Volume 14, Issue 2 - Special Issue: The economics of long-term care, Guest editor: Helmuth Cremer

Long-term care expenditure is expected to rise, driven by an ageing population. Given that public long-term care expenditure is high in many OECD countries, governments are increasingly concerned about its future growth. This study focuses on three relevant issues. First, we discuss factors that affect the growth of long-term expenditure and its projections. These include demographics, the balance in provision between informal and formal care, whether higher life expectancy translates into higher disability, the interrelation between health and long-term care, and whether long-term care suffers from Baumol’s disease. Second, given that a significant proportion of long-term care expenditure is nursing- and care-home expenditure, we discuss the role of government regulation aimed at ensuring that individuals receive appropriate quality of care in such institutions. We focus in particular on price regulation, competition, and the non-profit sector; these have been the subject of considerable empirical work (mainly in the United States). Third, we discuss the relative merits of public and private insurance. Countries differ greatly in their approach. Some countries have nearly exclusively public insurance but in others this is small. We consider the conditions under which public insurance can overcome the limitations of a private insurance market.

Informal care is the largest source of long-term care for elderly, surpassing home health care and nursing home care. By definition, informal care is unpaid. It remains a puzzle why so many adult children give freely of their time. Transfers of time to the older generation may be balanced by financial transfers going to the younger generation. This leads to the question of whether informal care and inter-vivos transfers are causally related. We analyze data from the 1999 and 2003 waves of National Longitudinal Survey of Mature Women. We examine whether the elderly parents give more inter-vivos monetary transfers to adult children who provide informal care, by examining both the extensive and intensive margins of financial transfers and of informal care. We find statistically significant results that a child who provides informal care is more likely to receive inter-vivos transfers than a sibling who does not. If a child does provide care, there is no statistically significant effect on the amount of the transfer.

: Long-term care (LTC) is mainly provided by the family and subsidiarily by the market and the government. To understand the role of these three institutions, it is important to understand the motives and the working of family solidarity. In this paper, we focus on the case when LTC is provided by children to their dependent parents out of some norm that has been inculcated to them during their childhood by some exemplary behavior of their parents towards their own parents. In the first part, we look at the interaction between the family and the market in providing for LTC. The key parameters are the probability of dependence, the probability of having a norm-abiding child and the loading factor. In the second part, we introduce the government which has a double mission: correct for a prevailing externality and redistribute resources across heterogeneous households.

The public provision of long-term care (LTC) can replace family-provided LTC when adults are not sufficiently altruistic towards their parents. But State intervention can modify the transmission of values and reduce the long-run prevalence of family altruism. To characterize the optimal LTC policy, we develop a three-period OLG model where the adult population is divided into altruistic and non-altruistic agents, and where the transmission of altruism follows a socialization process `a la Bisin and Verdier (2001, The economics of cultural transmission and the dynamics of preferences. Journal of Economic Theory 97:298–319). It is shown that public LTC benefits, by reducing parental investment in children, make the long-run survival of family altruism less likely. However, whether crowding out arises or not depends on individual preferences and on the socialization mechanism at work. We also study the incompatibility of the optimal short-run LTC benefits with long-run social welfare maximization. Finally, we discuss the robustness of our results to introducing savings and universal LTC benefits.

Fertility and the provision of long-term care are connected by an aspect that has not received attention so far: both are time consuming activities that can be produced within the household or bought at the market and are, thus, connected through the intertemporal budget constraint of the household that accounts for time and money. This paper models that link and analyzes the effect of intervention in the long-term-care market on female labor-market related decisions. It shows that women’s fertility and their labor supply when young are affected by such policies. The overall effect can be decomposed into an opportunity-cost effect and a consumption-smoothing effect that each impact fertility as well as labor supply in opposite directions. Using survey data, the paper provides some evidence that in the member states of the European Union the consumption-smoothing effect is dominant.

This paper studies public provision of long-term care insurance in a world in which family assistance is (i) uncertain and (ii) endogenous, depending on the time parents spend raising their children. Public benefits will be paid in case of disability but cannot be combined with self-insurance or family aid. The benefits are provided equally to all recipients and financed by a proportional payroll tax. The paper shows that tax distortions imply that full insurance is undesirable. It characterizes the optimal tax and identifies the elements that determine its size. Of crucial importance are the extent of under-insurance, the effect of the tax on the probability of altruism, the distortionary effect of the tax, and, with wage heterogeneity, the covariance between the social marginal utility of lifetime income and (i) earnings (positive effect) and (ii) the probability of altruism default (negative effect).

A highlighted issue in long-term care (LTC) financing is the presence of unfortunate incentives in financing schemes. For instance, in Norway, a high share of high-income recipients provides financial incentives to the local governments (the agencies in charge of the LTC system) to increase reliance on nursing home care relative to community housing and home-based care. This article examines the effects of the Norwegian LTC funding system on the composition of LTC services at the local government level. I use a cross-section from 2009 of 391 local governments to estimate a fractional probit model using quasi-maximum likelihood estimation. Controlling for need and geographical variations in care costs, I find that the share of “rich” elderly has a significant association with three measures of the volume of nursing home care relative to home-based care.

We develop a model where individuals all have the same probability of becoming dependent and vote over the social long-term care insurance contribution rate before buying additional private insurance and saving. We study three types of behavioral biases, all having in common that agents under-weight their dependency probability when taking private decisions. Sophisticated procrastinators anticipate their mistake when voting, while optimistic and myopic agents have preferences that are consistent across choices. Optimists under-estimate their own probability of becoming dependent but know the average probability, while myopics underestimate both. Sophisticated procrastinators attain the first-best allocation, while myopics and optimists insure too little and save too much. Myopics and optimists more (resp., less) biased than the median are worse off (resp., better off), at the majority-voting equilibrium, when private insurance is available than when it is not.

We look at the effects of physical activity (PA) recommendation policies by considering a social multiplier model in which individuals differ in their concern for PA. The government can either observe this concern (and implement the First Best) or not (and implement a uniform policy). Whichever the type of policy implemented, while the welfare of individuals the most concerned with PA increases in the social multiplier, the welfare of those the least concerned may decrease in it. For a sufficiently high social multiplier, both government interventions improve the welfare of those most concerned with PA but worsen the welfare of the least concerned individuals if they are not too many. However, compared to the First Best, a uniform recommendation improves the welfare of those most concerned with PA more than it reduces the welfare of those least concerned.