Having Universal Care Does Not Put the United States Over the Finish Line
PUBLISHED July 31, 2026
Long-term care is not the same as health insurance. As people age, they may need assistance preparing their own meals, going to the bathroom, or taking a shower.
Having someone around to help out costs money. In 2025, the median annual cost of a private room in a nursing home was $129,500, according to CareScout. Staying at home and hiring a full-time aide costs care users approximately $80,000 a year.
In the United States, Medicaid is the primary payer for nursing home care. Those relying on Medicaid to pay for their nursing home expenses can usually keep their home, but generally have to spend down their “countable assets” like stocks, bonds, and cash to about $2,000.
Maintaining Dignity
Japan is different. The Ministry of Justice says that the purpose of the country’s long- term care system is to “maintain dignity and an independent daily life routine.” Japanese long-term care emphasizes home and community-based support over institutional care.
A person in need of long-term care must first fill out an application with their municipal government. A representative will then interview them at their home and a panel will decide how much in benefits the state will provide each month.
Japan has five levels of long-term care. Level 1 is for an individual who needs partial help with their daily activities while someone who is fully dependent on others and needs constant care would receive Level 5 benefits. The higher the level, the higher the benefits.
A person who wants to stay in their home could work with a care manager and contract out for local support programs. Depending on their care program, support programs could include assistance with bathing, toileting, and eating along with home visitations for rehabilitation. Additionally, care users could sign up for night-time visits.
Community organizations also play a role in helping people to stay out of nursing homes. Japan has outpatient rehabilitation services and community centers where care users can receive daily life support services so that they can continue living in their neighborhood. Of particular interest are the one-day service centers, somewhat comparable to what we might call adult day care centers.
Imagine for a moment a similar initiative in the U.S. where caregivers could drop off a loved family member in the morning, go to work, and then pick them up at the end of the day. A caregiver’s life would not be put on hold for taking care of a loved one. For the care user, an adult day service center should offer support services and be a place to meet friends, relax, and interact socially.
Nursing Homes
As a rule, nursing home stays are expensive, but less so than in the United States. Japan has both public and private nursing homes. Public nursing homes are cheaper, but they may have a two-to-five-year waiting list. In either case, care users pay the room and board charges required by the nursing home, but the government pays for an individual’s long-term care costs. The exact share of nursing home costs covered by Japan’s long-term care insurance is difficult to determine from the available data.
In Japan, only 34.9 percent of long-term care benefits go to nursing homes; in the United States,1 that number is roughly 56 percent.2 A household with an all-hands-on-deck attitude, in my opinion, could probably get by with just home and community care in lieu of having to put a family member into a nursing home.
As an aside, I also think that caregiving could be made even easier if tech companies could come up with an affordable robot to help care users go to the bathroom and empty bedpans. Such an invention would bring dignity to both care users and caregivers.
With respect to dementia patients, Japan goes the extra yard. To begin, elementary school students learn about dementia and how to support people living with dementia. In addition, community organizations play a major role in providing long- and short- term care options while neighborhood venues like community cafés help reduce stigma, provide preventive care, and allow people living with dementia to stay engaged more with society.
Unfortunately, long-term care programs cost billions of dollars. Japan devotes a little more than 2 percent of its GDP to long-term care. The Netherlands devotes almost 4 percent.
Could the United States afford such a luxury?
The answer is yes, and surprisingly so. In my next blog, I will discuss how.
Note: This is an ongoing series of blogs to develop an affordable, universal health care plan before the 2028 presidential election.
Footnotes
1Ministry of Health, Labour and Welfare, Health and Welfare Services for the Elderly (Chapter 10: Outline of the Long-Term Care Insurance System) (Government of Japan, 2002), 232.
2To get “roughly 56 percent”, I used NHE Tables 14 and 15. I first added $169.4 billion (Table 14, 2024, Home Health Care) + $219.9 billion (Table 15, 2024, Nursing Care Facilities) to get $389.3 billion. Next, I calculated the percentage: $219.9/$389.3 = 56.4%.
References
Akiya Japan. (2026, June 2). Healthcare in Japan for older foreign buyers: Senior care, NHI, and what to plan before you relocate. https://akiyajapan.com/articles/japan-healthcare-older-foreign-buyers-senior-care-nhi
CareScout. (2026). Cost of Care Survey 2025: Median cost data tables.
Centers for Medicare & Medicaid Services. (2026). National health expenditure accounts: Table 14, home health care expenditures, and Table 15, nursing care facilities and continuing care retirement community expenditures, by source of funds, selected calendar years 1960–2024. U.S. Department of Health and Human Services.
Chen, L.-M., Inoue, M., & Buckley, N. (2024). Case studies on community care in Japan: Considerations for mitigating social isolation and loneliness in older adults with dementia. Frontiers in Public Health, 12, 1411217. https://doi.org/10.3389/fpubh.2024.1411217
Chidambaram, P., Burns, A., Neuman, T., & Rudowitz, R. (2025, May 28). 5 key facts about nursing facilities and Medicaid. KFF. https://www.kff.org/medicaid/issue-brief/5-key-facts-about-nursing-facilities-and-medicaid/
Elder Care Resource Planning. (2026, June 8). Medicaid’s 2026 financial and functional eligibility requirements for long-term care. https://www.eldercareresourceplanning.org/medicaid-faq/eligibility/criteria/
Ministry of Health, Labour and Welfare. (2014). Health and welfare services for the elderly: Outline of the long-term care insurance system. Government of Japan.
Ministry of Health, Labour and Welfare. (n.d.). Long-term care insurance system. Government of Japan. https://www.mhlw.go.jp/content/12300000/000614772.pdf
Noguchi, H., Shimizutani, S., & Suzuki, W. (2023). Long-term care in Japan (NBER Working Paper No. 31829). National Bureau of Economic Research.
Osaka Prefecture. (2024, April). About the long-term care insurance system. https://pref.osaka.lg.jp/documents/29569/kaigohoken-eigo.pdf