Aging in Democracy: Accomplishments and Challenges of Long-Term Care Policy in Post-Authoritarian Taiwan

Background and Purpose: Taiwan has one of the fastest-growing aging populations in the world. As a rapidly aging society facing demographic transition and the declining familial caring function, the Taiwan government implemented a national universal Long-Term Care service (LTC) program in the early 2000s. The enactment of the Long-Term Care Services Act in 2017 was a milestone in institutionalizing LTC, establishing the contract-based model that increases the provision by integrating fragmented existing programs into a centralized delivery network. Democracy played a crucial role in establishing LTC through legislation and parliamentary scrutiny. This paper investigates how democratic politics contributes to the accomplishments of elder care policy in the recently democratized Taiwan. It draws on scholarship from classic people’s sovereignty and the alternative governmentality theory to examine the processes of democratic politics in response to the aging society.

Methods: This paper blends archival data and ethnographic data in an extended case study approach to examine the following research questions: How does democracy shape the LTC policy in Taiwan? How does the implementation of LTC respond to democratic politics? It first examines the political background establishing LTC through archives and document analysis, including academic literature, government documents, and press media. It subsequently examines ethnographic data from six rural care facilities (n=500 hours) to analyze implementation. Finally, this study incorporates data from semi-structured interviews with care providers and social workers.

Results: Older adults and their needs comprised a nascent social identity with unique interests that merge elders, caregivers, and business owners in the aging society. Amplified through their population size in multi-level electorate participation, they further propelled the advocacy for national-level policies and public service. Promoting the well-being of elders became the common rhetoric across partisan campaigns to gain voters’ support in multilevel elections, which created momentum for establishing universal LTC. Nevertheless, without a robust social insurance system, the tax-based governmental budget implied the financial insecurity and scrutiny of LTC. Solid regulations monitor effectiveness and efficiency and uphold political accountability, including the comprehensive care facilities criteria, professional care providers credentialing system, service fee table, and care assessment and case management system. These regulations created incompatibilities between the local knowledge of caregiving and public services administration that may inhibit service development.

Conclusions and Implications: The LTC resembles the trajectory of paternalistic governance and administrative centralization in the elder's care by the democratic welfare state in Taiwan. The democratization established channels for private interests to be institutionalized, bridging a bottom-up path for welfare development. However, gaps created by accountability regulations hinder the compatibility of interventions at the local level, especially in marginalized areas and populations. People’s sovereignty enables the state to perform paternalistic governance, but it depoliticizes elders' care in administration and turns older adults into the governable population. Localization and diversification have become the following goals for LTC in Taiwan; several grassroots campaigns may provide notable implications. This case study offers critical insights for developing sustainable care policies in aging democratic states worldwide.