Public long-term care insurance (LTCI), which provides home and institutional care benefits, was introduced in July 2008 in South Korea. This study aims to evaluate the effects of the introduction of LTCI on older people's medical service use, including outpatient visits, inpatient services and longer stays (181 days or longer) in hospitals by implementing a quasi-experiment design with a generalised difference-in-difference method. The results showed that the introduction of LTCI did not change the use of outpatient medical services, although the medical costs of older people who used medical services at least once decreased by 9.4%. For the inpatient services, hospitalisation rates declined by 2.7% as a result of the LTCI. Length of stay and inpatient expenses decreased by 15.6 and 9.5%, respectively. For older people of LTC grade 2, eligible for long-term care facilities (LTCF), prolonged hospitalisation rates decreased by 1.6% due to the LTCI. In conclusion, the introduction of LTCI in South Korea has contributed to decreasing the use of inpatient services and longer stays in hospitals, which suggests that the utilisation of LTCF has become a substitute for some social admissions in hospitals.

To date, social long-term care insurance (SLTCI) systems have been introduced in six countries globally: the Netherlands, Israel, Germany, Japan, Luxembourg and South Korea. Applying an actor-centred, multi-dimensional framework and fuzzy-set analysis, the present article investigates the typical characteristics and variations of these SLTCI schemes at introduction and today. In short, we find that the SLTCI model features dominant social contribution financing, a mix of for- and non-profit providers, and state regulation. In light of the relevance of corporate self-regulation often associated with social insurance systems, the dominance of state regulation is unexpected. The analysis also reveals considerable variance between cases, most notably concerning the extent of private individual actors’ involvement. While geographical proximity of countries does not explain differences between SLTCI systems, “temporal clusters” seem to partly drive the variation of SLTCI actor configurations.

Fish harbour many types of nutrients that are beneficial for preventing cognitive decline. Therefore, habitual fish intake might contribute to a lower risk of incident dementia. However, few prospective cohort studies have investigated fish consumption in relation to incident dementia, and their findings have been inconsistent. To investigate the association between fish consumption and the risk of incident dementia, we collected data on the consumption of fish and other foods using an FFQ in a baseline survey of individuals aged ≥65 years living in Ohsaki City, Japan. After 5·7 years of follow-up, the incidence of dementia was 1118 (8·5 %) among 13 102 participants. We then used a multivariate-adjusted Cox model to estimate hazard ratios (HR) and 95 % CI. Compared with subjects with the lowest fish intake (Q1), the multivariate HR were 0·90 (95 % CI 0·74, 1·11) for Q2, 0·85 (95 % CI 0·73, 0·99) for Q3 and 0·84 (95 % CI 0·71, 0·997) for Q4 (Ptrend = 0·029). Such associations were also observed even after excluding participants who were diagnosed with dementia in the first 2 years of follow-up and those who had poorer cognitive function at baseline. In conclusion, an association was observed between higher fish consumption and a lower risk of incident dementia among healthy elderly people without disability. These findings suggest that habitual fish intake may be beneficial for the prevention of dementia.

This paper reviews the past development of the publicly funded long-term care (LTC) system and aims to advance further discussion of LTC in Taiwan. The Ten-year Long-Term Care Plan 2.0 introduced in 2017 calls for a major reform of a publicly funded LTC system in Taiwan. The reform expands on the previous universal tax-based LTC system, allowing for more comprehensive and accessible subsidies on LTC services. This paper provides a brief overview of the political context of the reform and an introduction to the legal basis, financing and delivery mechanisms of the reform plan. To this end, as a preliminary evaluation, this paper identifies major institutional and socio-cultural tensions that could challenge the implementation of the plan. Institutional tensions include the dominant foreign worker caring model, which relies on approximately 220,000 foreign workers to provide LTC services, and the discontinuity between health and social care governance, which leads to a discontinuity between curative and LTC care. Socio-cultural tensions focus on conflicting values in the allocation of responsibility of care and in the understanding of disability between universal social citizenship in the modern state and traditional Confucian ethics. Policy implications of these tensions for the LTC system are then discussed.

This paper explores a notional defined contribution (NDC) approach aimed at helping pensioners to cope with the cost of long-term care (LTC). It develops the necessary technicalities to fully integrate an LTC benefit, graded according to the annuitant's degree of disability, into a generic NDC retirement framework with a minimum pension benefit for both contingencies. It also discusses the policy implications of various issues that should be taken into account before any decision is made to put the model into practice. Finally, to enable policymakers to better understand how the proposal would function, the paper includes a realistic numerical example.

We investigate the application of natural hedging strategies for long-term care (LTC) insurers by diversifying both longevity and disability risks affecting LTC annuities. We propose two approaches to natural hedging: one built on a multivariate duration, the other on the Conditional Value-at-Risk minimization of the unexpected loss. Both the approaches are extended to the LTC insurance using a multiple state framework. In order to represent the future evolution of mortality and disability transition probabilities, we use the stochastic model of Cairns et al. (2009) with cohort effect under parameter uncertainty through a semi-parametric bootstrap procedure. We calculate the optimal level of a product mix and measure the effectiveness provided by the interaction of LTC stand alone, deferred annuity and whole-life insurance. We compare the results obtained by the two approaches and find that a natural hedging strategy for LTC insurers is attainable with a product mix of LTC and annuities, but including low proportion of LTC.

Although some experimental biological studies have indicated that citrus may have preventive effects against cognitive impairment, no cohort study has yet examined the relationship between citrus consumption and incident dementia. In a baseline survey, we collected data on daily citrus intake (categorised as ≤2, 3–4 times/week or almost every day) and consumption of other foods using a FFQ, and used a self-reported questionnaire to collect data on other covariates. Data on incident dementia were retrieved from the Japanese Long-term Care Insurance database. A multivariate-adjusted Cox model was used to estimate the hazard ratios (HR) and 95 % CI for incident dementia according to citrus consumption. Among 13 373 participants, the 5·7-year incidence of dementia was 8·6 %. In comparison with participants who consumed citrus ≤2 times/week, the multivariate-adjusted HR for incident dementia among those did so 3–4 times/week and almost every day was 0·92 (95 % CI 0·80, 1·07) and 0·86 (95 % CI 0·73, 1·01), respectively (Ptrend=0·065). The inverse association persisted after excluding participants whose dementia events had occurred in the first 2 years of follow-up. The multivariate HR was 1·00 (reference) for ≤2 times/week, 0·82 (95 % CI 0·69, 0·98) for 3–4 times/week and 0·77 (95 % CI 0·64, 0·93) for almost every day (Ptrend=0·006). The present findings suggest that frequent citrus consumption was associated with a lower risk of incident dementia, even after adjustment for possible confounding factors.

Unlike the mortality risk on which actuaries have been working for more than a century, the long-term care (LTC) risk is relatively new and as of today hardly mastered. Semi-Markov processes have been identified as an adequate tool to study this risk. Nevertheless, access to data is limited and the associated literature still scarce. Insurers mainly use discrete time methods directly inspired from the study of mortality in order to build experience tables. Those methods however are not perfectly suited for the study of competing risk situations. This article provides a theoretical framework to estimate biometric laws associated with a LTC insurance portfolio. The presented method relies on a continuous-time semi-Markov model with three states: autonomy, disability and death. The process describing the state of disability is defined through its transition intensities. We provide a formula to infer the mortality of autonomous people from the mortality of the whole portfolio, on which we have more reliable knowledge. We then propose a parametric expression for the remaining intensities of the model. In particular, incidence in LTC is described by a logistic formula. Under the assumption that the disabled population is a mixture of two latent populations with respect to the category of pathology that caused LTC, we show that the resulting intensity of mortality in LTC takes a very peculiar form and depends on time spent in the LTC state. Estimation of parameters relies on the maximum likelihood method. Our parametric approach, while inducing model uncertainty, eliminates issues related to segmentation in age categories, smoothing or extrapolation at higher ages and thus proves very convenient for the practitioner. Finally, we provide an application using data from a real LTC insurance portfolio.

Public policies that provide incentives for higher middle-income people to purchase private long-term care insurance (LTCI) have been proposed as a way to shield large numbers of middle-income people from the risk of needing costly long-term care. A proposal to promote purchases of private LTCI that has gained modest traction in the United States of America is the Partnership Program. The structure and public–private nature of the Partnership Programs are reviewed along with the trends in sales of both regular private LTCI policies and Partnership LTCI policies to show that both experienced low purchase rates. Implementation efforts for the Partnership Programs were very modest, in part because many were launched when the Affordable Care Act was passed. At the same time, several well-known insurers withdrew from selling private LTCI. Understanding why the Partnership Program is not a success provides lessons for other counties interested in creating similar public–private ventures.

South Korea has been experiencing unprecedented socio-economic transformations in which an ageing population is widely regarded as a key challenge. As an unlikely consensus on state intervention in care has emerged since early 2000, South Korea has achieved rapid development of welfare state programmes. The introduction of long-term care insurance (LTCI) in 2008 is one of the important steps. However, it is still highly debatable whether the Korean welfare state has departed from its path of both developmentalism and Confucianism. This paper aims to analyse the nature of LTCI in South Korea and to examine whether its introduction could mean a divergence from these two important policy legacies. This research has reached an ambiguous conclusion. The regulatory role of the government and concerns about the costs of LTCI are regarded as a developmentalist legacy, whereas Confucian legacies seem to be withering away since LTCI shifts care responsibility from the family to the state. However, the study found that the state has difficulty in regulating the market and costs, and deeply embedded familialism seems difficult to overcome.