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Tuesday, 11 August 2026
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Ageing: who actually pays for care, and what five countries found out

There are 32.6 people over 65 for every 100 workers in the OECD, and 55.2 are projected by 2054. Japan built an insurance for it in 2000. England has been legislating one since 2011 and still has none.

Checked on

All ten problems

Across the OECD there are 32.6 people aged 65 and over for every 100 people aged 20 to 64. Thirty years ago there were 21. By 2054 the projection is 55.2, and by 2084, 67.7. Japan is already at 54.9. Korea, at 29.3 today, is projected at 122.0 by 2084 — more pensioners than workers.

That fraction is where every argument about paying for care starts, and it is worth knowing its two soft edges. Ageing is driven by longer lives, fewer births and migration, and only the last of those moves quickly. And the projections themselves disagree: the OECD notes that for Italy and Spain the ratio projected for 2050 is 10 percentage points lower using Eurostat’s population model than using the UN’s, and 8 points lower for Austria and Germany. Two respectable sources, one country, a decade of difference.

What follows is five attempts at the money question. Japan and Germany built compulsory insurance and watched the bill grow. Denmark automated the retirement age. England has legislated a cap on care costs three times and delivered none. And the United States wrote a voluntary national care insurance into law and could not make the sums close.

How this is measured

One number, named and sourced. Everything on this page is argued against it, so you can check us.

Demographic old-age to working-age ratio — people aged 65 and over per 100 people aged 20 to 64 per 100

OECD, Pensions at a Glance 2025, Table 6.2, values for 2024; underlying data United Nations World Population Prospects 2024

Who is actually ahead

Ranked on the number above — not on reputation.

Demographic old-age to working-age ratio — people aged 65 and over per 100 people aged 20 to 64
Country Result Why
South Africa 11.3 The youngest country on this board, and the youngest in the OECD's comparison set. Projected to reach 20.8 by 2054, still below where Australia is today.
Mexico 14.0 Projected at 31.4 by 2054 and 56.0 by 2084. Mexico's working-age population is one of the few the OECD expects to still be growing in 2064.
Israel 24.1 Reaches only 30.0 by 2054, the mildest path in the OECD. Its working-age population is projected to grow about 70% by 2064 — a clear outlier.
South Korea 29.3 Younger than the United States today and projected at 84.5 by 2054 and 122.0 by 2084. The fastest ageing on record among OECD countries.
United States 30.8 Below the OECD average of 32.6, and projected to stay comparatively low at 42.9 in 2054, largely on migration and fertility.
Czechia 35.7 Just below the EU27 average of 36.0, and projected at 59.7 by 2054 — the same figure as Germany, reached from a younger start.
Germany 39.8 Roughly two workers per pensioner already. Projected at 59.7 by 2054, when the ratio approaches three older people for every five of working age.
Japan 54.9 The oldest country in the comparison, and the one every other country is reading for instructions. Projected at 80.0 by 2054.

What has actually been tried

Real countries, real policies, and what the numbers did afterwards — including where it went wrong.

Japan

Japan created a separate compulsory long-term care insurance, Kaigo Hoken, in April 2000. Everyone aged 40 and over pays into it. People over 65 can claim for any care need; those aged 40 to 64 only for age-related conditions. Users pay 10% of the cost of the services they use, raised to 20% for higher incomes in 2015 and 30% in 2018.

What happened. Certified users went from 2.18 million in the 2000 financial year to 6.33 million in 2018 and about 7.1 million in 2024 — 19.4% of the 35.9 million people insured aged 65 and over. Spending went from ¥3.6 trillion to ¥11.1 trillion over the same first eighteen years, around 1.8% of GDP by 2023. The national average monthly premium for over-65s rose from ¥2,911 in 2000 to ¥6,225 for the 2024–2026 period.

The catch. The premium is set by each municipality, so where you grow old decides what you pay. For 2024–2026 it ranges from ¥3,374 a month in Ogasawara village to ¥9,249 in Osaka city — a 2.7-fold gap inside one national system, and the higher figures tend to be in the places with the most older people and the fewest workers.

Japan Ministry of Health, Labour and Welfare, announcement of 14 May 2024; Nakamura, 'Japan's welfare for the elderly', AHWIN, December 2018; ILO Global Care Policy Portal

Germany

Germany added long-term care insurance as a fifth branch of social insurance on 1 January 1995, paid from payroll and split between employer and employee, with a surcharge for people without children. It was designed from the start as partial cover, not full cover — a Teilkaskoversicherung, in the German phrase, like third-party car insurance.

What happened. People receiving benefits rose from about 2.75 million in 2016 to about 5.6 million at the end of 2024. Spending went from €31 billion in 2016 to €68.2 billion in 2024, with €73.82 billion budgeted for 2025. The contribution rate rose from 3.4% to 3.6% of wages on 1 January 2025, which the health ministry calculated would raise about €3.7 billion in that year. People without children pay 4.2%.

The catch. Partial cover means the family pays the rest. In July 2026 the vdek association of health insurers put the average out-of-pocket cost of a nursing home place in the first year at €3,364 a month — €256 more than a year earlier — ranging from €2,891 in Saxony-Anhalt to €3,761 in Bremen. The care share alone rose 12% in one year.

German Federal Ministry of Health, press release of 20 December 2024; vdek press release of 14 July 2026; AOK, facts and figures on long-term care insurance

Denmark

Denmark stopped arguing about the pension age and wrote a rule instead. Under the 2006 Welfare Agreement, parliament reviews the state pension age every five years and raises it if the life expectancy of 60-year-olds has risen. On 23 May 2025 the Folketing adopted the next steps: 68 in 2030, 69 in 2035, 70 in 2040.

What happened. Everyone born after 31 December 1970 will reach the state pension at 70, the highest in Europe. The change is projected to strengthen Danish public finances by about 15 billion kroner by 2040. Denmark's old-age to working-age ratio, 36.2 in 2024, is projected to reach 47.4 by 2054 — one of the gentler paths in the EU, whose average goes to 59.6.

The catch. Life expectancy is an average and the retirement age is not. The rule gives the same 70th birthday to a bricklayer and an accountant, and healthy life expectancy diverges by social class far more than total life expectancy does. Automatic indexation removes the political fight, which is the point, and also removes the place where that difference used to be argued.

European Pensions — 'Denmark to raise state pension age to 70 in 2040', May 2025; OECD Pensions at a Glance 2025, Table 6.2

United Kingdom

England has been trying to cap what any one person pays for care since 2011, when the Dilnot Commission recommended a lifetime limit of £35,000. The Care Act 2014 put a cap into law with a start date of April 2016. It was postponed to April 2020, then postponed indefinitely in December 2017, then relaunched in September 2021 at £86,000 with £3.6 billion of funding and the means-test threshold raised to £100,000, then delayed in November 2022 to October 2025.

What happened. On 29 July 2024 the Chancellor cancelled it, saving, in the government's words, over £1 billion by the end of the following year. Fifteen years, one commission, three start dates and no cap. The upper capital limit above which a person in England pays the full cost of their care remains £23,250, where it has sat for years. Sir Andrew Dilnot: “We have failed another generation of families.”

The catch. That saving is real money in a real budget, and councils had also said they were not ready to administer the scheme. England is also not the whole United Kingdom: Scotland has provided free personal care since 2002, so the same islands run two answers. A further commission, chaired by Louise Casey, is due to report in 2028.

House of Commons Library, 'Introducing a cap on care costs', briefing CBP-9315, 31 July 2024; Community Care, 31 July 2024

United States

The Affordable Care Act of March 2010 contained a national long-term care insurance called CLASS — Community Living Assistance Services and Supports. It was voluntary, funded entirely by premiums, and paid nothing until a member had contributed for five years. The Congressional Budget Office scored it as reducing deficits by $70.2 billion over ten years, precisely because it would collect for five years before paying anything.

What happened. It never opened. On 14 October 2011, after 19 months of work, Health Secretary Kathleen Sebelius reported that she could not design it to be solvent over 75 years as the law required: “I do not see a viable path forward for CLASS at this time.” Congress repealed it in the budget deal passed on 1 January 2013 and replaced it with a commission.

The catch. The failure was arithmetic, not administration. If insurance is voluntary, the people who buy it are the people who expect to claim, so the premium rises, so the healthy leave, so the premium rises again. Every country on this page that made long-term care insurance work made it compulsory. That is the finding, and it is not a comfortable one.

Commonwealth Fund — 'Obama administration halts implementation of health law's long-term care program'; Gleckman, Forbes, 1 January 2013

What a machine would optimise for

This is arithmetic, not advice and not a prediction. We name the single number being maximised and follow it wherever it goes. The point is to see the shape of the answer a calculator gives.

The number being maximised

The single number is the old-age to working-age ratio: people aged 65 and over, divided by people aged 20 to 64, times 100. Push it down and ignore everything the fraction does not contain.

  1. Redefine the line rather than the population. The 65 in the numerator is a convention, not a fact about bodies. Move the boundary to 70 and everyone aged 65 to 69 crosses from the top of the fraction to the bottom, twice improving the ratio without anyone ageing differently. Denmark wrote that move into law on 23 May 2025.
  2. Fill the denominator from outside. The OECD projects the working-age population falling 13% across its members by 2064 and 23% across the EU, while Israel's rises about 70%. Migration is the only input that changes the bottom of this fraction within one generation.
  3. Harvest the people already inside the denominator who are not working. OECD employment rates in 2024 were 75.7% at ages 55 to 59, 56.5% at 60 to 64 and 26.4% at 65 to 69. The gap between the first two figures is nineteen percentage points of people who exist, are of working age, and are counted as a cost either way.
  4. Buy care hours at the lowest unit price the system tolerates. Japan charges users 10% and Germany covers only part of a nursing home bill; both keep the public ratio of cost to worker down by moving the remainder onto households, where this indicator cannot see it.

The arithmetic

Germany, checkable in three steps. Raising the care insurance rate 0.2 percentage points, from 3.4% to 3.6% on 1 January 2025, was calculated to bring in about €3.7 billion in a year. Care insurance spending in 2024 was €68.2 billion. So one fifth of a point of payroll buys 3.7 ÷ 68.2 = 5.4% of a year's care bill. Spending grew from €31 billion in 2016 to €68.2 billion in 2024, a rise of €37.2 billion; at the same exchange rate that increase would have cost 37.2 ÷ 3.7 × 0.2 = about 2.0 percentage points of every wage in the country. Germany's ratio in 2024 is 39.8 and projected at 59.7 in 2054.

What the machine would miss

The most important part of this page. A number that goes up can still be paid for by somebody, and some things never make it into the number at all.

Who pays

In Germany, the family. The vdek's July 2026 figure for a nursing home place is €3,364 a month out of pocket in the first year, up €256 in twelve months, against a typical statutory pension nowhere near it — so the money comes from savings, a house, or adult children. In Japan the answer depends on your postcode: the same national insurance costs ¥3,374 a month in Ogasawara and ¥9,249 in Osaka city.

What the number flattens

The ratio treats everyone over 65 as a cost and everyone aged 20 to 64 as a payer, and both halves are wrong. In Japan, the oldest country measured here, 7.1 million of 35.9 million insured people over 65 were certified as needing care in 2024 — 19.4%. Four in five older Japanese needed none. A 66-year-old and a 96-year-old are one unit each in this fraction, and they are not remotely the same problem.

What a spreadsheet cannot see

Whether a body lasts to the line. Denmark's rule sets the same 70th birthday for a bricklayer and an accountant because life expectancy is calculated as an average, and healthy working life diverges by occupation far more sharply than lifespan does. None of that difference appears in the 15 billion kroner the reform is projected to save, and none of it appeared in the vote.

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We are a newspaper, not a government and not an adviser. Nothing on this page is a recommendation to you or to anyone in office. It is what was tried, what it measured, and what a calculator would say if you let it loose on the same problem.

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