LTC Bullet: Sweden Shrugs on LTC

Thursday, July 18, 2002


*** The Center for Long-Term Care Financing thanks the Standard Insurance Company and the Milbank Foundation for their quick and complete response to our appeal in last Tuesday's LTC Bullet. Thanks to their generous support, we will conduct a series of briefings on the problems with and better alternatives to Hawaii's proposed CarePlus mandatory LTC financing scheme. We encourage all Bullets readers in Hawaii to contact Richard Rowland, President of the Grassroots Institute ( or 808-487-4959), if you would like to attend and/or support one of these meetings. ***

*** The Great LTC Debates are coming. Block out November 17 to 19, 2002 on your calendars, book a flight to St. Louis, and reserve a room at the Adams Mark Hotel, near the Arch. Contact Jesse Slome, editor of "LTCi Sales Strategies" magazine, ( or 888-599-5997) for complete program details on the "National LTCi Producers Summit" featuring The Great LTC Debates. This will be a unique opportunity to watch and hear some of the leading movers and shakers in long-term care going head-to-head, locking intellectual horns over the hottest controversies in the field. We're looking forward especially to a high-minded but frank luncheon discussion between Center President Steve Moses and NAELA-President-Elect Bill Browning, tagged "Medicaid Planning: Damned or Destined." The conference costs $395, but if you let "Sales Creators" know you learned of it in LTC Bullets, organizer Slome will knock $25 off your cost AND donate $25 to the Center for Long-Term Care Financing (your cost $370 for Early Registration). Furthermore, the Center is planning an LTC Graduate Seminar program on the day after The Great LTC Debates, November 20, 2002. If you attend both, we'll drop the grad seminar price $25 too, a great deal for $200. To pre-register for the LTC Graduate Seminar, call or email Amy Marohn at 425-377-9500 or ***

*** We've just published the "LTC Week in Review for July 15 - 19, 2002: LTC E-Alerts #176-#180" in the donor-only zone at What is the LTC Week in Review? Every week, Center President Steve Moses scans numerous electronic newsletters, captures the stories most likely to interest you, and provides a brief summary, usually with a hyperlink to the original. The LTC Week in Review is like having your own personal clipping service. But you need a user name and password to get it. Instructions on how to "Zone In" follow this list of the newest donor-zone content.

LTC E-Alert #176--Bleak Forecast for Nursing Homes

LTC E-Alert #177--Senior Housing Crisis

LTC E-Alert #178--Elder Deputies to Patrol Nursing Homes

LTC E-Alert #179--NYT Reports Corporate Elder Care Benefits Rising

LTC E-Alert #180--Pill Crushing, Danger Lurks in the Strangest Places

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LTC Comment: For decades, advocates of government-financed social benefits, including long-term care, have pointed to Sweden as their paradigm of a successful system. Now comes the news that Sweden is backing away from publicly financed long-term care and relying more and more heavily on informal family care and publicly financed institutional care. The following article in the prestigious, peer-reviewed journal The Gerontologist lays out the latest facts. Read our analysis after the abstract and excerpts which follow.

Gerdt Sundström, Ph.D., Lennarth Johansson, Ph.D. and Linda B. Hassing, Ph.D., "The Shifting Balance of Long-Term Care in Sweden," The Gerontologist, Vol. 42, No. 3, June 2002, pps. 350-355.


"Purpose: This study describes the Swedish debate on the role of family and state in care of elderly persons. It provides empirical evidence on the shifting balance of family, state, and market in the total panorama of elderly care.

"Design and Methods: Secondary analysis of older (1954) and more recent data sources (1994 and 2000) is used to assess living arrangements and care patterns for persons 75 years or older living in the community.

"Results: Total spending on aged adults has stagnated, and institutional care is shrinking in absolute and relative terms, but public Home Help for elders in the community is decreasing even more. Family members increasingly shoulder the bulk of care, but privately purchased care also seems to expand. This study calculates how public and informal care changed between 1994 and 2000: Informal care is estimated to have provided 60% of all care to elders in the community in 1994 and 70% in 2000.

"Implications: The results parallel a crisis of legitimacy of public elderly care in Sweden. They also call into question various metaphors used to describe patterns of care."


"One of the oldest discussions in gerontology and, indeed, in social science concerns the role played by the state and the informal network around elderly people in need of help and support and how this has changed. Welfare states like Sweden have been thought to represent paradigmatic cases of special interest.

"Swedish policy makers are now worried about rising burdens of care and pension expenses, and a recent major reform of the pension system has reduced its 'pay-as-you-go' structure. The new system has a savings (funds) part to it, and the individual return from the system will be based on lifetime earnings and on general economic growth.

"A peculiar trait of Swedish society used to be unquestioned mutual trust between individuals and the state, demonstrated for example in opinion surveys that showed substantial willingness to pay taxes for public elderly care. Recent cutbacks in services for elderly people have undermined this tacit 'contract,' and there are many indications that these changes lead to a new balance of responsibility for elderly people. Opinion polls indicated declining trust in public pensions and public elderly care." (p. 350)

"It is intriguing that cutbacks have been greater for the much less costly Home Help service than for institutional care. Home Help is designed to help elderly people remain in their own homes and to be a cost-effective program. Cut backs in this service contradict official policies at both the national and local levels of supporting elderly people at home, policies that emerged after the . . . public scandals of institutional care in the 1950s." (p. 352)

"The fact that families provide a growing part of care for elderly adults and that the state has withdrawn its flagship, the Home Help, from central areas of support to Swedish elders has already led to questioning of the legitimacy of this service and pressure group formation. Also, other nonpublic alternative emerge and, as mentioned, privately purchased help expands among elder adults. The tacit contract between family and state is less tacit today and is increasingly called into question." (p. 355)

"In conclusion, the welfare state has retracted its more far-reaching ambitions. The question is whether it has also resigned from a basic but mostly silent premise of the welfare state: the idea that public services support and strengthen informal structures and that they are mutually reinforcing. This has been called solidarity . . ., but it is also a matter of everyday social policy, as practiced in myriad local cases of help to aging persons. Both individuals and families have received support, and caring family members usually could trust that they would not stand alone with their tasks and commitment. Ever more strict rationing of these very services and the increasing focus on individuals that live alone and may have no family to help them jeopardize the silent understanding that the state and family are partners in this undertaking. This may, in the not-so-long run, undermine the welfare state itself." (p. 352)

LTC Comment: Like their U.S. peers, these authors just can't understand why Sweden is cutting back on its more cost-effective home care program and relying more heavily on institutional care. The answer is simple. When governments run out of money and cannot tax more because their citizens are tapped out and fed up, the only way they have to control costs is to offer services nobody wants. That's why Medicaid home and community-based care remains so under-financed and why America retains a service delivery system so heavily reliant on institutional care. Instead of the U.S. moving toward Sweden, Sweden is moving toward the U.S. The only hope for quality long-term care in both countries is to target publicly financed long-term care toward the genuinely needy and encourage everyone else to save, invest or insure. If that were done, Medicaid and Medicare could offer better care across the whole spectrum of long-term care to a smaller population of beneficiaries. With more people insured or otherwise able to pay privately for care, everyone would have access to quality care in the private marketplace at the most appropriate level.