When Policy Meets Reality: Municipal Leaders' Views Amid Rising LTC Expenditure.

Background: Long-term care (LTC) expenditure in Norway has increased by a far higher rate than GDP. While aging is still seen as the predominant challenge, younger users (<60 years) are disproportionately represented among the top-5% high-cost users, who accounted for 39% of LTC costs in 2019. Aim: This study investigates how municipal leaders perceive the main drivers of LTC expenditure growth and what they consider to be the most pressing challenges. Methods: We conducted semi-structured interviews with 13 municipal leaders between November 2023 and February 2024. Using thematic analysis, we explored their perspectives on expenditure growth, causes, and challenges. Municipalities were selected across KOSTRA groups to ensure variation in demographics and finances. Results: Three main themes emerged. Municipal leaders identified younger users with complex mental health needs requiring intensive services, workforce shortages forcing reliance on expensive purchased services, and expanding rights creating gaps between expectations and capacity. These pressures are compounded by fiscal asymmetries-national policies expand mandates while implementation costs fall on municipalities with constrained budgets and labor markets. Conclusions: Expenditure growth stems from both demographic drivers and governance challenges. While young users and workforce shortages directly increase costs, fiscal asymmetry makes these pressures difficult for municipalities by removing their flexibility to adapt services to available resources. Implications for health services management: Managers need tools to manage fiscal asymmetries between national policy and local implementation.