There are two answers to that question. On the face of it, the low-level of spending on long-term support services in the United States reflects a different age profile. So that even though Germany and Japan spend more on long-term care, they have a much larger proportion of their populations are 65 and over. That demographic, that grip of the population 65 and over tend to be an important group in need of long-term care. So in that sense, one could say that the United States spending on long-term support services or long-term care reflects a different age profile. But that would be to ignore the significance of the problem of long-term care spending and the question of how the United States has managed to sustain that long-term care spending. So let's go back to basics and note that long-term care spending is about two separate sources of need. One is in relation to disability. That is, a person who has a disability may be in need of various forms of long-term support in order to be able to live with that disability, that can be basic needs in the house, it can be needs around self-care. The goal in relation to long-term support for disability is to ensure that a person can live as full a life as possible with that disability. But that is misleading in part because, one of the characteristics of humanity is the process of aging. Aging isn't really a disability, as Atul Gawande pointed out in his book, Mortality, it is not a disability, is a fact of human life. So long-term care is also concerned with supporting people in the process of aging. So the first important point to note is that, even though the United States has different age profile than Germany and Japan, there is an increase in proportion of the population who will be 65 and over. So in the next 20 years, it will increase from currently of around 16 percent of people who are 65 and over to 25 percent in 2030. So there's an increase in the group of people who will be in need of long-term care. But that in itself doesn't fully give a proper explanation of the problem because there are additional features of an aging population. Greater life expectancy has resulted from the diminution or the fall in the number of acute diseases. That is, both acute diseases that we're better able to treat, but also removal of some lifestyle practices that have contributed to acute hubs. So for example, smoking. Reductions in smoking have reduced the incidence of lung cancer and that has had an effect on life expectancy. More importantly than that is that, aging comes with an increasing chronic diseases; diabetes and high blood pressure. These are a set of concerns which create needs over the long-term and requiring more intensive forms of long-term care. So when we think about the need for long-term care, we've got to think about both the question of aging, but also the question of the increased need for long-term support. Again that background is being used to just to reflect on long-term support spending in the United States. Most of that spending comes by way of Medicaid. Long-term supports spending both for the young and the aged in Medicaid takes up around 50 percent of total Medicaid spending. So it's a relatively small proportion number-wise in Medicaid account for high levels of total Medicaid spending. Secondly, in relation to Medicaid spending, in order to obtain access to long-term support, particularly for the aged, those 65 and over, there are important income requirements, the income and asset requirements. So that in order to get access to long-term care, it's necessary for recipients to spin down their resources. So that's one way in which the United States actually maintains relatively low levels of spending on long-term care. So when you ask, how does the United States get away with it? Well, it is dealing with it by treating the need for long-term care as a form of disability and then placing main test upon access to that care. What does that mean? Well, one of the things it means is this. In 2009, it is estimated that the total amount of unpaid care provided by families and friends was in the vicinity of $450 billion. Just to note, in 2009, total Medicaid spending was $373 billion. So the US is highly reliant upon high levels of unpaid care, both for those with disabilities and more generally, for meeting the needs of an aging population who are living longer and are experiencing greater levels of need. So what I would say is that the level of long-term care spending in the United States is a complex nested problem that is concerned with the biggest question of how we conceive of our mortality and how we age, and then more narrowly, how we can save of disabilities and how we provide support for those with disabilities. Then institutionally, perhaps the biggest issue is that Medicaid is really not the right vehicle to provide support for long-term care, neither state government budgets are simply not going to be able to support the need for increased levels of care. So as with many things in the health system, I would say that this question of low levels of spending on long-term support services in the United States is indicative of multiple, complex, interwoven questions.
