Tracing Stigma in Long-Term Care Insurance in Israel: Stakeholders' Views of Policy Implementation.

Almost all developed countries provide some answers for long-term care, but only a few countries in the world, such as Japan, Austria, the Netherlands, Germany, and Israel, have implemented long-term care insurance (LTCI) based on legislation and entitlement principles. In Israel, a community-based LTCI social program has achieved multiple goals and considerably improved the life of frail older people. However, some studies show that despite the rising costs of home care and the mandatory and almost universal nature of LTCI there are still cases in which people with Alzheimer's disease (AD) and other types of dementia or their relatives vacillate or even decline to make use of their rights. We examined the question of whether these patterns may reflect the presence of welfare stigma (i.e., stigmatized views of LTCI) either related to identity stigma of persons with AD or to treatment stigma, usually associated with welfare bureaucracy. Based on a qualitative design, this article uses a methodology of personal in-depth and focus group triangulation, by which the views of three groups of stakeholders are explored and compared: persons with AD, relatives, and professionals. Findings showed the presence of stigmatic self-images among persons with AD or other types of dementia and the absence of such images in relatives' and professionals' views of them and of LTCI. However, treatment stigma was found to be primarily associated with eligibility determination procedures. The study concludes that LTCI, even when mandated and almost universal, may also generate welfare stigma due to the ways in which it is implemented.