The need to provide Long-Term Care (LTC) for growing elderly populations is a public policy issue in all industrialized countries. Unlike other OECD countries, the U.S. lacks a foundation for universal LTC benefits. Much can be learned by examining other industrialized countries. LTC systems. In this paper, we will examine how other countries' provide LTC services for their glowing elderly populations, finance the costs of LTC services, determine eligibility for services, and encourage and support informal caregivers.

Aging populations pose major health policy issues worldwide [1]. Projections indicate that by 2050, the world’s population 60 years of age or over will double rising to 2.1 billion. Twenty-five percent of the European population is currently over 60 and is expected to soar to 35% by 2050. Even in developing countries, the population over 60 is expected to rise to 9% by 2050 and to 20% by 2100. As a result, the number of workers per retiree is projected to shrink to 2.3 in the U.S., 1.5 in Japan, and 0.7 in Italy by 2050. This aging population is expected to have a profound effect on long-term care policy. The different ways that countries confront the issue of providing care for their aging populations will be addressed in this paper. The methodology used is comparative. Long-term care policies in countries such as Denmark, Germany, France, Switzerland, Canada, Australia, the UK, China, Japan, South Korea, Turkey and Mexico will be compared to the U.S.

United States

Unlike other Organization for Economic Cooperation and Development (OECD) countries, the U.S. does not provide long-term care coverage. Elderly needing institutional long-term care must rely largely on out-of-pocket expenditures Sixty percent of all nursing home residents rely on Medicaid to pay for their care [2]. The share of the older population receiving government-subsidized care in most of the OECD countries is much larger.

It is estimated that 70% of Americans who reach the age of 65 years and older will need some form of long-term care in their lifetime [3]. Currently 42% of elderly Americans experience limitations of an Activity of Daily Living (ADL) or an Instrumental Activity of Daily Living (IADL).

The cost of LTC in the U.S. is borne by Medicaid (44%), Medicare (23.4), out-of-pocket (18%), and private insurance (6.4%) [3,4]. Medicare only covers limited post-acute care stays in nursing homes. Medicaid is a welfare-based program funded by the state and federal governments. These programs have stringent financial eligibility criteria and require people to exhaust most of their income and assets in order to qualify. This complex funding system often results in inadequate care and financial risk.

Denmark

Denmark, Sweden, and Switzerland are the leaders in providing long-term care for all eligible citizens. Fully 27% of the elderly population in Denmark receive government-supported care. No new nursing homes have been established since 1987 because of an integrated homecare system. The Home Prevention Act mandates twice-a-year home visits to assess the needs of elderly citizens. This policy has resulted in a leveling off of long-term care expenditure and a drop in the percentage of the GDP devoted to long-term care [5].

The long-term care Danish system provides universal coverage for the elderly and disabled persons. Local authorities are responsible for the delivery of long-term care services. A needs assessment is performed twice a year on citizens 75 years of age and older by a public health nurse. The Home Prevention Act mandates twice-a-year visits to recipients of care. Eligible individuals have the free choice of providers. Home care services include personal care, practical assistance, and technical aids. Informal caregivers play a smaller role in providing care than in many other countries. Institutional care includes senior center residences, assisted living units, and nursing homes that are like group homes since Denmark outlawed traditional institutions.

Local authorities fund the cost of long-term care through Local taxes and block grants from the central government fund long-term care The government reimburses families for lost wages incurred by providing informal long-term care. This provides families with many choices for care. Since 2003, private providers have been permitted subject to quality and price standards. Three-quarters of municipalities sponsor integrated home care systems. As a result, the number of people living in nursing homes has fallen dramatically. Danish long-term care expenditures have leveled off and spending for those 80 years of age and over has fallen as a percentage of GDP.

Sweden

In Sweden, reform of the government's long-term care policy in 1992 that decentralized care resulted in a 50% reduction in the ratio of hospital beds to older adults [6-8]. The cost is borne by local municipalities (85%), national grants (12%), and out-of-pocket expenditures (4%). Care managers assess individual needs and create a home health care plan. There is a monthly cap of $193 on long-term care costs for users.

Long-term care in Sweden is funded by local taxes. Federal grants cover an additional 12% of the costs. The individual recipient of services pays a fee based on his/her ability to pay subject to caps set at the federal level.

Care managers assess an individual’s level of need. Home health care services may include assistance with household tasks, delivery of meals, personal and medical care, and transportation needs. Some municipalities issue allowances to caregivers to employ relatives. Fully 63% of municipalities have an “allowance program.” Since 1992, the elderly may opt for private home care. The private care industry has increased fivefold since the reforms of 1992. With Alzheimer’s disease on the rise, Sweden has made the care of these patients a priority. Separate nursing facilities are provided for elderly persons with dementia.

Switzerland

Responsibility for Long-Term Care (LTC) in Switzerland lies with Municipalities and Cantons to organize and provide or guarantee care for the aged. This arrangement differs from Germany, the Netherlands, and Japan in that in Switzerland there is no mandatory long-term care insurance. Part of the expenditures for long-term care is covered by mandatory health insurance, the old age benefit system, and supplementary benefits to pensions [9]. The general health insurance law covers medical costs in nursing homes and part of the costs of home-based services. Formal long-term care is provided in elderly or disability facilities, nursing centers, and at home. The costs of construction of public and some private nursing homes are subsidized by the Canton.

Long-term care is financed through a complex system of public support and social insurance (40%) and by households (60%). The financial burden on households is significantly reduced through supplementary benefits to old-age and invalidity pensions paid by the federal and regional governments. It is estimated that households pay about 36% of the costs.

There are no standardized criteria to assess needs. Home-based care involving comprehensive domestic aid is provided to the disabled. However, due to a lack of a trained workforce, 21% of the Swiss provide informal care to relatives. Caregivers in the same household are entitled to a bonus or tax deduction for their care as an encouragement for informal care of the elderly.

Germany

A social insurance program for long-term care that provides universal coverage was enacted in Germany in 1994 [10]. LTC benefits are based on the need for assistance with ADLs. Germany provides three levels of assistance depending upon the required hours of assistance per day. Disabilities in activities of daily living are assessed. Subsequently, the elderly can arrange their own services within a fixed budget.

The long-term care insurance premium is fixed at 1.7% of salary. Employers and employees each pay half. Germany is distinctive in that the majority of the long-term care beneficiaries and the funds are in community-based settings.

Eligibility for care is based on a person’s need for assistance with activities of daily living (ADLS). There are three eligibility categories based on the time required for assistance and frequency. Eligible persons can choose home or institutional care. The elderly can arrange for their own care within a fixed budget. There is no case management at the individual level. The program allows for a cash benefit as an income supplement. Almost three-quarters of beneficiaries receive care outside of nursing facilities and choose cash payments rather than services. This provision is designed to encourage family caregiving. Beneficiaries are subject to periodic visits in order to ascertain that adequate care is being provided.

France

France provides universal compulsory healthcare to its citizens. Since 1975, public LTC has revolved around allowances. France passed the Allowance for Personal Autonomy (APA) in 2002 [11-15]. This act was supplemented by the Act on Adapting Society to an Aging Population in 2015 in anticipation that by 2060 one-third of the French population will be 60 years of age or over. These acts focus largely on home-based care for older citizens. Funds are provided to meet housing and transportation needs, adopt private housing to permit the elderly to remain at home and create civil volunteering for seniors. The act increased the number of recipients by extending access to medium-dependent individuals. Second, the APA established national guidelines for allowances. By setting national standards, the APA sought to avoid local disparities in allowances.

Policyholders pay monthly premiums and some life insurance plans have an option for early payout in the event of dependency. APA allowances rarely cover the full extent of an older person’s needs, so private LTC insurance is “complimentary”. The APA increased the number of recipients by extending access to medium-dependent individuals. Second, the APA established national guidelines for allowances. Previously, local governments set allowance criteria for dependent older citizens. By setting national standards, the APA sought to avoid local disparities in allowances. The National Solidarity Fund for Autonomy was established to oversee the distribution of allowances. Individual’s needs are assessed and they are sorted into one of six categories. Guidelines for assessment are set at the national level to avoid local variation and disparities. Beneficiaries are assessed on the criteria of telephone communication, orientation, coherence, clothing, food, urinary continence, transferring, movement indoors, movement outdoors, and toileting. By 2012, 1.2 million older French citizens (aged 60 and above) received allowances from the APA.

Australia

The elder care system in Australia offers a range of options to meet the different care needs of individuals. Many older Australians desire to remain in their own homes as they age. As a result, there has been an increasing focus on the provision of aged care services in community settings [16-18].

The majority of the elderly population is enrolled in Medicare, similar to America’s program of the same name. One downside to this type of insurance is that it does not cover in-home long-term care. The elderly have two main types of care options: residential care and community-based care. Residential care includes permanent care (long-term facility with customized care, low versus high care, which has since been consolidated) and respite care (short-term care facilities that promote at-home care as long as possible). Community-based care includes the Commonwealth Home Support Programme (CHSP) consolidated older programs that assist with daily activities and the Home Care Packages Program which includes personalized care at home. The hours of nursing and personal care and benefits paid for depends upon the assessed level of need.

A multidisciplinary assessment is conducted by the Geriatric Assessment Program prior to admission to a nursing home. Afterward, the Director of Nursing carries out a second assessment to determine the hours of nursing and personal care benefits required.

Canada

Under the Canada Health Act, provinces and territories are responsible for providing LTC services for all their residents [19]. To help pay for these services, the federal government provides general health and social transfers to provinces and territories, Health services, including long-term care, for Aboriginals and veterans is the responsibility of the federal government.

LTC is provided through home care programs, community-based programs, and nursing homes. Admission to nursing homes is based on a needs assessment of a person’s health status and level of functional impairment.

Provincial taxes and transfers from the federal government fund public care in nursing homes. One’s income and/or assets determine the level of personal contributions. The government subsidies individuals who require financial assistance. In 2006, about 20% of the total costs of care were covered by private payments. While provincial/territorial governments cover health services, personal contributions are required to help cover board and lodging.

Provinces and territories are required to cover a core group of services; however, there are variations in coverage. Some plans require personal contributions based on personal income; while in other provinces, home care services are provided free of charge to eligible clients.

The delivery of home care services also varies from province to province. In some instances, the public sector is responsible for the assessment of eligibility and the provision of the full range of services. Other provinces provide assessment by the public sector. Professional services and home support are contracted to non-profit groups or for-profit agencies. In 2004, provincial governments agreed to provide first-dollar coverage (i.e., no client charge) for the following home care services, based on assessed need: short-term acute home care, medications related to discharge from hospitals, short-term acute community mental health care, and end-of-life care.

United Kingdom

In the U.K., local governments under the auspices of the Departments of Social Services provide long-term care. Support services are provided designed to encourage the elderly to remain at home as long as possible [20,21]. Community support includes home-helpers, district nurse visitations, physical therapy, daycare centers, and meals-on-wheels Geriatric Assessment units in every district hospital apply a means test to eligible individuals. Qualifying adults are provided with a package of services by local governments including institutional care, community-based care such as home care services and personal assistance, rehabilitation services, adult day care centers, and assistive devices.

Services, termed social care, are financed by the federal government. Since 1990, the Community Care Act requires persons with assets above $16,000 to contribute to the cost of institutional care and persons with assets above $25,600 to pay the total cost. In 1999 a decision was made to provide nursing services for free to eligible elderly. They are still required to pay co-payments based on needs to cover living costs.

A policy of outsourcing services for the elderly was established in order to reduce public expenditures. According to a recent report, one-third of the U.K.’s private healthcare providers for the elderly are at risk of financial failure. The problem stems from the attempt to adopt a Swedish-style private program for elder care while maintaining an American level of taxation.

Mexico

Mexico lacks a federal long-term care program. Responsibility to decide what, if any, LTC services to provide for the elderly is left to the states [22,23]. The majority of the elderly live with their close relatives who provide care. Currently, changes in fertility rates, rural-urban migration, and women’s increasing participation in the labor force, have changed family composition and pose future challenges to household care.

Tax incentives and monetary support for LTC or respite care for informal caregivers are lacking. Private LTC insurance plans that are available are expensive. Consequently, only a small fraction of the population takes advantage of it. Long-term care insurance.

Japan

There is much greater variation in long-term care policies in Asian countries. Traditionally, in Japan, China, and South Korea, family members have provided long-term care at home. However, as social structures have changed, the burden of older adult care has become a government responsibility. These governments have begun to set up long-term care insurance systems. Japan has traditionally relied on families to provide care for elderly relatives. With its burgeoning elderly population, projected to be 26% by 2020, longer life expectancy, and more women entering the workforce, the need for long-term care in-home services has increased by 109%. As a result, Japan adopted a Long-Term Care Insurance (LTCI) Policy in 2000 [24-26]. Municipal Long Term Care Councils classify the elderly needing care into care groups. The LTCI funds institutional and home care.

There was no publicly funded long-term care in Japan until 2000 when Japan adopted the Long Term Care Insurance Policy. Before 2000, the lack of publicly funded care resulted in “social hospitalizations.” The elderly were admitted to hospitals for long periods for no medical reason.

The Long Term Care Insurance program is funded by compulsory premiums for citizens 40 years of age and over and by national and local taxes. Elders who need care can access a wide range of community or institutional services. Two categories of citizens are eligible for long-term care services: older adults over 65 years of age and adults 40 years - 64 years of age with one or more of 15 geriatric diseases such as Alzheimer’s disease or stroke. Citizens who apply for long-term care services receive an on-site assessment and are classified into one of six levels or are rejected. Those who quality may receive at-home care, institutional or community-based services

Since the long-term care system in Japan is a national system, 45% of long-term care service finances are from the general tax, and another 45% are from social contributions. Out-of-pocket covers 10% of the total cost, and according to their pension status, people older than 65 pay it from the pension or direct payment to insurers. In addition, people who are 40 to 64 years old with geriatric disease are able to withhold payments from their medical insurance premiums. There is also the upper limitation of out-of-pocket payments.

Japan is developing technology to support long-term care. Smart Cards are designed to track the recipient’s care and whereabouts. Also, Japanese companies are developing robots known as Carebots designed to aid elderly people due to the shortage of caregivers. It has been predicted that there will be a shortage of one million caregivers by 2025. One-third of the Japanese government's budget is allocated to developing Carebots. The global personal robot market could reach $17.4 billion by 2020, according to a Merrill Lynch report.

Japan has also created a credit system called Fureai Kippu. (Caring Relationship Tickets) so that people can earn credits by helping seniors. Seniors may help one another or persons in the community may provide assistance. A ticket is issued which recognizes the efforts of people to support one another. Services such as cooking are credited with a ticket that can be banked and can be used later to purchase services. A ticket is issued which recognizes the efforts of people to support one another. The credit is based on the kind of service and the number of hours devoted to service. Credits may be used when the person becomes sick or elderly in exchange for services. Also, the users may transfer credits to someone else. The elderly appear to prefer services provided by others through personal connections under this system rather than commercial services paid for out of pocket. Two clearinghouses exist that transfer credits from one side of Japan to the other. China has begun to implement a similar credit system. By 2005, the largest exchange system in the world was in China.

China

In China traditionally, family members cared for the elderly. While care for the elderly is still largely provided by family, migration from rural to urban areas and the one-child policy has resulted in not enough family to care for the elderly. Currently, China is piloting several LTC programs. In Qingdao City, the pooling of insurance is in effect. About 90% of the elderly needing services receive care at home or in residential locations [27].

China does not have a national long-term care insurance system. Different cities are developing their own policies. In Shanghai, both cash payments and services are provided similar to Korea and Japan. However, long-term care facilities are of poor quality. Three types of services are provided depending on the city: residential, community, and institutional. Each city has its own financing mechanism. Local government provides some subsidies but a large portion of the cost is out-of-pocket.

South Korea

The elderly in South Korea are covered under the Long-Term Care Insurance (LTCI) policy enacted in 2008 [28-31]. Older adults 65 years of age or older with geriatric diseases are eligible for long-term care services. Professionals from the National Health Insurance Service visit the home and assess the needs of the elderly person. The individual is classified into one of three service categories.

To support the national long-term care system, the government covers 20% of LTCI and 6.55% of total National Health Insurance revenue financially supports it. General users pay 15% for in-house services and 20% for residential care, and people with low income pay 7.5% for in-house services, and 10% for residential care. Low-income, people do not have co-payments.

Turkey

Health reform occurred in 1992 with the development of the Green Card program. This program provided healthcare to the poor who met certain criteria. The next biggest change to the Turkish system occurred in 2003 with the passage of the Health Transformation Program, otherwise known as HTP [32,33]. While aiming to improve the entire system, it specifically focused on reorganizing delivery and financing. This transformed the previous Green Card program into Universal Health Insurance. This act consolidated the then-existing five health insurance schemes into a Universal Health Insurance) scheme managed by the newly created Social Security Institution. As a result, health insurance coverage of the Turkish population expanded significantly, reaching over 95% of the population.

At the same time, Turkey has the lowest coverage for institutionalized long-term care compared to European countries and major Asian nations. There are no long-term care insurance plans and there is a severe lack of facilities for elderly needing care. A strong tradition of family care for the elderly still exists in Turkey. This forces residents to pay out of pocket for any services they may need.

The only services covered for the elderly under the insurance program are inpatient care. This is problematic, as it does not provide any long-term care coverage that citizens 65 and older desperately need. However, Turkey’s UHC program offers an extensive list of covered services. Some services most important for the elderly include eye care, dental care, emergency treatment, pharmaceuticals, inpatient treatment, preventive care, and much more.

What we can learn about LTC from other countries

Financing: All of the industrialized countries discussed except the U.S. provide universal medical coverage. In most cases, LTC is financed separately. The tendency is for the national government to create programs to cover medical care while social services for the elderly are relegated to communities. The result is variation in services, depending upon local financing. The federal government provides some financial assistance to local programs. Block grants are provided in Canada and the U.K.; matching funds are provided to support state Medicaid programs in the U.S. LTC insurance programs in Germany and medical insurance programs are both administered by the Sickness Funds. This results in more integrated care for the elderly than in most other countries. In the U.K., the National Health Service and the local Departments of Social Services responsible for LTC are working more closely together by pooling budgets and merging some services in order to better coordinate care for the elderly.

Germany introduced social insurance programs covering LTC. Funding is provided by taxes or premiums that cover institutional or community-based care. LTC or social care in the U.K. is financed by the national government out of general tax revenue. In Denmark, long-term care is funded by local taxes supplemented by federal block grants. In the U.S. Medicare is funded by taxation while Medicaid is funded by states with matching funds from the federal government. Japan’s long-term care insurance program is financed by a combination of premiums and taxes.

Containing costs: Denmark has not established a new nursing home since 1987 because of the integrated homecare system. This policy has resulted in a leveling off of long-term care expenditure and a drop in the percentage of the GDP devoted to long-term care. Spending for those 80 years of age and over has fallen as a percentage of GDP. In Sweden, reform of the government's long-term care policy in 1992 that decentralized care resulted in a 50% reduction in the ratio of hospital beds to older adults.

At the same time in the U.K., a policy of outsourcing services for the elderly was established in order to reduce public expenditures. According to a recent report, one-third of the U.K.’s private healthcare providers for the elderly are at risk of financial failure.

Eligibility: Every country has some form of screening to determine eligibility for LTC benefits. In the U.S., Medicaid applies a means test to determine eligibility for services. Most of the other developed countries rely on a needs assessment. Denmark has a comprehensive assessment system. Needs assessments are performed twice a year by public health nurses on citizens 75 years of age and over. For those requiring care, a home care manager helps them develop a care plan. Similarly, in Sweden care managers assess the level of needs for individuals.

Germany does not rely on case management. Instead, elderly persons who require care may determine and arrange for their own care within a fixed budget. The vast majority of citizens receiving home care in Germany opt for cash payments to finance their own care. These funds are unrestricted and may be used to pay family members for care. Beneficiaries receiving cash payments are subject to periodic visits to ensure that adequate care for the elderly is being provided. This system is designed to encourage families to provide care for elderly family members. Because of the provisions that permit those qualifying for LTC to arrange for their own services, the number of agencies providing home care and the number of home care workers has increased dramatically in Germany.

Informal caregiving: Countries like China and Turkey rely almost entirely on family caregivers as was the case in Japan until the passage of the LTC Insurance Act in 2000. Even in the industrialized nations, families continue to provide much of the care for the elderly. Germany’s LTC insurance program is designed to encourage families to provide support for the elderly. The vast majority of persons who need care receive informal support. Support services are provided to informal caregivers that range from training to respite care to credits to assist caregiving with their future retirement.

In order to facilitate informal caregiving, Japan has instituted a credit system called Caring Relationship Tickets. If persons support elderly persons needing assistance with ADLs or IADLs, they receive a credit which they can use when they become sick or elderly. Japan is also developing robots that help to provide care for the elderly.

In Denmark, informal caregivers provide less LTC than in other OECD countries. However, informal caregivers can claim compensation for wages lost in caring for the elderly.

The U.K. has taken different measures to encourage informal caregiving. Instead of cash payments, the government provides a range of social support services such as adult day care and other respite services. Japan’s LTC program does not include cash benefits, out of concern that such payments might result in families feeling an obligation to provide informal care for elderly family members.

The U.S. LTC system that provides care for the elderly is under pressure from demands on federal and state budgets. Some legislators are proposing the privatization of Medicare. Others are calling for stringent work requirements in order to qualify for Medicaid benefits. Many elderly Americans experience catastrophic expenses for LTC and are forced to exhaust their income and resources in order to qualify for services. The lack of a universal system that is need-based is the fundamental feature that differentiates the U.S. from all of the other OECD countries.

1. World Population Projections 2050. https://www.un.org/en/desa/world-population-projected-to reach-98-billion-2050-and-112-billion-2100
2. Medicaid’s Role in Nursing Home Care. https://www.kff.org/infographic/medicaids-role-in-nursing-home-care
3. Frank RG. Long-term care financing in the United States: sources and institutions. Applied Economic and Policy. 2012. 34(2): 333-345.
4. Brown JR and Finkelstein A. Insuring long-term care in the United States. Journal of Economic Perspectives. 2011; 25(4):119-141.
5. The Chronicle Herald Special Report, Care in Crisis, A Better Way to Care for the Aging https://www.thechronicleherald.ca/careincrisis/A better...way-to-care-for-the-aging Denmark Long Term Care, OECD. 2011
6. Da Roit B, Le Bihan B. Similar and yet so different: cash-for-care in six European countries' long-term care policies. Milbank Q. 2010 Sep;88(3):286-309. doi: 10.1111/j.1468-0009.2010.00601.x. PMID: 20860573; PMCID: PMC3000929.
7. Glenngard AH. The Swedish health care system. The Commonwealth Fund. 2016.
8. Szebehely M. and Trydegard GB. Home care for older people in Sweden: A universal model in transition. Health and Social Care in the Community. 2012; 20(3):300-303. https://www.census.gov/content/dam/Census/library/publications/2016/demo/p95-16-1.pdf
9. Switzerland Long-term Care. https://www.oecd.org/switzerland/47878092.pdf
10. Gibson MJ, Redfoot DL. Comparing Long-term Care in Germany and the United States: What Can We Learn from Each Other? https://assets.aarp.org/rgcenter/il/2007_19_usgerman_ltc.pdf
11. Durand-Zaleski I. The French Healthcare System.  The Commonwealth Fund. 2016. http://international.commonwealthfund.org/countries/france/
12. Joel M, Dufour-Kippelen S, Duchene C, Marmier M. The long-term care system for the elderly in France. European Network of Economic Policy Research Institutes. 2010. http://www.ancien-longtermcare.eu/sites/default/ files/ENEPRI%20_ANCIEN
13. le Bihan B. France Anticipates Ageing Society through New Piece of Legislation. ESPN Flash Report 2016/18, http://englishbulletin.adapt.it/wp-content/uploads/2016/05/ESPN-Flash-Report-2016-18-FR-April-2016.pdf
14. Chevreul K, Brigham KB. Financing long-term care for frail elderly in France: Milbank The ghost reform. Health Policy. 2013; 11 213-220.
15. Doty P, Nadash P, Racco N.  Long-term care financing:  Milbank Quarterly. 2015; 93(2):359-391.
16. Aged Care Data. Australia. https://www.genagedcaredata.gov.au.
17. Australia. http://www.aihw.gov.au/australias-health/2014/health-system
18. Health System Overview: Australia (commonwealth fund). https://www.commonwealthfund.org/sites/default/files/2020-12/2020_IntlOverview_CAN.pdf
19. Canada OECD. Health Data 2010, Paris. 2010.
20. De Freytas-Tamura K. Britain’s Model for Outsourcing Services May Be Cracking. New York Times. February 1, 2018; A4.
21. Tomoko Shinoda-Tagawa and Soichi Koike. Long-Term Care Lessons from the United Kingdom, Germany and Japan. http://www.hcs.harvard.edu/~epihc/currentissue/spring2002/shinoda-tagawa-koike.php
22. Johnson JA, Stoskopf Comparative Health Systems: Global Perspectives. Boston: Jones and Bartlett. Mexico. 2010; 219-235.
23. Mexico LTC. http://www.oecd.org/mexico/47877877.pdf
24. Campbell JC, Ikegami N. Japan’s Radical Reform of Long-Term Care. Social Policy and Administration. 2003; 37:21-34.
25. Muoio D. Japan is running out of people to take care of the elderly, so it's making robots instead.  http://www.businessinsider.com/japan-developing-carebots-for-elderly-care-2015-11
26. Shimizutani S. The future of long-term care in Japan. Asia-Pacific Review. 2014; 21(1):88-119. https://www.theguardian.com/social-care-network/2014/mar/27/japan-solution-providing-care-ageing-population
27. Liu T. Nursing Care for Elderly People in Germany and China: A Bilateral Comparison and Exploration of Policy Transfer. 2014, September 29. https://www.omicsonline.org/open-access/nursing-care-for-elderly-people-in-germany-and-china-a-bilateral-comparison-and-exploration-of-policy-transfer-2167-1168-3-206.php?aid=3111
28. Johnson JA, Stoskopf Comparative Health Systems: Global Perspectives. Boston: Jones and Bartlett. Korea. 2010; 337-347.
29. Kwon S, Kim SJ, Jung Y. Introduction of Long-term Care Insurance in South Korea. http://umdcipe.org/conferences/policy_exchanges/conf_papers/Papers/1661.pdf
30. Kwon S. Future of long-term care financing for the elderly in Korea. J Aging Soc Policy. 2008;20(1):119-36. doi: 10.1300/J031v20n01_07. PMID: 18198163.
31. Kwon S. Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage. Health Policy Plan. 2009 Jan;24(1):63-71. doi: 10.1093/heapol/czn037. Epub 2008 Nov 12. PMID: 19004861.
32. Johnson JA, Stoskopf. Comparative Health Systems: Global Perspectives. Boston: Jones and Bartlett. Turkey. 2010; 273-285.
33. http://documents.worldbank.org/curated/en/565451468319153981/Toward-universal-coverage-Turkeys-green-card-program-for-the-poor