De-familialization of care and the emerging crisis of unmet needs among older adults in South Korea

Abstract

Unmet long-term care (LTC) needs are a critical policy indicator for aging societies. Using repeated cross sectional data from the nationally representative National Survey of Older Koreans (2014 and 2023), we examined changes in unmet LTC needs among community-dwelling older adults aged 65 and over with at least one limitation in activities of daily living (ADL) or instrumental ADL (IADL). The analytic samples comprised 1754 and 1648 individuals in 2014 and 2023, respectively. Guided by Andersen’s Behavioral Model of Health Services Use, we employed Blinder–Oaxaca decomposition to quantify the contributions of predisposing, need, and enabling factors—including sociodemographic factors, health status, and caregiving arrangements—to the observed changes in unmet care needs and family caregiving. Unmet LTC needs rose sharply from 20.1 to 54.7% despite substantial expansion of the universal Long-Term Care Insurance (LTCI) system. Blinder–Oaxaca decomposition showed that 77.9% of this increase was attributable to changes in observable characteristics, with the decline in family caregiving as the dominant factor. Family-provided care fell from 72.7 to 36.4% during the study period, yet only 13.6% of this reduction could be explained by shifts in family composition or socioeconomic status, suggesting that unmeasured structural changes such as health beliefs on care played a predominant role. These findings indicate that the withdrawal of informal caregiving has outpaced the expansion of formal care, underscoring the urgency of population-level monitoring of unmet LTC and tiered-universal, preventive benefit packages with coordinated caregiver supports to keep LTC systems resilient ahead of demographic tipping points.