John Hersey
Among the United States’ health care system’s many flaws is its failure to adequately fund and invest in caregiving, possibly an artifact of cultural messages about rugged individualism and self-reliance. While the U.S. is not alone in its struggle to value caregiving while simultaneously preparing for an increase in the elderly population, some countries have led the way in creating more-sustainable models. Policymakers should take their cues from these efforts.
Obamacare architect and co-director of the University of Pennsylvania’s Health Transformation Institute Ezekiel Emanuel recently told Vox’s Ezra Klein that the Netherlands and Germany have two of the best systems for long-term care. “Unlike every other country we looked at, they have secured the financing for long-term care,” he said on the Ezra Klein Show podcast.
Emanuel’s latest book compared health care programs around the world, but he admitted that when it comes to elder care, these European countries are where he would personally prefer to live out his days.
Part of what makes the Netherlands and Germany so far ahead of the United States is their commitment to funding for the aging populations in government programs or compulsory insurance schemes. Any system that lacks dedicated funding for elder care shifts the responsibilities to the relatives of those who are aging, and most of the time those relatives are women.
The Netherlands was one of the first countries to make funding for long-term care mandatory, starting in 1968, and it has advocated for personal care budgets since the 1990s. It also spends the highest percentage of its GDP, at 3.7 percent, on long-term care, according to a study from the Organisation for Economic Co-operation and Development. The Dutch budget supports both medical and nonmedical care services, which can include cleaning, preparing meals, and other home chores.
In 1995, Germany’s long-term care law was implemented, creating an independent social insurance program that covers the majority of the nation’s elderly.
What’s unique about the Dutch health insurance program compared to its European neighbors is that all health insurance is provided by private, nonprofit companies, and purchased by individuals who receive government subsidies for their services. The private market is tightly controlled to prevent unaffordable prices, but it also mandates that everyone is covered—even so-called “high-risk” customers. Germany’s system is mostly government-run; about 90 percent of Germans receive their care from the government, with the remaining 10 percent enrolled in a tightly regulated private market. Despite these differences, both systems relieve the burden on relatives and friends of being responsible for someone else’s long-term care needs.
Making long-term care a priority has allowed for more consumer choice. Dutch and German people who need long-term care have more flexibility than in other countries as to where they receive their care, with more people opting to stay in their own homes.
Some European lawmakers have also taken an additional step to consider the many people who perform unpaid long-term care for a relative. This is consistent with a global consensus on paid family and medical leave that the United States, virtually alone, has chosen to ignore. Only three of the United Nations’ 193 countries don’t mandate paid parental leave: New Guinea, Suriname, and the U.S. On paid sick leave, America is one of only 13 countries without it.
Germany and Italy have the oldest people in Europe. Thanks to a 2012 law in Germany, full-time employees who need time off to care for a family member can borrow against their future wages. They may reduce their work hours to part-time for up to two years while retaining 75 percent of their normal salary, and when they return to work they continue receiving 75 percent of their wages until the borrowed balance evens out.
In Italy, employees are able to take three days every month to care for a family member with a disability up to three degrees of separation, which means it can include grandchildren caring for grandparents, as well as nephews caring for uncles, for example.
Admittedly, the United States ranks quite high on national polls when it comes to long-term elder care, but the system is mostly dependent on an individual’s ability to afford quality care. Alternatively, when elderly Americans can rely on family members for their care support, there are not mandated systems in place to support those family members, either through paid leave schemes or a federal paid leave program.
A complete federal program that sets rates and wages for nursing homes, long-term facilities, and workers both at home and in those facilities, and provides the necessary care for our aging population, without mandatory buy-ins or participation requirements is not a pipe dream. Countries like Taiwan and Finland boast a publicly funded, universal system open to every resident, guaranteed as a human right, and administered at the municipal level, with care recipients given broad choices on at-home or facility-based care. The program is widely celebrated, and it’s been effective at keeping costs surprisingly low. That it loses money is functionally irrelevant, as it should be in the United States. Long-term care is a social imperative.
Any system that lacks dedicated funding for elder care shifts the responsibilities to the relatives of those who are aging, and most of the time those relatives are women.
On the other end of the care spectrum, the United States could also benefit from international examples to improve the quality of care for young children. Emanuel said the biggest return on investment in the U.S. health care system would be made by investing in children, especially the nearly 15 percent of children who are born into poverty every year.
For America’s potential model, it needs only to look north to neighboring Canada. Twenty years ago, Quebec introduced its universal child care program, charging people less than $4 a day for pre-kindergarten education and care. That rate has increased to about $6 per day for middle-class families. The Quebecois government foots the remaining $1.5 billion of the universal child care bill, but the cost is sufficiently offset by the value of women re-entering the work force. The Swedes and the Danes also have similar programs.
The French model is similar to their former colony, but it goes further by offering an expanded universal child care program. In addition to les écoles maternelles, preschool for children ages three to six, there are crèches, which take children as young as three months old and are open for slightly longer than the length of an average workday, from about 7:30 a.m. to 8 p.m. The hourly rate for children is based on a sliding scale adjusted for the parent’s income.
Preschool is not mandatory for children under six, but because it’s so affordable about 95 percent of eligible children attend. As a result, more than 80 percent of French mothers with one child work outside the home, compared to about 60 percent of their American counterparts.
There is also a tax break for families who prefer to hire a nanny. This in-home care worker can be either a child care professional or an assistante maternelle who is licensed by the government. The family pays for the nanny’s benefits and in return receives a rebate from the French government based on the family’s income. This differs widely from the situation in America. A 2017 survey from Park Slope Parents showed that 60 percent of nannies were being paid completely under the table, compared to 13 percent on the books.
At the minimum, there is a vast disparity in early child care choices between the U.S. and the world’s early child care leaders. When considered with the limitations of long-term care in the United States, families can become sandwiched by caregiving responsibilities. A 2019 UNICEF study ranked the U.S. dead last among high- and middle-income nations for family-friendliness.
The biggest return on investment in the U.S. health care system would be made by investing in children, especially the nearly 15 percent of children who are born into poverty every year.
Emanuel described the U.S. health care system as à la carte: “[If] you want socialized medicine, à la Britain, we’ve got that, it’s called the VA [Veterans Affairs]; if you want single-payer system, where the government pays out to private hospitals on a fee-for-service basis, we’ve got it, it’s called Medicare; you want more like Germany and the Netherlands, where you put money in a pot and then you pay it to private insurers, and private insurers organize the care, we’ve got it, it’s called Medicare Advantage and the exchanges; we’ve got everything.” Emanuel also adds the private, nongovernmental system, which is like the system in Switzerland, which we call employer-sponsored insurance.
What America does not have is a federal family care infrastructure. The complexity of managing different, mostly inadequate systems adds not only to the enormous administrative cost but also to the confusion for everyone involved, from providers to patients. While no countries have an integrated universal family care system, most have strategies that cover paid family and medical leave, early child care, and long-term care. These models can form the basis of a transformed U.S. system.
