When inpatient caregiving becomes a public benefit: fiscal projections of South Korea's Integrated Nursing and Care Service, 2025–2050
This study projects that South Korea's Integrated Nursing and Care Service will impose a fiscal burden exceeding National Health Insurance revenue between 2038 and 2046 by 2050, driven by user base and bed expansion rather than increased per-user utilization, thereby highlighting an urgent need to align benefit growth with post-acute care and payment reforms for long-term sustainability.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In many aging societies, a quiet crisis is unfolding in hospital wards. When a patient recovers from an acute illness but cannot yet return home—perhaps because they are frail, live alone, or lack family support to help with daily tasks—they often remain in a hospital bed. This is not because they need active medical treatment like surgery or chemotherapy, but because there is no safe place for them to go. In South Korea, this situation has long been a private burden, where families hire caregivers to sit by the bedside, a cost that falls entirely on the household. To address this, the government introduced a program called the Integrated Nursing and Care Service. This initiative moved the responsibility of daily care from private families to the public system, allowing hospital nurses to provide personal care as a standard benefit covered by the National Health Insurance. The goal was noble: to ensure dignity for patients and relieve families of a crushing financial weight. However, as the program grows, a critical question remains: can the public purse afford to keep this promise for the next few decades?
A team of researchers set out to answer this by looking far into the future, projecting how the costs of this care program might evolve from 2025 to 2050. They did not simply guess; they built a detailed model using real data from millions of patients to understand who uses the service, how long they stay, and how much it costs the government each day. They combined these usage patterns with official population forecasts and different scenarios for how the program might expand. Their work reveals a stark trajectory. If the current pace of growth continues, the money the government pays for this care will eventually outstrip the total revenue the National Health Insurance collects. In the most likely scenarios, this tipping point arrives between 2038 and 2046. By the year 2050, the cost of this single service could consume between 149% and 260% of the entire health insurance budget, a level of spending that would make the system financially unsustainable without major changes.
The researchers discovered that the driving force behind this massive cost increase is not that individual patients are staying in the hospital longer. In fact, the average number of days a single user spends in the program has remained steady. Instead, the explosion in cost comes from a rapidly widening circle of users. As the population ages and the number of hospital beds available for this type of care increases, more and more people are entering the system. The study also found that the length of stay is not the same for everyone. Patients in lower-income brackets, particularly those who rely on government medical aid, tend to stay longer than those with higher incomes. Similarly, people living in regions outside the capital city stay longer than those in the capital. This suggests that for many, the hospital bed is serving as a substitute for missing community care or family support. When a patient has nowhere else to go, the hospital becomes their home, and the public system pays the bill.
The study challenges the idea that simply adjusting the daily price of care or trying to shorten stays will solve the problem. The researchers found that the expansion is structural, driven by the sheer number of people needing a place to stay and the availability of beds to hold them. They noted that while the program has successfully shifted the burden from families to the public, it has also shifted the financial pressure onto the health insurance system. Without a parallel expansion of post-hospital care, such as rehabilitation centers or long-term care facilities, the hospital will continue to act as a holding pen for patients who have finished their medical treatment but have no other option. The authors suggest that for the program to survive, the government must align the expansion of this benefit with a broader redesign of how care is delivered and paid for, ensuring that investment in nursing and care is rewarded rather than leading to an endless cycle of rising costs.
The projections used in this study are based on specific assumptions about how the population will age and how the supply of nurses and beds will grow. The researchers tested their model against recent years of data to ensure it was accurate, and it performed well in predicting past trends. However, they acknowledge that if the government changes policies to slow the expansion or if the demand for care shifts, the future costs could be lower. What is certain, based on the current path, is that the financial burden will grow faster than the money coming into the health insurance fund. The study serves as a warning that socializing the care of the elderly and the sick is a necessary step for a modern society, but it requires a carefully balanced system. If the focus remains only on the acute hospital bed without building a robust network of care that follows the patient home, the public system risks being overwhelmed by the very people it aims to help.
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