Care poverty is embedded in multiple social inequalities , but also forms an essential dimension of inequality on its own. Furthermore, it poses a serious threat to the well-being and health of older people—and in grave situations, even to their life. According to Oxford English Dictionary, the welfare system is ‘a system whereby the state undertakes to protect the health and well-being of its citizens, especially those in financial or social need’ (Lexico, 2021). Care poverty is exactly the kind of issue that a welfare state is expected to address. But do real-life welfare states manage to lift their older citizens out of care poverty and protect their health and well-being? Are their policies equipped to tackle unmet care needs and eradicate inequalities in access to adequate care? When compared to each other, how do different care regimes perform in this respect? Which policy models work best against care poverty?

This chapter collects available evidence for the relations between care poverty and long-term care systems in different countries for the purpose of discussing how different policies work to reduce care poverty among the older population. The chapter opens with presenting findings from the few existing international comparisons on unmet needs, showing first the results of differences between European care regimes. Next, it discusses lessons for social policy gleaned from the few available two-country studies on unmet needs. We then return once more to the local and national studies presented in Chaps. 4, 5, and 6: what can we learn from their key findings about the impact of different care policy designs on care poverty?

Care Poverty and European Long-Term Care Regimes

The lack of comparable data on unmet long-term care needs has largely hampered the development of comparative research on the issue. Consequently, international literature remains very scarce. Still, the 2010s saw the publication of the first larger international studies on unmet care needs.

Bień et al. (2013) were among the first to analyse unmet needs comparatively. They used questionnaire survey data collected from family carers of people aged 65+ for the EUROFAMCARE project. The proxy-respondent data came from six European countries: Germany, Greece, Italy, Poland, Sweden, and the United Kingdom. As the dataset does not include questions on ADLs or IADLs, respondents were asked about eight different areas of need—the contents of which were illustrated by examples. Four out of these eight areas were included in the analysis:

  • ‘Health needs’ (e.g., assistance with medication, rehabilitation)

  • ‘Physical/personal needs’ (e.g., washing, dressing, eating)

  • ‘Mobility needs’ (e.g., moving around in- or outside the house, transportation)

  • ‘Domestic needs’ (e.g., housework)

‘Physical/personal needs’ cover ADLs, while ‘domestic needs’ include IADLs. ‘Mobility needs’ refers to IADLs and some ADLs, and and ‘health needs’ to IADLs as well as some other needs. Unmet ‘physical/personal needs’ thus reflect personal care poverty, while the three other areas are at least partly about practical care poverty.

The results show variations in the four areas between the six countries (Fig. 8.1). The findings are surprisingly consistent across the different areas of needs. For all four areas, Greece has the highest prevalence of unmet needs followed by Italy. The next three countries (the United Kingdom, Germany, and Poland) are not much different from each other, although when all the four areas are counted together, Poland clearly has more older people who are deprived of several kinds of help. Sweden has the lowest levels of personal and practical care poverty in all four areas.

Fig. 8.1
figure 1

Prevalence of proxy-reported unmet care needs in six European countries. (Source: Bień et al., 2013)

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These findings mostly follow the usual understandings of care regimes, wherein formal care provisions are seen as stronger in Northern and Western Europe than in Southern and Eastern Europe (e.g., Bettio & Plantenga, 2004; Lightman, 2020). But it is not self-evident that care poverty rates should follow the availability of formal care. This is because for care poverty, informal care also plays a decisive role. The results of this study nevertheless suggest that informal care in Greece and Italy does not manage to complement the paucity of formal care. Northern welfare states Sweden and the United Kingdom seem to succeed better in cutting down personal and practical care poverty. The authors of the study conclude that expanding formal social care might be the most effective strategy to reduce unmet needs.

Next, Vilaplana Prieto and Jiménez-Martín (2015) analysed unmet care needs with Eurobarometer 67.3 data from 18 countries. As with EUROFAMCARE, this dataset focuses on informal carers (or more accurately, on the level of interest within the adult population in becoming an informal carer). Here, the data consist of proxy-respondent understandings of the unmet needs of older people. These were measured in a very particular way by asking whether the respondent knew anyone in need of long-term care whose experience with care services was fairly bad or very bad, whose access to care services was fairly or very difficult, or who found care services not very affordable or not at all affordable. Thus the focus falls on the availability and quality of formal care rather than on unmet care needs in the usual broad sense. But as international studies of unmet needs are so rare, the results from this study are included here.

Vilaplana Prieto and Jiménez-Martín (2015) report their findings separately in terms of three reasons for unmet formal care needs (poor quality, poor accessibility, and poor affordability). However, they also provide a figure that represents all respondents who mentioned at least one of these three issues (Fig. 8.2). Affordability and accessibility prove to be the main problems, while quality issues were mentioned less often. Out of the 18 countries, the total prevalence of unmet formal care needs is the highest in the Czech Republic (79%), Hungary (75%), Slovakia (75%), and Italy (74%). It is the lowest in Sweden (34%), Denmark (35%), and Luxembourg (39%).

Fig. 8.2
figure 2

Prevalence of proxy-reported unmet formal care needs in 18 European countries. (Source: Vilaplana Prieto & Jiménez-Martín, 2015)

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The authors grouped the countries into four clusters: the ‘standard model’ (Austria, Belgium, the Czech Republic, Finland, France, Germany, Italy, and the United Kingdom), the ‘Nordic model’ (Denmark, the Netherlands, and Sweden), the ‘family model’ (Spain and Ireland), and the ‘transition model’ (Hungary, Poland, Slovenia, and Slovakia). This grouping is exceptional as it does not follow usual care regime clusters. The first group includes nations from the north and the south as well as the east and west of Europe. Many countries are not placed in their usual clusters: for example, the Czech Republic is not in the ‘transition model’, Finland is not in the ‘Nordic model’, and Italy is not in the ‘family model’. Luxembourg was not included in any model.

When comparing these four country groups, the authors report the ‘transition model’ (70%) as having the highest total prevalence of unmet needs. This is followed by the heterogeneous ‘standard model’ (66%), the small ‘family model’ (59%), and finally the ‘Nordic model’ (40%). The analysis thus supports the results from Bień et al. (2013) in that the volume of unmet needs is the greatest in Central Eastern Europe and the smallest in Northern Europe. This, however, is not a surprise as the study focuses only on the lack of adequate formal care and does not take informal care into account. The study is also based on a very specific kind of proxy-reporting, which could explain the very high reported levels of unmet needs.

The same year two other comparative studies were also published in a book comprising chapters analysing SHARE data. SHARE does not have a question about the adequacy of care, so the two chapters used the absolute approach. People were defined as having unmet needs when they reported receiving no formal or informal care while having I/ADL-based care needs. The chapter by Laferrère and Van den Bosch (2015) does not report the national prevalence of unmet needs but instead compares the prevalence across three different care regimes: Northern Europe (Denmark, the Netherlands, and Sweden); Central Europe (Austria, Belgium, France, and Germany); and Southern and Eastern Europe (Spain, Estonia, Italy, Slovenia, and Switzerland).

For the group with the greatest care needs, those with several ADL and IADL limitations, unmet needs were the most common in Southern and Eastern Europe (around 15%, compared to around 10% elsewhere). For the second group with only one IADL limitation, the situation was the opposite: unmet needs were rarer in Southern and Eastern Europe (around 35%) than elsewhere (around 50%). The findings show that the extent of need could be an important mediating factor in measuring care poverty, at least in the case of absolute care poverty. Informal care, which is the basis of support in Southern and Eastern Europe, may more easily suffice to cover less severe (practical care) needs. Formal care, which is more available in Northern and Central Europe, seems necessary to get people with extensive needs out of (personal ) care poverty.

The other chapter from the same volume used a slightly different definition for care needs, covering people who had at least two I/ADL limitations (Srakar et al., 2015). The study analysed data from 15 countries to show that the prevalence of unmet needs, measured again with the absolute approach, was the highest in Eastern Europe (especially Estonia and Slovenia) and the Mediterranean region (especially Israel and Italy), and lower elsewhere (especially in the Netherlands, Austria, Sweden, and Denmark). However, it is not clear from the publication whether the prevalence of unmet needs was determined from only those respondents with care needs or from all respondents. The very low reported prevalence figures (all under 5%) suggest the latter—which would mean that they do not actually indicate the level of care poverty.

International comparisons of unmet needs have been hindered by the absence of quality international datasets. The datasets used in the aforementioned studies are either based on proxy-reporting (Eurobarometer, EUROFAMCARE) or lack a question on unmet needs (SHARE ). The situation may be improving, however. EHIS (European Health Interview Survey) is a new European survey conducted among the population aged 15+ in all EU member states as well as Norway and Iceland. This survey includes specific questions on unmet care needs: it asks about 12 different I/ADLs and, above all, whether people need more help for these activities. The survey thus employs the relative approach to measuring unmet needs.

Comparative results from the second wave of EHIS, which ran between 2013 and 2015, were published by Eurofound (2020) to show levels of unmet care needs in the EU27 countries and the United Kingdom. The findings are reported separately for ‘lack of assistance with personal care’ and ‘lack of assistance with household activities’, thus measuring personal and practical care poverty. The reported figures are extremely high overall, the reason for which is unclear. The results show Bulgaria as having the highest prevalence of both kinds of unmet needs, followed by Malta and Romania (in terms of personal care) and by Romania, Finland, and Luxembourg (in terms of household assistance). Still, there is a major problem with these figures: they were counted from all respondents aged 65+, not from only those with care needs. Hence, the results do not indicate care poverty rates .

It however is possible to download country-level data from the Eurostat website and count national care poverty rates by excluding respondents without care needs from the calculation. The results from such recalculation are rather surprising (Fig. 8.3): it is now Luxembourg together with Bulgaria that has the highest level of unmet personal care needs, both showing an extremely high rate of personal care poverty (91%). They are followed by Finland (75%), Malta (73%), and Germany (73%). At the other end of the continuum are Estonia (19%), the Netherlands (23%), and Latvia (37%). For practical care poverty, the recalculation does not much alter the countries with the highest figures (Bulgaria 87%, Finland 78%, and Luxembourg 72%) nor the nations with the lowest rates of care poverty (the Netherlands 25%, Latvia 26%, Estonia 30%, and the United Kingdom 30%).

Fig. 8.3
figure 3

Personal and practical care poverty rates in EU27 countries and the United Kingdom. (* Low reliability for personal care poverty rate; ** Low reliability for personal and practical care poverty rates. Source: EHIS 2014 dataset [Eurostat, 2019a, 2019b])

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But there is still one more problem with the data. Eurostat has marked figures from Denmark, Germany, France, Luxembourg, and Finland (for both personal and practical care) in addition to Austria (for personal care) as having only low reliability, probably due to a small number of respondents in the relevant categories. The survey covers the whole population aged 15+, so the number of respondents aged 65+ with care needs can be expected to be limited in several countries. From Belgium and Ireland, figures are not available at all. When these countries are removed from the list, personal care poverty is the most common in Bulgaria, Malta, and Poland. Practical care poverty would be the most common in Bulgaria, Czechia, and Romania. The countries at the other end of the line would remain unchanged. But as the number of older respondents with unmet needs is probably limited for all countries, caution is needed when interpreting these results.

It nonetheless seems that countries from Eastern Europe, in particular, display high levels of care poverty in the EHIS (with the exception of Slovenia and the Baltic states). Nordic countries do not show up so well as usual; only Iceland is among the least problematic countries. In contrast, Southern European nations do somewhat better than in most care policy comparisons. Countries from Western and Central Europe are scattered around the list. Rates of personal and practical care poverty in a country seem consistently close to each other, save for in Malta and the United Kingdom, where practical care poverty rates are distinctively lower than personal care poverty rates, and in Czechia, where the situation is the opposite.

On the whole, comparative evidence on unmet long-term care needs is still very weak. The few existing studies suggest high rates of care poverty especially in Eastern and Southern European countries. They thus reflect the level of development of formal long-term care systems and follow the typical categorisations of care regimes. The evidence regarding Southern Europe is less consistent, though. Nordic countries (except Finland), the Netherlands, and the Baltic countries are reported to have the lowest rates of care poverty, but different studies generate somewhat dissimilar results. We are still waiting for reliable international datasets that have large enough samples of older respondents with care needs in order to really know whether or not the level of care poverty follows the usual categorisations of long-term care systems.

Care Poverty and Long-Term Care Systems in Two-Country Studies

In addition to the aforementioned European studies, there are a few comparative studies of another sort that analyse unmet care needs in a pair of countries. Davey and Patsios (1999) were the first to conduct such a two-country study, comparing the situation in the United Kingdom and the United States. Using the absolute approach and combining personal and practical care, they uncovered a high prevalence of unmet needs in both countries: 44% in the United Kingdom and 53% in the United States. Access to both formal and informal care was more common in Britain, and the authors emphasised that while Britain had a community care system at the time of study, no national long-term care system for community-based services existed in the United States.

Shea et al. (2003) examined the United States in relation to Sweden. Even though the US prevalence of unmet needs reported in this study was considerably lower than the one shown by Davey and Patsios (1999), the contrast between the two countries proved very strong: the absolute personal care poverty rate was 22% in the United States, but as little as 1% in Sweden. The study discerned dramatic differences in the patterns of assistance across the two countries, especially when it came to ADL needs: only few people in Sweden failed to receive help for personal care needs, while in the United States a substantial proportion of people with ADL limitations received no formal or informal support. Older people in Sweden were much more likely to receive some formal help. The authors concluded that without a well-coordinated system of long-term care, the United States was failing to meet the personal care needs of its residents.

Gannon and Davin (2010) also used the absolute approach to compare unmet needs across France and Ireland, combining personal and practical care domains in the analysis. Data from SHARE showed high figures for both countries, but unmet needs proved somewhat more common in Ireland than in France (63% vs. 51%). Slightly more older people received informal care in Ireland (23% vs. 17%), but the share of those who received formal home care was more than double in France (24% vs. 9%). The paper states that in Ireland, formal care is provided on an ad hoc basis, while in France the system is more structured.

Finally, a recent two-country study from Austria and Slovenia (Kadi et al., 2021) differs from other comparative analyses in that it is not based on a questionnaire survey, but on qualitative interviews of care dyads—that is, older people and their informal carers . Kadi et al. (2021) define unmet needs through approachability, acceptability, and availability in addition to the accommodation, affordability, and appropriateness of formal care services. Their focus thus clearly falls on evaluating access to adequate formal care, although informal care was also discussed in the dyad interviews. The study used the relative approach as it examined people’s perceptions of unmet needs. Instead of identifying major differences between the two countries, the results showed that both systems are based on familialism that has led to gaps in formal care provisions. In both countries, social and emotional needs of older people typically go unaddressed. Unmet needs were also linked to how the delivery of formal care was organised, which could involve uncomfortable timing or high staff turnover among other issues.

So, what do these two-country studies tell us about the relation between care poverty and long-term care systems? Once again, some caution is needed when interpreting the results as most studies are based on a secondary analysis of datasets that are not fully comparable. In any case, the last mentioned study compares countries with rather similar care systems, and its results show no major differences in care poverty across the pair. In contrast, the first three studies compare countries with different care regimes. Each shows a higher rate of care poverty for the country that has less extensive and less systematic formal care provisions. The datasets still leave a lot of room for improvement as the surveys were not originally collected for a comparative analysis of unmet needs. Nevertheless, these findings support the importance of formal home care in reducing care poverty.

Care Poverty and the Design of Long-Term Care Policies

While comparative knowledge of care poverty remains limited, existing local and national studies offer findings that may help with starting to build an understanding of the relationships between care poverty and the design of long-term care policy. Due to their methodological diversity, as we learned in Chap. 4, these studies do not provide us with firm comparable knowledge of the level of care poverty in different countries. Nonetheless, they can help outline some connections between policy design and the unmet care needs of older people.

The United States has produced the largest body of literature on unmet care needs, and it is American studies, in particular, that have addressed the role of long-term care policies. These studies regularly deal with one or both of the two main federal social policy programmes relevant to long-term care: (1) Medicare, which covers the whole older population but, as a health insurance programme, does not provide much social care; and (2) Medicaid, which provides social care (institutional as well as home-based care) but is based on means-testing and covers only low-income older people (e.g., Komisar et al., 2005; Allen et al., 2014). Although these two are federal programmes, the states have a considerable amount of discretion in implementation regarding eligibility and the scope of benefits.

By the mid-1980s, the US General Accounting Office had already analysed how these two policy programmes were managing to address unmet care needs. Its report highlighted how Medicare was not intended to cover the personal care needs of community-dwelling older people, and while Medicaid worked better in this respect, it was not widely available (GAO, 1986). The report also provided a list of policy options to deal with the future home care needs of the growing older population. While further encouraging private long-term care insurance and family care through tax incentives, the main suggestions focused on expanding the home care coverage of Medicare and the availability of Medicaid—two policy recommendations that have since been repeated a number of times in American studies of unmet needs.

The landmark study from Allen and Mor (1997) occurred at a time when ‘managed care’, a controversial policy model aiming to reduce health care costs, was becoming widely implemented in Medicaid and Medicare. Some elements of managed care (e.g., consumer involvement) were supported by the authors, as these were seen appropriate for decreasing unmet need. But as resources for both Medicare and Medicaid were also being cut under managed care, they estimated that the policy model would likely lead to an escalation of unmet need.

Muramatsu and Campbell (2002) brought a comparative approach to American research on long-term care needs by analysing the situation across US states. Combining macro-level data on home care service expenditures and micro-level data on the receipt of informal and formal care, they observed—not very surprisingly—that in states with the highest home care expenditures, the share of older people receiving formal care was the highest (especially among those with the greatest personal care need). More interestingly, they found that the likelihood of receiving no informal or formal care—that is, the rate of absolute care poverty—in these same states was the lowest (14% vs. 27% in states with the lowest expenditures). The study concludes that a higher level of state commitment to home- and community-based services not only leads to greater provision of formal care, but also strengthens the existing informal care system. Strengthening informal as well as formal care can certainly be expected to reduce care poverty.

A few years later, Komisar et al. (2005) continued the comparative line of unmet need research by analysing the situation of ‘dual eligibles’, that is, of older people eligible for support from both Medicaid and Medicare, across six states. Their findings show that the greater the use of formal home care in a state, the lower the likelihood of unmet personal care needs. The receipt of formal care, primarily from Medicaid, was found to substantially reduce the level of unmet need. Moreover, the impact was the largest among those with the greatest needs. The authors end up calling for a change in federal policy either by creating a universal federally defined benefit through Medicare or by establishing greater uniformity across states for Medicaid through increased federal funding and standardisation.

Kemper et al. (2008) also compared US states based on their Medicaid home care spending to analyse whether such spending affects the probability of not receiving help with an ADL limitation—that is, absolute personal care poverty. They found the likelihood of not receiving personal care 10 percentage points lower in states at the top quartile of Medicaid home care spending per capita. In particular, the share of low-income older people with personal care needs not receiving help was significantly lower in states that spent the most on Medicaid home care. As such a difference was not observed in higher-income groups excluded from Medicaid, the researchers concluded that Medicaid reduces the proportion of older people who are not getting help despite their ADL limitations—that is, the proportion of people in absolute personal care poverty. Thus, they recommended expanding Medicaid home care.

Li (2006) also shows the key role of Medicaid in cutting down care poverty in the United States; her study found that enrolment in Medicaid reduced the likelihood of unmet needs by 70%. At the same time, Li emphasises that Medicaid programmes are generally underused, which reduces their impact. Accordingly, she recommends that older people in low-income neighbourhoods should be encouraged to participate in Medicaid.

Besides Medicaid and Medicare, the United States has a number of local and state-level long-term care policies (many of which use Medicaid or Medicare funding, nonetheless). These include intervention programmes that expressly target older people who lack adequate support. PACE (Program of All-inclusive Care for the Elderly) is one of the oldest. Started in San Francisco in the 1970s, it has since spread to most American states (Gonzalez, 2017). PACE is a comprehensive medical and social service programme that provides a package of individually tailored services including, for example, day centres, home care, and medical care. Its services are available to older people who are certified as needing care at the level of a nursing home but want to stay in their homes. Sands et al. (2006) evaluated the impact of the programme on the consequences of unmet personal care needs, especially hospital admissions. They found that 7–12 weeks after enrolment in the programme, hospital admissions fell considerably for those who earlier had no formal or informal care. At least in this respect, PACE proved effective at decreasing the negative consequences of personal care poverty.

Another way that Medicaid can be implemented is through the Cash and Counseling option, wherein Medicaid-eligible participants or their families are paid a monthly cash allowance rather than providing formal home care services. With this allowance, users can hire personal care attendants (i.e., personal assistants). Among younger disabled people, experiences with this model are very positive, as their unmet needs are reduced and user satisfaction is improved (Harry et al., 2016). Among older people, the results are more ambivalent. A study (Brown et al., 2007) observed that in one state, unmet needs were significantly lower among Cash and Counseling users in terms of both personal and practical care. But in another state, they were lower only for practical care. In a third state, no statistical difference was found between users of participant-directed and more traditional services. Likewise, a three-year follow-up on the model found a significant impact on the reduction of nursing home admissions in only one of the three states (Dale & Brown, 2006). These results thus seem to echo research from other countries showing that individual budgets and personal assistance usually work well with younger disabled people, but there may be more complications in getting them to serve older people (e.g., Leece & Bornat, 2006; Glasby & Littlechild, 2016; Kelly, 2020).

In Canada, Dubuc et al. (2011) evaluated an intervention programme called PRISMA (Program of Research to Integrate Services for the Maintenance of Autonomy). In the PRISMA model, an integrated service delivery network is embedded within the health and social care system using all of the public, private, and voluntary health or social service organisations involved in caring for older people within a given area. The model was implemented in three zones in Quebec, while three other zones served as control areas. In a three-year follow-up, it was found that unmet ADL needs were significantly less common in the experimental areas than in the control zones (31% vs. 47%). The same was true for unmet IADL needs (5% vs. 12%). The authors say that the level of empowerment among service users was higher in the programme zones and that the control zones may have had more accessibility problems. Overall, the study concludes that the service integration model appears to be effective at meeting the care needs of older adults—especially those with high needs.

Also in a six-year follow-up study in Sweden, the coordination of formal and informal care was highlighted as a key reason why rates of unmet need remained low for older adults despite a decline in the provision levels of formal home care (Savla et al., 2008). Shea et al. (2003), too, emphasise that the Swedish care system is well coordinated, targeting assistance carefully to those with personal care needs and leaving almost no one without support. This is unlike the American system, which, the authors say, largely targets those with a short-term post-acute need and fails to meet the long-term needs of its residents.

Conclusions

The local and national studies reviewed above are limited in number, and almost all come from the United States. Their analyses are fragmented, and thus, only some preliminary conclusions can be drawn. Still, one thing is very clear: the Medicaid programme has obviously played a major role in cutting down care poverty in the United States. Several studies show that more Medicaid spending leads to lower levels of unmet care needs and that Medicaid enrolees have a lower risk of care poverty than other older people with care needs. In the absence of a universal long-term care system that would provide home care to all who need it, Medicaid has been efficient at reducing unmet needs in the United States. This is because it is targeted precisely at those groups at the highest risk for care poverty: low-income older people with extensive care needs who typically come from deprived areas and racial and ethnic minorities. Specific interventions that use Medicaid resources to develop more comprehensive and integrated service packages, such as PACE, have further strengthened the care poverty mitigation effect. These American studies prove that targeted programmes such as Medicaid can have a major impact on care poverty.

At the same time, Medicaid has its limitations. It covers only a portion of older people with care needs. Even within this limited target group, not everyone is enrolled in the programme. Medicaid is also repeatedly subject to budget cuts, which has almost certainly weakened its impact. Differences between US states also remain large, reducing the potential for Medicaid to tackle unmet care needs across the country. As only the low-income minority is included in the programme, older people who fail the income test will continue to be at major risk of care poverty. This is the dilemma of all means-tested social policies: they may be efficient in their target group, but only in that group. Their impact ends where their eligibility ends.

Due to the limited quality and comparability of their data, the two-country and comparative studies reviewed here should be treated with caution. They nonetheless suggest that access to formal care is key: care poverty rates seem the lowest in countries with the most extensive and systematic provisions for formal care. In Europe, the highest rates of care poverty are found in Eastern Europe, where most countries have not yet managed to build strong care provisions, especially for home-based non-institutional care. Southern European countries, which are often understood to count on family care instead of formal provisions, do slightly better in these comparisons than they normally do, which raises a question about the impact of familialistic policies on care poverty. It may be outdated, however, to cluster all countries from the south of Europe as ‘the family care regime’; Spain, for example, has aimed to develop its formal care system in the twenty-first century.

While the data are far from excellent, European comparisons provide preliminary support for the strength of universal formal care systems in reducing care poverty. This makes sense as only universal systems strive to cover the needs of all older people. More evidence is needed before final conclusions can be drawn and firm policy recommendations are provided. But based on the current state of knowledge, the creation of a well-resourced, universal long-term care system seems to be the most effective policy choice when aiming to eradicate care poverty. However, if the welfare state context and political realities do not allow for the creation of such a system, a well-targeted national programme that provides formal care to those with the greatest personal care needs and the lowest incomes appears to be a good second choice: it will not fully annihilate care poverty, but it can still succeed at substantially alleviating unmet needs.