remote monitoring devices
can track glucose levels in diabetics, detect falls and in more advanced cases, even
be linked to analytical systems that predict impending heart failure.82 Similarly,
medication adherence can be tracked by smart pill bottles that notify a caregiver via
text message of cases of non-compliance.83 Locator devices can assist with the
management of dementia patients.84 And various tele-health initiatives can reduce
admissions to hospitals, number of home visits and visits to general practitioners.85
These and other remote interventions can be less expensive than constant monitoring
in a nursing facility, and increase quality of life by helping people stay at home.
Innovation can also offer support to

informal care providers.
There are also new devices that help caregivers coordinate overall care needs. An
example is an online tool called Grouple, which is being piloted in the UK for carers of
the elderly with dementia. The platforms aim is to establish harmonised routines and
patterns of care among multiple family caregivers, and to provide access to an online
network of peers to share concerns and experiences.86
79 See for example Discovery Vitality: http://www.hr.uct.ac.za/usr/hr/remuneration/healthcare/

vitality_2014.pdf (accessed 1 September 2014).
80 Australian Academy of Technological Sciences and Engineering, (2010), op. cit.
81 J. Coughlin and J. Pope, Innovations in health, Wellness, and Aging-in-Place, IEEE Engineering in
Medicine and Biology Magazine, July/August (2008).
82 mHealth: A new vision for healthcare, McKinsey and Company, (2010).
83 Medication non-adherence accounts for more than 10% of older adults hospital admissions, nearly
25% of their nursing-home admissions, and 20% of preventable adverse drug events in the community
setting, Technologies to Help Older Adults Maintain Independence: Advancing Technology Adoption,
Center for Technology and Aging (2009), and Statistics you need to know: statistics on medication,
American Heart Association, (2009).
84 McKinsey and Company, (2010), op. cit.
86 P. Hope et al., (2012), op. cit.
Paying for home modification and essential

non-medical equipment instead of a nursing
home may be cost-efficient in some cases.
To prolong a persons independence, home modifications may be necessary. This

includes non-medical equipment such as special chairs, hoists, rails, ramps into the
house, adapted toilets, showers and baths, lifting equipment and more.87 Paying for
such equipment and modifications rather than for nursing home care may be more
cost-efficient and also improve quality of life.
A step up from basic modifications is

the concept of smart homes, which in
the future can enable the elderly to live
independently longer.
A step up from basic modifications is the concept of smart homes with an array of
wireless sensors that address intelligent health services, home automation, security
and safety, communication and entertainment.88 Insurers are unlikely to find
efficiencies in paying for such custom-built houses as part of LTC solutions, but the
sensors could help those who may well be living in smart homes in the not-so-distant
future retain their independence for longer than is possible today. Robots capable of
simple tasks like lifting could also be part of care services in the coming years, both
in the home and in support facilities. Overall, the elder care tech industry is projected
to be a USD 20 billion market by 2020.89
Some insurers and developers have

built entire care-continuum-friendly
retirement cities.
Purpose-built retirement cities consisting of independent- and assisted-living

apartments, a nursing home-type facility and a hospital are gaining popularity.
Sometimes, this concept is referred to as a Continuing Care Retirement Community.
In Florida, a retirement village in this vein with golf courses and social amenities for
retirees alongside healthcare facilities is the fastest growing metropolitan area in the
US.90 In similar residential developments in China financed by China Life and Ping
An Life,91 apartments are fitted with remote sensing equipment to monitor the vital
signs of high-risk residents. Other countries have retirement developments of this
nature also.
Innovative private insurance care solutions for older lives

Current care insurance products require
a fundamental re-think of design and
purpose.
Immediate-needs annuities, bought

when a dependant has to move into
a nursing home,...
Insurance alone cannot solve all care service and solution issues, but it can help
diversify the risks and make care more efficient. However, to meet the growing
demand and the same needs as classic LTC products, but in a more tangible and
easily sold way, a fundamental re-think of the design and purpose of current care
insurance products is required.92
Annuity products
Immediate-needs annuities (INAs) have been introduced in some markets. This
single-premium product is bought at the point when a dependant has to move to a
nursing home, so the benefit is very tangible compared to a traditional deferred LTC
policy. The issuer of the policy agrees to pay the costs of the stay, no matter how
long the dependant will require institutional care.
87 R. Tarricone et al. (2008), op. cit.

89 H. Kelly, Sensors let Alzheimers patients stay at home, safely, CNN International, 26 August 2014,
http://edition.cnn.com/2014/08/25/tech/innovation/alzheimers-smart-home/index.html?hpt=hp_
bn5 (accessed 1 September 2014).
90 T. Olorunnipa, Fastest-Growing Metro Area in U.S. Has No Crime or Kids, Bloomberg News, 27 June
2014.
91 China Life and Ping An Life are two major Chinese insurance companies. See Insurance Market Report.
Healthcare: Life&Benefits. China, Axco, (2013).
92 Traditional comprehensive LTC insurance products are not well suited for everyone, but in countries
where there is no public provision, or only lender of last resort-type cover for low-income individuals,
comprehensive LTC insurance may be a good way of dealing with LTC risks for those who can afford it.
have emerged as an alternative to

traditional LTC products.
The value proposition of INAs to the consumer is that it eliminates the risk of paying
for an extended and sometimes unaffordable stay in the nursing home. As mentioned
earlier, a BUPA study in the UK revealed that the average length of stay in a care
facility is 2.2 years, but 25% of the patients stay 3.6 years or longer, and 10% stay for
more than six years (see Figure 8).93 Thus, buying at the point of need provides value
to the consumer: he/she may have enough accumulated assets to be able to afford a
year or two of institutional care, and the immediate needs policy removes the risk of
running out of assets while there is still need for care.
However, immediate needs annuities are

expensive and unaffordable for many.
A disadvantage of INAs is that the policies are expensive (though cheaper than an
extended nursing home stay). In a competitive market the premium needs to cover
the average costs of the nursing home stay for the duration of stay plus the costs of
providing insurance.
Figure 8:
Survival rates of residents in a nursing
home, the UK , November 2008May
2010
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0 3 6 9 12 15 18 21 24 27 30 33 36 45 39 48 42 51 54 57 60 63 66 69 72
Survival in months
Source: J. Forder and J. L. Fernandez, Length of stay in care homes, PSSRU Discussion Paper 2769,
Canterbury: PSSRU, (2011).
The tail risk of care needs can also be

addressed with deferred immediateneeds annuities.
Hybrid products may be easier to sell

because they provide a payout to the
insured whether or not a need for LTC
arises.
A significantly less expensive option is the deferred immediate-needs annuity (also

known as a deferred care plan). This is bought at the time of admission to a nursing
home, but pays care costs only after a waiting period such as two years, thereby
eliminating the tail risk of the costs. The waiting period is like a deductible and the
price, therefore, only a fraction of a deferred LTC or an INA because only the few
dependants staying longer than the average in these care settings receive benefits.
Hybrid products
Hybrid products combine LTC insurance with life, retirement/pension or critical illness
products. They pay out the death benefit early, or increase the monthly payment
from the annuity at the onset of the LTC need. Their advantage over traditional LTC
products for the consumer is that if care is not needed, the underlying life or
retirement product still gives the insured a payout. This can help overcome the loss
aversion and the mental accounting challenges traditional LTC insurance faces.
93 J. Forder et al., (2011), op. cit.
Hybrid products have a lower risk

profile and can be sold for less.
Assisted living insurance provides relief

with professional services and financial
support in the initial stage of dependency.
In some cases, products can address

specific aspects of the care need.
Within current products,

re-labelling may be helpful.
Reverse mortgages allow homeowners

to tap into their home equity to finance
care solutions.
From the insurers perspective, hybrid products have a lower risk profile than standalone LTC insurance, as some risks diversify. In particular, the sensitivity to changes
in assumptions (about investment income, lapses mortality and incidence rates) is
materially lower for hybrid products. This reduces the costs and hence the price of
these products.94 The LTC feature can also be a rider on a traditional life/annuity
product, rather than a full combination product. For example, in Hong Kong a global
life insurer offers a rider to a term annuity that pays an extended income for life if the
policyholder becomes unable to perform certain specified activities of daily life.95
Services and financing
Assisted living insurance (also known as short-term care insurance) is intended to
help support a policyholder and his/her family in the initial stages of dependency.
It provides financial support for a set period and advice in cases of unexpected care
costs, allowing the individual and family some time to organize financing for future
care costs. The insurance also provides access to a suite of services from care,
assistance, financial advice, to offering solutions and taking over arrangements as
needed.
Other insurance approaches
In some cases, it may be better to address specific aspects of the care need rather
than the entire range of care solutions in one product. This would make the insurance
products more affordable and less complex for consumers. For example in South
Korea, targeted products in senior health and cancer care have met with some
success. Dementia and arthritis have been some of the other targeted conditions,
with success largely due to appropriate distribution, low price and simple and
understandable lump-sum benefits. This could be replicated in other markets by
finding niche needs and addressing them from the ground up as opposed to
analysing and trying to address the total need at once. However, this is very countryspecific because of cultural reasons and the different public schemes in place.
Re-labelling existing LTC insurance products in more positive terms could also help.
The current LTC insurance products focus on compensation for loss of independence,
and in particular ADL failures, which for many consumers seems like a horrendous
personal state to experience. This is an additional psychological reason not to buy.
Products which extend independence may have a much more positive marketing
message and be purchased more readily than current LTC products. Marketing with
wording reference to lifestyle maintenance or independence assistance, for example,
may lead to higher sales of LTC insurance.
Non-insurance solutions
Some of the elderly, at least in the advanced markets, are asset rich but cash poor.
Products to monetize illiquid assets can provide relief and may complement the suite
of existing solutions to finance care. Reverse mortgages, known in some markets as
equity release products, allow mortgage-free homeowners access to the equity in
their house. The homeowner can either sell the house at a discount and be allowed
to stay there for life (sale model). Or he/she can get a lump-sum payment, periodic
payments for life, access to a line of credit, or any combination of these options (loan
model). During the life of the loan, the homeowner makes no interest or principal
payments, and accrued interest is added to the principal. The loan falls due only
when the borrower and their partner both die or permanently move. At that time,
the house is sold and the proceeds used to repay the mortgage and interest. Any
additional funds go to the borrower or their estate.
94 See Quantification of the Natural Hedge Characteristics Long-term Care Combination Life or Annuity
Products Linked to Long-term Care Insurance, SOA, (2012).
95 Insurance Market Report. Healthcare: Life&Benefits. Hong Kong, Axco, (2013).
However, these products have their own

challenges for both insurers and
consumers.
The market for reverse mortgages is well developed in the US and UK. The estimate
for continental Europe is that EUR 20 billion could be released from home equity in
the next 10 years.96 In China, with an eye on the ageing challenges ahead, a pilot
plan for reverse mortgages has been launched.97 Insurers could be natural suppliers
of reverse mortgages given the long-term nature of their business and the link to life
risks. However, there are many challenges as it is difficult to manage and hedge the
risk related to the properties, which are often run-down and not well-maintained.
Similarly, consumers may be wary of them because they are difficult to understand,
and they preclude the elderly from leaving a legacy. The availability of reverse
mortgage solutions also depends on legal and regulatory aspects. For example,
under Solvency II, its not clear how reverse mortgages can be used to back life
insurance liabilities.
96 See Equity Release, Accessing Housing Wealth in Retirement, Towers Watson, (2013).
97 ChinaDaily, 14 October 2013, http://www.chinadaily.com.cn/opinion/201310/14/
content_17029281.htm (accessed 14 October 2013).
Conclusion
Addressing the rising care needs of the
aging population is a complex challenge.
Demographic trends will result in an increase of elderly persons with long-term care
(LTC) requirements. The needs of the aging population and how these will evolve is a
complex question that is not yet fully understood. Indeed, the financing and provision
of effective care solutions for the elderly will be one of the most challenging issues
facing society in the coming years.
The current funding and provision

systems for LTC are unsustainable.
Todays means of funding and providing care services are not sustainable. Both
societies and individuals are generally unprepared for the LTC challenge. To cope
with the coming silver tsunami, a multi-stakeholder approach is required. From the
outset, more focus on health management at older ages will help people remain
independent and living at home for as long as possible. This will help to save costs
and increase the quality of life for all.
Insurance can be part of the solution for

care needs
Insurance is not a silver bullet to the care conundrum and cannot in isolation solve
the challenges ahead. However, insurance can help make the use of scarce funds
more efficient through risk diversification.
but a fundamental re-think of the

current product space is required.
Private voluntary LTC insurance has not been a runaway success and to become an
integral part of the care solutions package, insurance products need fundamental rethink. Traditional LTC products have proven unappealing to both buy and sell. There
is a great deal of scope for product innovation and improved design to overcome the
perceived weaknesses of traditional LTC insurance products. In particular, re-designed
products should present a more visible and tangible value proposition that is at once
both more appealing and affordable for many people.
Immediate-needs annuities, hybrid

products and short-term care are just a
few examples of innovative products.
For example, immediate-needs annuities are bought when severe dependency sets
in and they reduce the tail risk of LTC needs. Hybrid products offer a payoff even if
the insured does not become dependent. Short-term care provides professional
support and services at the initial stages of dependency. In some markets, targeted
products that address specific aspects of the care need rather than the full range of
care solutions have provided significant support for the elderly.
Governments also have to tackle lack of

consumer awareness regarding available
LTC solutions.
Last but not least, consumer awareness about LTC needs, their risks and costs must
be raised. In line with this, governments must better communicate the public funding
and services available, and what is the realm of individual responsibility. This will
help foster consumer engagement with and preparation for individuals own oldaged care requirements.
Appendix: LTC solutions in select countries

Insights on private LTC insurance
from specific markets.
The US has the largest private LTC

insurance market.
In this appendix, seven markets for private LTC insurance are discussed, along with
a brief description of the public LTC sector which defines the operating environment.
The selection is based on the size of the private LTC insurance market, but also with
regards to any policy and business insights that can be drawn from the examples.
The US private LTC insurance is the main mechanism for risk sharing
The largest private LTC insurance market is the US. LTC insurance policies were very
popular in the 1990s and premium volume grew from about USD 2 billion in 1995
to USD 11.5 billion in 2012. Around 80% of these premiums were for individual
business, and the rest sold as group business. In recent years, however, business
growth has been weak and often driven by rate increases rather than new sales.98
Private funds have to be exhausted

before dependants are eligible for
public LTC support.
A key driver of demand for private LTC insurance in the US is the lack of a universal
LTC scheme. Medicaid does finance LTC but only on a means-tested basis, and
private funds virtually have to be exhausted before one becomes eligible.
The typical LTC insurance policy in the

US offers reimbursement of LTC costs.
The typical insurance solution offers reimbursement of LTC costs to a daily cap. The
vast majority of policies provide comprehensive coverage, which pays for both home
care and care in nursing facilities. Often there is a limited benefit period, but lifetime
contracts are (were) also available. Most contracts have a waiting period of around
three months before the insurer starts to pay care costs that acts as a deductible.99
LTC insurance is the problem child in

the US L&H industry.
Despite its size, the US is not the showcase for private LTC insurance. Life insurers
have suffered heavy losses and were forced to increase rates on large blocks of
policies, which upset many policyholders and resulted in a loss of reputation of the
industry. Moreover, many insurers have exited the market.
Among other things, assumptions made

at the time of pricing have proved to be
too optimistic.
The main issues confronting the US LTC insurance market were lower-than-expected
lapse rates, low investment returns, high capital requirements, underwriting
challenges, and problems with distribution networks (high commissions).
New hybrid life products have been sold

successfully in the past five years.
However, the Pension Protection Act of 2006 improved the tax treatment of LTC
insurance and allowed for the development of hybrid products. These new products,
mainly life insurance with acceleration riders, where the death benefit from the life
insurance can be withdrawn for LTC or chronic illness needs, have been introduced
and sold successfully in the past five years. Specifically, premiums for hybrid
products grew strongly between 2009 and 2013 (CAGR 34%) and new business for
2013 reached USD 2.6 billion.
In Germany LTC insurance has been

compulsory since 1995.
The social and private mandatory LTC

insurance schemes provide the same
level of benefits and eligibility.
Germany mandatory LTC and supplementary private LTC insurance

In Germany compulsory universal LTC insurance was introduced in 1995. There are
two parallel mandatory schemes: social LTC insurance for those with social health
insurance and private LTC insurance for those with private health insurance. The
social LTC insurance is pay-as-you-go-financed through payroll contributions. Private
LTC insurance is pre-funded through premium payments (see left panel of Figure 9).
Benefit eligibility criteria and payments are equivalent for both systems. Benefits
comprise daily allowances for informal care, formal care at home and in nursing
homes. The amount paid for each of the three benefit types is explicitly defined and
graded depending on the level of dependency.
98 Source: LIMRA.
99 Various options that enhance coverage for LTC insurance have been sold. Typically policies offer a
benefit that escalates over time at a pre-determined fixed rate, eg 5%, to compensate for inflation. Some
policies offer a non-forfeiture option which, for a higher premium, provides some benefits in the case
that the policyholder stops paying the premiums. Other services offered by some policies include
hospice care, respite care, care after a hospital stay, or caregiver training for family members.
Supplementary LTC insurance is available

to cover the remaining protection gap, ...
It is well understood that benefits from the mandatory systems do not cover the full
costs of long-term care. The mandatory LTC insurance is estimated to pay about 43%
of the total nursing home costs for light dependency and 47% for heavy dependency.
In absolute terms, the annual protection gap per person is thus USD 20700 for light
and 26000 for heavy dependency, respectively.100 Supplementary LTC insurance to
cover the gap is available from both life and health insurers. Health insurers offer
supplementary LTC insurance with full or partial cost reimbursement on top of what
is covered by the mandatory plan and daily allowances. Life insurers offer long-term
care annuities which pay a fixed amount depending on level of dependency. Life
insurers also offer stand-alone LTC products and LTC riders to a life policy.
...and is growing rapidly.
Between 2002 and 2012, voluntary LTC insurance in Germany grew by 20%
annually to about EUR 852 million (USD 1090 million, see right panel of Figure 9).
This growth was fueled by an omnipresent debate about the sustainability of the
mandatory social LTC insurance mechanism, the protection gap and how to
incentivize consumers to privately provide for their LTC needs.
Government allowances further

accelerated supplementary LTC
insurance sales.
To increase the uptake of supplementary LTC insurance and close the protection gap,
a program called Pflege-Bahr, named after the health minister Daniel Bahr, was
introduced in 2013. Those who purchase Pflege-Bahr with premiums of at least
EUR 10 per month receive a EUR 5 government subsidy. In the first year of the
program, two thirds of the 500000 new supplementary LTC policies purchased
were Pflege-Bahr contracts.
Figure 9:
LTC contributions and premium income, in
EUR million, for mandatory LTC insurance
(left panel) and voluntary/ supplementary
LTC insurance (right panel) in Germany
25 000
700
600
20 000
500
15 000
400
10 000
300
200
5 000
100
0
2000
2002
2004
2006
2008
Social LTC insurance

Mandatory LTC written by private health insurers
2010
2012
2000
2002
2004
2006
2008
2010
2012
Supplementary LTCI, total, written by private health insurers

Supplementary LTCI, total, written by life insurers
Source: Bundesministerium fr Gesundheit (German Federal Ministry of Health), Steria Mummert, based on Bafin.
100 V. Leienbach and A. Besche, Sonderdruck 30 Jahre Pflegeversicherung, Versicherungswirtschaft,

(2014) https://www.pkv.de/w/files/pflegekompetenz/30jahre_pflegeversicherung_200x280_druck.
pdf (accessed 1 September 2014).
In France a universal LTC scheme

provides income-related benefits for
dependants above 60 years of age.
France social health insurance, government and private LTC solutions

In France, financial support for LTC at home or in an institution is mainly provided
for by the universal public health insurance system and personalized allowances
for autonomy (APA). APA is intended for people aged 60 and above to help pay for
expenses linked with loss of independence. The level of benefit is a function of an
individuals degree of independence. However, APA is also means tested and
depending on ones income, benefits can be reduced by up to 90%.101
The public LTC benefits dont cover

the full LTC costs, not even for the poor.
For formal home-care, APA provides support towards any expenses incurred in line
with a personalized care plan identified by a social-medical team. In 2010, benefits
varied from EUR 1235 per month for the most severe cases to EUR 530 for low
dependency levels.102 Neither level of benefits is sufficient to cover the full estimated
costs of home-care of EUR 1500 to 4000 per month.
Large parts of nursing home costs must

be borne by the dependant and his/her
family.
The costs of staying in a nursing home were estimated at EUR 34705 in 2012,
with three components: (1) the health cost of EUR 11844, which is borne by social
health insurance; (2) the accommodation cost of EUR 11616, which is paid fully by
the dependant;103 and (3) the care cost (ie, non-medical care needs such as feeding,
help with dressing etc.) of EUR 11844, for which APA makes means-tested
contributions, with any remaining portion borne by the dependant and his/her
family.104 It is estimated that families spent at least EUR 6 billion in 2007 for
accommodation and dependency fees (total LTC expenditures were estimated to
be EUR 34 billion in 2007, or 1.8% of GDP).105
Co-payments are significant and private

LTC insurance to cover them is quite
successful.
Life insurers provide supplementary LTC insurance to reduce the remaining gap.
Premium income was EUR 466 million in 2012 with 1.8 million insured (of which
75% were individual contracts). So called Mutuals 45 and Institutions de Prvoyance
also offer LTC insurance, and generated premium income of EUR 138 million and
EUR 25 million, respectively, in 2011, from 3.6 million and 0.3 million insured. The
vast majority of the contracts are written on a group basis. In France, more than 16%
of the population over 40 years of age has private LTC insurance (2012), compared
with about 5% in the US.106
French life insurers provide lean LTC

insurance.
The contracts provided by French life insurers are defined benefit. In other words,
once the policyholder is eligible, a regular fixed amount of money is paid for life
(although there are also lump-sum policies and contracts with limited payment period).
For contracts covering light and severe dependency, benefits averaging EUR 371
per month were paid in 2012. For contracts only covering severe dependency,
benefits were EUR 574 on average.107
Japan introduced a universal public LTC

social insurance system in 2000.
Japan social LTC insurance crowds out private solutions

In 2000, Japan created a public LTC insurance system funded by a combination of
premiums and taxes that finances approved in-kind services. The scheme covers
the population aged 65 and above as well as age-related illnesses for those aged
4064. Benefits are only provided in the form of services (in kind), with no possibility
of receiving a cash benefit. The fact that cash benefits are not offered was a specific
design feature to avoid the burden of care falling on (unpaid) female family members
(sometimes referred to in Japan as daughter-in-law syndrome).
101 Fact sheet on France, Help Wanted? Providing and Paying for Long-Term Care, Paris, OECD, (2011).
102 Fact sheet on France, OECD, (2011), op. cit.
103 Those who cannot afford it may be eligible to public social assistance for housing (laide sociale
lhbergement).
104 http://www.maisons-de-retraite.fr/Ehpad/Actualites/Actualites-generales/Le-cout-d-une-place-enmaison-de-retraite-c-est-2-892-euros-par-mois (accessed 1 September 2014)
105 Different social insurance agencies also provide benefits. For instance, retirement insurance proposes
benefits in kind such as home assistance for people whose dependency level is not severe enough to
receive APA.
106 Own calculations based on Lassurance dpendance en 2012 Aspects quantitatifs et qualitatifs,
FFSA GEMA, (2013) and OECD, (2011), op. cit.
107 FFSA GEMA, (2013), op. cit.
The public LTC insurance system is very

generous, which strains sustainability
The LTC system operates on social insurance principles, with benefits provided
irrespective of income or family situation. The overall cost of the LTC insurance system
doubled between 2000 and 2006 because the new system gave more opportunities
for elderly persons to use formal LTC services. The government has projected that
the cost of LTC services will rise even further, from 1.6% of GDP in 201011 to 3.3%
by 202425. As the burden increases, the government may need to increase copayments, introduce means-testing or reduce access to some services.
and has also crowded-out private

solutions.
Private LTC policies are available either as principal coverage or as a rider to life and/
or medical insurance policies. Typically they allow the insured to receive cash benefits
after reaching a certain level of dependency (paid as a lump sum, an annuity, or a
combination of the two). However, with the introduction of the universal (and very
generous) public LTC insurance system, private LTC insurance volumes have suffered
a setback.108
In Israel, a publicly-funded universal LTC

insurance program supplements informal
care.
Israel high risk awareness helped develop a LTC market

In Israel, the Long-term Care Insurance Program (LTCIP, a publicly-funded LTC scheme)
provides services and benefits designed to supplement informal care provided by
family and friends, and encourages elderly people to remain in their communities as
long as possible. Individuals must be citizens or permanent residents of Israel and be
above the retirement age of 67 (for men) or 62 (for women).
The public scheme is means-tested,

although most meet the eligibility
requirements.
Eligibility for services from the program is means-tested. However, the means test is
sufficiently high so that only the very wealthy are excluded. The LTCIP services cover
about 80% of the elderly population, at a cost of approximately USD 1 billion in 2011
or 0.5% of Israels GDP.
LTC risk awareness is high and Israel has

one of the biggest private LTC markets.
Awareness of LTC risk is widespread and Israel is one of the biggest private LTC
insurance markets. Claimants receive compensation for the cost of care in a nursing
home or care provided at home up to a specified amount. Benefits are ADL-triggered
and tiered. Premium income grew from USD 118 million in 2003 to USD 710 million
in 2012, making LTC insurance the fastest growing L&H line of business. Two thirds
is written on a group basis, typically sold through affinity groups and employers.
In Singapore LTC is financed through a

mix of savings, disability insurance and
medical insurance.
ElderShield is a public-private partnership

designed by the government, but priced,
sold and managed by private insurers.
Singapore a public-private partnership

Singapore has a mandatory national medical savings scheme called Medisave, which
helps individuals put aside part of their monthly income into individual Medisave
accounts to meet their own or their familys healthcare expenses. LTC costs are
financed through a mix of government subsidies109 and disability insurance
(ElderShield), the premiums of which can be paid for from individuals Medisave
accounts. In addition, families unable to afford remaining LTC costs even with
subsidies and insurance can receive further assistance from Medifund, a safety net
for needy Singaporeans.
The ElderShield program was launched in 2002. It is a public-private partnership
designed by the government but priced, sold and managed by private insurers.
ElderShield provides automatic enrolment for individuals at the age of 40. However,
individuals can opt out of the plan within the first three months. By 2013, premium
income amounted to about USD 160 million/SGD 199 million. The number of
ElderShield policies increased from 0.75 million in 2008 to 1.1 million in 2013,
an increase of 5.2% per annum.110
108 F. Yasukawa and T. Inoue, A Primitive Study on the Relationship Between Public Long-term Care
Insurance Policy Reform and the Performance of Private Long-term Care Insurance: How to Relieve the
Burden of Care?, ITEC Working Paper, no 0732, Institute for Technology, Enterprise and
Competitiveness, Doshisha University, (2007).
109 This includes Government subsidies for various LTC services, as well as Government schemes like the
Foreign Domestic Worker Grant and Seniors Mobility and Enabling Fund (SMF).
110 Singapore Ministry of Health.
The popularity of the program may

engender a false sense of security
because ElderShield does not cover
the full cost of care.
The popularity of the program has been aided by the ease of paying the ElderShield
premiums, which are deducted automatically from an individuals Medisave account,
and the relatively cheap premiums. However, there is a debate around whether this
engenders a false sense of security, as the benefits are roughly enough to pay the
cost of a home helper (who may have minimal training in eldercare).
However, ElderShield can be topped

up with supplementary insurance.
ElderShield benefits are up to SGD 400 per month, for up to six years.111 Depending
on the degree of dependency and the quality of the accommodation, nursing home
charges range from about SGD 1000 to SGD 3500 per month.112 ElderShield
policyholders wanting additional insurance to reduce the existing protection gap can
also purchase an ElderShield Supplement with higher benefits. The premiums for
ElderShield supplements can also be paid for from an individuals Medisave account.
In the UK, the bulk of LTC costs are borne

by the dependant.
The UK almost no public LTC funding

In the UK, the National Health Service (NHS)113 provides universal healthcare. LTC,
however, is not included and the bulk of the old-aged care costs must be borne by
the dependant and their families.
The means-test threshold for public LTC

benefits is very low; nearly all wealth has
to be exhausted before an individual is
eligible for state support.
For LTC benefits, there is a means-tested safety net requiring individuals to

significantly spend down their assets (including property if not occupied by the
dependant or spouse). Only once assets are below a certain threshold is the person
eligible for state support.114 As a consequence, the dependant is often forced to sell
their home or liquidate any available assets to fund nursing or residential home care.
There is a huge LTC protection gap in

the UK.
The LTC protection gap in the UK is significant. Private LTC insurance has been sold
since the early 1990s, but the market has grown slowly and there are only a few
players, mainly offering immediate-needs annuities (INAs). The traditional product
pre-funded LTC insurance with ADL and cognitive impairment triggers has not
been popular, and the last provider to offer pre-funded LTC insurance exited the
market in 2010. LTC bonds are similar to pre-funded care plans but allow inheritance
of unused capital. Even so, UK consumers have likewise not been big buyers of LTC
bonds.
INAs have been growing, but volumes

are small.
The most promising products in the UK insurance market are INAs. These are
purchased with a single premium when an individual is already in need of care.
INAs have been relatively successful, aided by certain tax efficiencies,115 although
premium income was only about GBP 130 million in 2012.
Private LTC insurance has not been a

big hit with UK consumers.
Given the tough eligibility requirements for state support, it is surprising that LTC
insurance penetration in the UK is so low. Either the products on offer do not meet
consumers needs, or many people are simply not aware of the LTC risks they face.
111 Plans that went in-force before end of September 2007 offered a benefit of SGD 300 for up to five
years.
112 L. Tan Ling, Nursing Home Charges, Singapore Ministry of Health, (2007).
113 There are four distinct NHS, one each for England, Scotland, Wales, and Northern Ireland.
114 The threshold for eligibility is GBP 23250 in England and Wales, and GBP 24750 in Scotland.
115 If pension savings are used to fund LTC nursing care costs and paid directly to the care provider via an
immediate needs annuity, the proceeds from the pension are tax free, whereas taking the pension as
cash income benefits (whether or not the money is then paid to a caregiver) would attract income taxes.
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Sigma5 2014 en

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No 5/2014

How will we care?

The provision and funding of care services

Care needs for the elderly progress with

The burden of care will increasingly

To date, various supply- and demand-side

This can change. Private insurance

and financially sustainable LTC solution.

Swiss Re sigma No 5/2014 1

The coming silver tsunami

The number of people aged 65 and

with Latin America and Asia seeing

2 Swiss Re sigma No 5/2014

A growing need for (long-term) care solutions

Other demographic trends are

Swiss Re sigma No 5/2014 3

The ageing population and its care needs

Morbidity varies from country to

The debate between the compression, postponement and expansion of morbidity

and even among sub-groups of

Care needs assessment what triggers dependency?

4 Swiss Re sigma No 5/2014

Care services refer to the support

Historically, care services and solutions

Advanced care need

End of life palliative

Early care need

Very early care need

*IADL=instrumental activities of daily living; ADL=activities of daily living; comorbid=medical condition(s)

Swiss Re sigma No 5/2014 5

The ageing population and its care needs

ADL/IADL are commonly-used

The fewer ADL/IADL an individual can

Other criteria for determining

6 Swiss Re sigma No 5/2014

There are several key risk factors

Key risk factors associated with old-age disability20

Dependency is strongly linked to age

Chronic diseases, cognitive impairments,

Health conditions: Chronic diseases, such as hypertension, diabetes and arthritis

Behaviour and lifestyle choices are also

Behaviour and lifestyle choices contribute to the development of disability in old

Married and socially active people are

The care needs of the elderly increase

Overall, (long-term) care solutions will

Swiss Re sigma No 5/2014 7

Long-term care today

The sources of LTC financing vary across

Total expenditure on LTC in OECD

In most OECD countries, LTC is financed

In most OECD countries, LTC is largely financed through government programs.

8 Swiss Re sigma No 5/2014

The value of informal care is significant

In emerging markets, informal/family

In emerging markets formal government-financed LTC schemes are rare. According

In all markets, private individuals face

Provision of long-term care

Swiss Re sigma No 5/2014 9

Long-term care today

Often this is the preferred form of

Demographic trends point to a growing

However, demographic trends point to a decline in the pool of potential caregivers.

Capacity of residential care homes is also