Financial social protection and individual out-of-pocket costs of long-term care in the USA and Europe: An observational study

BACKGROUND: Empirical evidence informing policies aiming at ensuring affordability of long-term care (LTC) costs is limited. Combining system-level with individual-level data, we quantify the burden of out-of-pocket costs of LTC services on households in 13 European countries and the USA and explore how social protection systems impact affordability of care. METHODS: In this observational study, we use harmonised data from the Health and Retirement Study (HRS), collected between 2012 and 2016, and from the Survey of Health, Ageing and Retirement in Europe, collected between 2013 and 2017. We assess the severity of LTC needs of older adults (65+) on the basis of self-reported limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). We classify countries' social protection systems in terms of affordability and progressivity using information obtained from country officials. We examine variation in individual-level out-of-pocket LTC costs by social protection systems' affordability and progressivity. FINDINGS: Out-of-pocket LTC costs are heterogeneous across countries and increase with individuals' needs. In countries where LTC is more affordable and social protection systems less progressive, older adults incur significantly lower levels of LTC costs. Within Europe, not only are costs lower where systems are characterized by higher affordability and lower progressivity, but they also represent a lower share of households' disposable income. INTERPRETATION: Our findings indicate that the social protection systems significantly affect the level of out-of-pocket costs faced and reported by older adults with LTC needs as well as the share of their income that is devoted to pay for care. FUNDING: We received funding from the National Institute on Aging (grant number R01 AG030153). The OECD programme of work on ageing and long-term care is partly funded by the European Union.