When Does a Home Become a Place of Care? Buying Care, When Care Leaves the Family and Enters the Market?(Part 1)

 Author's Note

This is Part 1 of the five-part series “When Does a Home Become a Place of Care?” The series traces how care has moved from being primarily a family responsibility into the market, and how products, industries, labor, and technology have increasingly become organized around the homes of older adults. In doing so, it examines how the global longevity economy—where healthcare, housing, daily living, culture, and technology intersect—has evolved, and how the care supply chain may be reshaped in the years ahead.

The Series

Part 1. Buying Care — When Care Leaves the Family and Enters the Market

Part 2. Care Products Coming Home — What Do People Buy for Care at Home?

Part 3. Care Industries Moving Toward the Home — Who Is Knocking on the Older Adult’s Door?

Part 4. Care Work Coming Home — Who Will Provide Care, Where Will They Come From, and Under What Conditions?

Part 5. How Will the Care Industries Around the Home Be Reshaped? — The Next Shape of the Home-Centered Care Supply Chain

An older parent can no longer bathe alone. If a daughter steps into the bathroom and helps wash her parent, that is family caregiving. If a care worker comes to the home, performs the same task, and is paid for it, the same activity becomes a service. The same is true of accompanying someone to a medical appointment, preparing meals, helping with dressing or mobility, and checking medications. The moment work once performed within the family becomes someone else’s paid labor, a transaction is created.

So when did people begin to buy care? More precisely, when does a need for care that once remained within the family become market demand? A growing older population does not automatically turn every care need into a market. This essay follows that transition.

1. What Does It Mean to Buy Care?

Care does not begin in the market. A person who has difficulty eating, bathing, or going to the hospital alone clearly has a care Need. Yet as long as a spouse or an adult child performs those tasks directly, that Need can still be met within the family. The situation changes when the family can no longer carry the full burden, an alternative service is available, and there is a means of paying for it. In this essay, Demand refers to the point at which a care Need becomes demand for a service that can actually be purchased or used.

The scale of Need and the scale of Demand are not the same. A 65-year-old daughter may care every day for her 90-year-old mother, reflecting an enormous care Need that barely appears in market statistics because the work is unpaid. But once the family begins using home care, meal support, or medical escort services, part of that same Need becomes formal Demand.

Purchasing power is therefore crucial. The money does not have to come only from the family’s own pocket. Long-term care insurance, tax-funded programs, or social-service benefits may cover all or part of the cost. For that reason, the welfare state and the care market should not be treated as simple opposites. When public institutions make it possible to buy services that families could not otherwise afford, Needs that had remained inside the family move into the market as Demand. Korea’s long-term care market, for example, has a large number of private providers, but much of the purchasing power and many of the basic rules are created by public institutions.

In this essay, the care market refers to the market that emerges as functions once performed by families are converted, one by one, into purchasable personal services. Home care, home nursing, daily-living support, and care management—services that intervene directly in maintaining daily life and responding to functional decline—are grouped here as the Core Care Industry. This is distinct from the healthcare sector as a whole, including surgery, acute hospitalization, and general medical care. Housing, technology, meals, mobility, and safety are closely connected to care, but are treated here as adjacent industries outside this core.

Who buys care cannot be explained by income alone. The distance between parents and adult children, women’s labor-force participation, public benefits, norms of family responsibility, and attitudes toward outside care all shape purchasing behavior. As service use expands, family members are no longer only direct caregivers; they also choose, pay for, and coordinate services. Unpaid care and paid services can coexist within the same family.

2. When Did Care Need Become Market Demand?

Care Needs are older than the welfare state. The United Kingdom in 1948 offers a symbolic moment when long-standing Needs were redefined as a social responsibility. Older people aged and became ill long before the National Health Service (NHS) and the National Assistance Act existed. What changed was not the existence of Need, but the social rules governing who would take responsibility and who would pay. Some Needs that had previously remained within the family, charity, or poor relief came to be recognized by the state and backed by public budgets.

The direction later shifted again. Expanding institutions alone was not enough. The desire to remain in familiar surroundings, together with concerns about cost, encouraged the growth of home- and community-based care. The United Kingdom’s NHS and Community Care Act 1990, the United States’ 1983 Medicaid Section 1915(c) Home- and Community-Based Services (HCBS) waiver, Japan’s Long-Term Care Insurance and Community-based Integrated Care System, Korea’s Long-Term Care Insurance introduced in 2008, and Korea’s 2026 Community Care Integration Act are different institutions, but they all reflect a broader movement toward connecting services in the places where people live.

Compressed into a long historical arc, the direction becomes visible: the institutionalization of care through the welfare state → the expansion of home- and community-based care → the integration of healthcare, long-term care, and daily-living support → Home-Centered Care. Not every country followed the same sequence. Yet across many countries, public systems have given purchasing power to Need, and the resulting Demand has increasingly moved toward people’s living environments.

Once public systems recognized certain Needs as eligible for benefits and provided entitlements and financing, work that had once been absorbed by families began to appear as formal service use. Rather than eliminating the market, the welfare state organized Demand by giving purchasing power to Need, while home- and community-based policies moved those services into the places where people live.

According to Korea’s National Health Insurance Service, the total amount of long-term care benefits reviewed and approved in 2025 was approximately KRW 17.7 trillion. In England, local-authority spending on adult social care totaled £34.5 billion in 2024–2025. In the United States, Medicaid spends hundreds of billions of dollars on long-term services and supports (LTSS). What once appeared to be simply “family work” has become economic activity on a scale involving governments, insurance systems, and household spending together.

These figures do not measure identical markets and should not be added together. OECD statistics also cover a different scope than the Core Care category used in this essay. Here, the figures are not used to rank countries by market size, but as reference points for understanding how much care Need in each society has become visible as formal service use and expenditure.

The location of care is also changing. Across 23 OECD countries, the share of long-term care recipients receiving services at home increased from 66 percent in 2013 to 70 percent in 2023. Yet the source of purchasing power and the burden placed on families vary, so even a common movement toward care at home can produce very different markets.

3. How Do Families Around the World Buy Care?

Population aging may be a common pressure, but the path from Need to Demand differs across societies. In Japan and Korea, public insurance systems recognized functional decline as an eligible condition and created service and provider systems, drawing part of what families had previously done into formal services. Yet even within social-insurance systems, the extent of direct purchasing outside insurance, the role of families, and the discretion of providers differ. Korea has many private providers, but purchasing and service conditions are closely tied to Long-Term Care Insurance. Even as the number of providers grows, prices, eligibility, and service scope are set by public institutions. In that sense, the system is closer to an institutionally managed quasi-market than to a fully free market.

Public insurance, however, does not absorb all care. Family time and additional purchases remain outside the benefit package. The balance among these elements shapes both family purchasing behavior and the Demand that firms encounter.

The United States and the United Kingdom show that families do not disappear as markets expand. The United States has a major public route through Medicaid HCBS, yet the number of family caregivers was estimated at about 63 million in 2025, and some are paid through public programs while caring for relatives. In England, local-authority spending on adult social care reached £34.5 billion in 2024–2025, while the 2021 Census counted roughly 5 million unpaid carers in England and Wales. Formal markets and family time exist simultaneously.

In the United States, paid family caregiver arrangements can channel public funding to care work without changing the family relationship itself. In the United Kingdom, self-funders purchase services directly alongside publicly supported care. These examples show why family care and market care cannot be understood simply as substitutes for one another.

In China, long-term care insurance is expanding rapidly, and the boundary is being formalized between Needs that remain within the family and those recognized for public benefits. Strong norms of family responsibility may delay the purchase of outside services. But when family members can no longer provide care directly, finding good services and paying for them may itself become a new form of family responsibility. Family care is not replaced by market care all at once; part of direct caregiving shifts toward family payment and selection.

Thailand and India show that markets do not necessarily begin with large corporations. Thailand has developed ways of training and organizing care that was once performed by families and communities, while supporting that care with public resources. In India, families remain central, but paid care begins to find space where life circumstances change—for example after the death of a spouse, the migration of adult children to cities, or the onset of living alone. Markets can emerge not after familism disappears, but at the point where families can no longer absorb every Need.

In Thailand, care managers and trained caregivers organize support in homes and communities. In India, outside paid help first becomes visible under living conditions in which the family’s capacity to provide care weakens. In both cases, Need becomes backed by funding and organized provision, but the starting points differ.

What Can We See Across These Different Paths?

If we remove the country names and look again, the differences repeatedly appear in three places. First, societies differ in how much of their care Need becomes formal service use. Second, they differ in who creates the purchasing power—the insurance system, government, or the family. Third, the family itself occupies different positions: direct caregiver, purchaser of services, coordinator across multiple providers, and sometimes even paid provider.

Different combinations produce different markets. Public purchasing power may create a large formal-service sector. Public purchasing and family direct payment may overlap with unpaid care. Families may continue to absorb much of the Need while markets open only at the margins. Or public resources may be directed to family and community care in order to organize it. There is no need yet to settle on definitive categories. What matters is that there is more than one pathway through which Need becomes Demand.

When these different pathways are placed on the historical trajectory described in the previous section, a common movement also becomes visible. In societies that developed institution-centered systems, services are moving from institutions into homes and communities. In societies where family caregiving has remained strong, public funding, paid workers, and professional services are beginning to enter homes that were once cared for almost entirely by family members. The starting points differ, but both changes alter the meaning of the home.

4. Is the Home Becoming a New Care Market?

Now shift the focus of comparison from institutions to living space. As home-based services expand, different systems and providers begin to enter the same person’s home. In the United States, Medicaid HCBS, private-pay care, and family caregiving overlap. Japan seeks to connect housing, healthcare, long-term care, prevention, and daily-living support within local communities. Korea has also begun placing its 2026 Community Care Integration Act on top of existing home-based long-term care services.

Looking across Medicaid HCBS in the United States, Japan’s Community-based Integrated Care System, community care in the United Kingdom, and the expansion of care systems in China and Thailand, the direction toward Home-Centered Care appears similar even though the starting points differ. Some societies are moving services out of institutions. Others are bringing public funding and paid workers into homes where care had previously been left almost entirely to families.

Daily life, however, does not unfold in separate institutional compartments. Imagine an older person returning home after discharge from a hospital. Medical treatment and home care may each exist, but who handles meals and transportation in between? Who checks whether medication is taken properly? Who keeps the family informed about changes in the person’s condition? Seen this way, the central question for the future is less about how many more people use home care and more about who will bridge the gaps between hospital and home, long-term care and daily-living support, and public benefits and family direct payment.

The work of families changes as well. Even if some direct caregiving shifts to outside services, families still have to decide which services to choose and how to combine them. In societies with strong norms of family responsibility, that responsibility may move from hands-on care toward searching for services, paying for them, and monitoring quality—potentially creating what we might call Family-Funded Demand.

What Becomes Visible Once Care Enters the Home

When a care worker enters a home, problems of daily life that cannot be solved by care services alone become visible. A fall risk in the bathroom may require home modification. Frequent missed medications may call for medication management or healthcare support. Long periods alone may create demand for monitoring and safety services. Difficulty getting to a hospital may require mobility support, while difficulty preparing meals may call for meal services. If adult children live far away, families may also need technology and coordination services to monitor conditions and organize support.

These services fall outside the Core Care Industry itself. But the more Core Care enters the home, the more clearly it reveals unmet Needs in adjacent areas. The next growth of the care industry may therefore come not simply from expanding home care, but from how housing, healthcare, meals, mobility, and safety technologies are combined around the home.

The home thus becomes both the place where services are delivered and the place where new forms of Demand become visible. A fall risk can become demand for home modification. Difficulty managing medications can become demand for home nursing or management technology. Anxiety among adult children living far away can become demand for monitoring and coordination.

McKinsey, drawing on a 2022 survey of physicians serving Medicare fee-for-service and Medicare Advantage patients in the United States, estimated that up to $265 billion in services then delivered in facilities—up to 25 percent of the cost of care—had the potential to shift into the home by 2025. This is a broad “Care at Home” estimate that includes healthcare and digital health, so it is not equivalent to the size of the Core Care market. It nevertheless provides a useful indication of the economic space created as spending moves toward the home.

Home-Centered Care does not imply a single model. In societies with strong public insurance, long-term care, nursing, and care management may develop first. Where direct purchasing is more important, meals, mobility, safety, and companionship may develop first. Where family caregiving remains strong, services that supplement family time may develop first as well. The marketization of care, the source of purchasing power, and the role of the family—examined in the previous section—ultimately shape what enters the home.

When Does a Home Become a Place of Care?

Return to the opening scene in the bathroom. The Need for care has long existed inside the home. What has changed is that money, services, and professional workers increasingly support that Need. As the resulting Demand moves toward homes and communities across many countries, the home is changing from a place where care is addressed primarily through family labor into a place where public funding, family spending, professional workers, and multiple daily-living services are organized together.

In that sense, the home is no longer merely the background against which care takes place. It is becoming a new point of market convergence, where multiple industries meet around the Need for care. If families have begun to buy care, and that care is increasingly entering the home, then what, exactly, are people beginning to buy for the home?

Next | Part 2. “Care Products Coming Home — What Do People Buy for Care at Home?”

About the Author

Dr. Sung-Kee Kim (Ph.D. in Social Welfare)

Director, The Care Biz Lab

Chairman, SE Empower Social Cooperative

Email: skkwelfare@gmail.com

References

OECD. Health at a Glance 2025: OECD Indicators. Paris: OECD Publishing, 2025. Data on long-term care use, the share of home-based care, and long-term care expenditure.

 [Source]

United Kingdom

UK Parliament, Joint Committee on the Draft Care and Support Bill. Draft Care and Support Bill. Background on the National Assistance Act 1948 and postwar social-care legislation.

UK Government. National Health Service and Community Care Act 1990.

Department of Health and Social Care. Adult Social Care Finance Report, England: 2024 to 2025.

Office for National Statistics. Unpaid Care, England and Wales: Census 2021. 

United States

Centers for Medicare & Medicaid Services. Medicaid Home & Community-Based Services Authorities and statistics on Long-Term Services and Supports.

AARP & National Alliance for Caregiving. Caregiving in the U.S. 2025.

Japan

Ministry of Health, Labour and Welfare, Japan. Community-based Integrated Care System. Materials on the integration of housing, healthcare, long-term care, prevention, and daily-living support within communities. 

Ministry of Health, Labour and Welfare, Japan. Statistics of Long-Term Care Benefit Expenditures. Data on long-term care benefit volumes and service use in 2025.

Korea

National Health Insurance Service. Long-Term Care Benefit Cost Review and Approval Statistics. 2025 total reviewed and approved long-term care benefit costs: approximately KRW 17.7035 trillion.

National Law Information Center, Republic of Korea. Act on Integrated Support for Community Care, including Medical and Long-Term Care Services. Effective March 27, 2026. 

Author’s previous essay: “Why Is Innovation in the Korean Care Business So Difficult? — What Are the Structure and Characteristics of Korea’s Care Market?.” Framework covering public direct provision, quasi-markets, consumer direct-purchase markets, and the structural characteristics of Korea’s care market.

China

National Bureau of Statistics of China. 2025 National Economic and Social Development population statistics.

National Healthcare Security Administration of China. Materials on long-term care insurance enrollment, beneficiaries, and system expansion, 2025–2026. 

Thailand

National Health Security Office, Thailand. Long-Term Care Program: Thailand’s Preparation for Entering an Aged Society. 

National Health Security Office, Thailand. Home Care Services for Vulnerable People. 

India

International Institute for Population Sciences. Longitudinal Ageing Study in India (LASI), Wave 1. 

International Institute for Population Sciences. Living Arrangements and Care Needs among the Older Population in India.

International Institute for Population Sciences. Evolving Family Dynamics and Redefining Support for Functionally Impaired Elderly in India. 

Care at Home

Bestsennyy, O., Chmielewski, M., Koffel, A., & Shah, A. “From Facility to Home: How Healthcare Could Shift by 2025.” McKinsey & Company, 2022.