1 Statistics
and Information Department, Minister's Secretariat. Ministry of Health and Welfare.
Abridged Life Table (1 996) .
2National
Institute of Population and social security Research, Ministry of Health and Welfare,
Latest Demographic Statistics (1997), Research series No. 292.
to
this Table, the risk of becoming bedridden (including those people who are bedridden and
have dementia) is 10%, and the risk of having dementia is 1.5% for those in the age group
of 80―84. The risk is 20.5% and
3.5% respectively for those in the 85 and older age group. The risk of at least one spouse
having a condition which requires care reaches about 50% over a person's lifetime in
Japan, where the average life expectancy has reached into the eighties.
Back in the 1950s, the main
cause of death was cerebrovascular strokes. In those days, many of the aggressive
treatment methods which are being used today were unavailable. As a result, many people
died relatively soon after suffering a stroke. In these circumstances, even if family
members cared for the sick, it is fair to say that the duration of care was relatively
short -- at most, several weeks3. We were able to cope with
the situation by conventional means of family care giving in those days, because of the
short care giving period and the greater number children per family than is the case
today. However, as public medical care insurance has spread among all the citizens, access
to medical care has improved4. Also, as critical medical
care has advanced substantially, such progress makes it possible to increase the number of
patients, including stroke victims, whose lives are saved and who then receive
rehabilitation and survive for quite a long time.
The second point is that the
conventional means of care giving, which is through the families of these elderly people,
has begun to encounter difficulty as a result of various factors.
As you all know, it has been
common in Japan for family members, especially a daughter or a daughter-in-law, to care
for elderly family members. The common belief
has been that it is the woman's responsibility to take care of her parents or her
husband's parents in their old age. It has been considered a shame to place parents in
nursing homes or make use of external services to care for them at home because it is akin
to abandoning their responsibility as children.
3 Yuzo
Okamoto (1996), Medical Care and Social Service for the Elderly (pp.29-33). Tokyo. Japan :
lwanami
Syoten.
4 Universal
coverage of medical care insurance in Japan was realized in the year of 1961.
However, there is a sharply
increasing number of cases where it is difficult to maintain the well-being of elderly
people predominantly through care given by family members.
One of the reasons for this
is the aging of the family care givers themselves. The majority of elderly people in need
of care are over 80 years old and their care givers (who may be their spouses or children)
are, in many cases, over 60 years of age5. When a care giver himself
or herself is advanced in age, it is difficult for him or her to provide physically
demanding personal care, such as helping a family member bathe, go to the bathroom or
change posture day and night. We often see that elderly people who regularly go to
hospitals for outpatient care are those who are, in turn, taking care of their elderly
parents. In such cases there Is the constant concern that they may "fall
together." The second reason that makes family care giving difficult is the declining
ratio of elderly people who live with their children. It is well-known that Japan's
cohabitation ratio (the number of adults living with their elderly parents) is higher than
in other developed countries. With changing perspectives among both parents and children,
however, this ratio has quickly fallen in recent years -- especially in the cities. In
Tokyo, the city with the highest population, in particular, the cohabitation ratio has
dipped below 50%6,thus, the number of cases
where children and their parents who need care are living separately is on the increase.
There are other reasons that
have made family care giving difficult in addition to those mentioned above. These include
the rapid increase in the number of women in the labor force and the weakening of the
feudalistic belief that a daughter-in-law should take care of her parents-in-law:
We will no longer be able to
solve problems through the conventional approach by which family members, particularly
women, provide most of the care needed by the
5 According
to the Comprehensive Survey of Living Conditions of the People on Health and Welfare by
Ministry of
Health and Welfare(1997), every other caregiver is 60 years old or older.
6 Statistics
and Information Department. Minister's Secretariat, Ministry of Health and Welfare.
Comprehensive
Survey of Living Conditions of the People on Health and Welfare (1997).
elderly.
Furthermore, we no longer believe such an approach is appropriate.
The third point in this
subject is the shortage of nursing homes and care workers who provide services to the
elderly in need of care.
In Japan, as in other
countries, care for the elderly is provided at special nursing homes and other
institutions and through various home care services in addition to care which is provided
by family members. Up until the late 1980s, however, Japan's national policies reflected
the basic belief that children should take care of their elderly parents. As such the
government did not make active efforts to increase the number of these institutions nor
workers.
On the other hand, the
medical care insurance system covered hospitalization of the elderly relatively
generously. Partly as a result of this, there were often cases in which elderly people in
need of care were neither cared for by their family members at home nor were admitted to
nursing homes (due to the long waiting lists). Instead, these people stayed in general
hospitals for long periods of time.
General hospitals are,
however, designed for the purpose of providing medical treatments. They do not have proper
or sufficient facilities for providing long-term care, such as private or semi-private
rooms, dining rooms and bathtubs. Also, they do not have enough staff engaged in providing
personal care to the patients who need long-term care. It has been said that elderly
patients in general hospitals do not improve their activities of daily living (ADL) and
that those who are bedridden deteriorate because of a lack of adequate care provided to
them.
It was not until 1989 that
the Gold Plan was formulated with the objective of promoting the development of facilities
and manpower. Later in 1994, the target levels were raised. With 1999 as the target year,
efforts are rapidly being made to develop institutions and train workers, but these
efforts still lag behind the actual needs created by the rapid aging of the population and
the increase in elderly people in need of care. A new fund which will be created under the
long-term care insurance system after the year 2000 is intended to encourage the entry of
the private sector into this market and dramatically expand the service volume (On the
other hand, some governmental officers and economists are concerned about the possibility
that the spending on the long-term care insurance will be substantially larger than
expected.).
History
of the Policies on Long-Term Care for the Elderly : From the Welfare Law for the Elderly
to the Long-Term Care Insurance Law
The
Welfare Law for the Elderly
Homes for the elderly, home
care aid services, respite care which is called "short stay program" and other
similar services have been covered by the funds from the taxes of the central and local
governments under the Welfare Law for the Elderly which was enacted in 1963.
When this law was enacted, it
was designed for the low-income elderly who had no
relatives to care for them. This policy went along with the prevailing belief of the times
that family members should take care of their elderly relatives. However, since then, as
the demand for long-term care has been increasing, the coverage has gradually been
expanded, too. Today, any elderly person, as long as he or she needs long-term care, can
basically receive services based on the Welfare Law for the Elderly.
Nevertheless, partly due to
the fact that taxes are used to fund these services as a "welfare" system, the
fees borne by users are divided into many levels depending on their income level. The fees range from free of charge to almost 100%
of the cost.
In addition, the municipal
governments decide who is eligible (whether applicants are qualified for benefits or not)
and set the content of the benefits, taking into account both the income of the elderly
person and their family members and family relationships, among other factors. In actual
practice, there still appears to be a strong tendency to provide services to low income earners and people without
relatives, while people with middle income are given a lower priority.
The
Health Service System for the Elderly
Facility services in special
nursing 'homes and home care aid services, among other services, which are provided under
the Welfare Law for the Elderly, have been placed under strict budgetary restraints each
year as a result of rigorous pressure from the Ministry of Finance. The reason for this is
because those services have been funded by taxes. As a result, the volume of services
provided has not been sufficient to meet the rapid increase in demand as the aging of the
population progresses.
Under these circumstances,
hospitals stepped forward to virtually offer living space to elderly people in need of
care, in place of special nursing homes. In Japan, all of the citizens are covered by an
insurance plan for medical services. Thus, people can have access to the hospital of their
choice regardless of their income status. Elderly people in particular can receive medical
services with a lower copayment than the
working generation under a special system for the elderly which is called the "Health
Service System for the Elderly" (Though there was no copayment, a copayment system
was later introduced, with the current percentage of copayment being about 5% of the total
expenses.).
Therefore, many elderly
people in need of care and their family members have continued to choose admission to
readily accessible hospitals, instead of the "welfare" system which involves
complex procedures and a check of income and details of the family situation.
As a result, the average
length of stay in Japanese general hospitals is much longer than in other developed
countries. It was 33.7 days in 19957 despite a gradual shortening
in recent years.
Table 4 shows a comparison
between Japan and the United States in terms of the number of hospital beds and beds in
homes for the elderly per 100,000 elderly population. You will notice that there are many
hospital beds in Japan and many nursing home beds in the US. It is still fair to say that
hospitals are the main facilities offering long-term care in Japan, though the situation
has been improving since long-term care facilities have been developed according to the
Gold Plan described below.
The Health Service System for the Elderly,
which was institutionalized in 1982, covers all of the medical services necessary for the
elderly, including admission to hospitals. Services such as health services facilities for
the elderly (which are a kind of
7 Statistics
and Information Department, Minister's Secretariat, Ministry of Health and Welfare,
Hospital
Reports
(1995).
long-term
care facility and primarily provide rehabilitation), home-visit nursing care and
home-visit rehabilitation have been gradually added as new additional benefits. It is
because long-term care, which can be regarded as a part of medical treatment for
illnesses, is encompassed in these medical services.
Long-term care services for
the elderly have thus far been provided in Japan, as mentioned above, based on two
different systems: the welfare system for the elderly and the Health Service System for
the Elderly.
The
Gold Plan
Recognizing that family care
giving for those elderly people in need of care was becoming increasingly difficult, the
Japanese government developed and implemented the Gold Plan in 1989 which defined specific
goals to be achieved over a ten-year period ending in 1999. These goals included numerical
targets for facilities and workers in the field of long-term care for the elderly.
In implementing the Gold
Plan, each of the municipal governments conducted fact-finding survey on the elderly
people living within its jurisdiction, and formulated a specific action plan for the
development of a service infrastructure based on the results of the survey. Prefectural
governments also drew their action plans based on the action plans of the municipalities
within their prefectures. Making these plans at these prefectural and municipal levels
increased public interest for the issue of long-term care for the elderly. This served as
an opportunity to raise the policy priority of this issue, which used to be at a
relatively low level, to a higher level both in the national and local political scenes.
Subsequently, however, while
in the process of creating action plans at local levels, it became apparent that the
target levels specified in the Gold Plan were not sufficient to meet the needs of the
people. So in 1994, the Japanese Government revised the Gold Plan and formulated the New
Gold Plan by raising the numerical targets. The New Gold Plan is designed to achieve the
goals shown below by 1999.
* Home care aides
170,000 people
* Respite care (short stay) service
facilities 60,000
beds
* Day care centers
1 7,000 locations
* Home-visit nursing care stations 5,000
locations
* Special nursing homes for the elderly 290,000
beds
* Health service facilities for the
elderly 280,000
beds
* Assisted living facilities (Care houses) 100,000
people
With the long-lasting
depression in the Japanese economy, however, the fiscal ituation of national and local
governments is deteriorating. Despite this setback, the status of progress under the New
Gold Plan has been relatively smooth, except in the case of assisted living facilities
(care houses). As far as the number of special nursing homes is concerned, the numerical
target set in the Plan will be achieved by the end of fiscal year 1998, and it is expected
to surpass the target in fiscal year 1999.
Nevertheless, many localities
have experienced more growth in demand than expected since the launch of the New Gold
Plan. The supply of home care services and facility services has not kept up with demand,
and in spite of the recent rapid increases of these services. It is anticipated that the
demand will further expand due to the enforcement of the public long-term care insurance
system in April of 2000. The development of a service infrastructure beyond the New Gold Plan is now an important challenge.
Under the public long-term
care insurance system, the national government is expected to set forth basic guidelines
on the development of the service infrastructure in order to systematically promote the
continued development of care facilities and the training of manpower. Then, all the
municipal and prefectural governments will draw up their specific development plans
accordingly.
Public Long -Term Care Insurance System
While the development of the service
infrastructure progressed based on the Gold Plan, we had to face the challenge of deciding
how to share the burden of the rapidly increasing long-term care expenses in the society.
The answer to this challenge is the public long-term care insurance system. The following
three points are the major factors in the background of the introduction of the public
long-term care insurance system.
One of the factors was the
need to ensure a stable revenue source. Since the launch of the Gold Plan, general tax
revenue has been used to fund the infrastructure development for "welfare-"
related long-term care services under the welfare system for the elderly, and insurance
funds have been used to fund the infrastructure development for "medical care-"
related long-term care services under the medical care insurance system. However, it was
expected that ensuring the necessary financial sources in response to the future rapid
aging of the population would be difficult, because each of these systems does not focus
on long-term care. People became more aware that a stable financial source should be
secured for the future, while the issue of elder care was one of the most worrisome
factors in post-retirement life8.
Another aspect to consider is
the criticism raised against the conventional allocation system. Today, home care
services, such as home care aid and day care services, and facility services, such as
nursing homes, are provided by municipal governments as a part of the "welfare"
system. When an application for the use of a service is filed by an elderly person in need
of care, the municipal government determines not only the necessity of providing the
benefit, but the content of the service and designating the provider which will offer the
service, after taking into consideration the income and family condition of the elderly
among other factors.
Today when the majority of
the public has begun to perceive the issue of long-term care as a relevant issue to their
lives, they criticize the current allocation system on the basis that it makes services
psychologically difficult to use because it stigmatizes people. They also dislike the fact
that the opinions of users are neglected as municipalities unilaterally determine the
contents and providers of services.
The third aspect is the deterioration in
the fiscal situation of medical care insurance caused by the long-term hospitalization of
elderly patients in need of care. Many elderly people in need of care avoid using the
welfare system because of various
8 According
to the survey conducted by the Prime Minister's Office in 1995, more than 80% of the
respondents
supported the establishment of the public long-term care insurance system, though the
system
will be
predicted to increase their burdens. The results of surveys by others also show the
similar
response and
present people's high expectation to the improvement of long-term care.
restrictions
on the use of services as well as the restricted quantity of services. Instead, they often
use the more readily accessible medical care insurance system (the Health Service System
for the Elderly) where they opt for a long stay in hospitals. In short, elderly people who
should be in special nursing homes, which are less costly, or who should receive services
at home, are staying in more costly hospitals9.
With this as the background,
the decision was made to integrate, as shown in Table 4, the two existing systems that
covered the long-term care for the elderly -- the welfare system financed by general tax
and the Health Service System for the Elderly predominantly funded by premiums -- to
create a new long-term care insurance system funded by both premiums and general tax.
Though people often think that the long-term care insurance system was created from
scratch, it is indeed a product of reorganizing and integrating the existing two systems.
The
Contents of the Long-Term Care Insurance System
Basic
Principles
The first is respect for the
choice of the elderly themselves. Specifically, elderly people should be entitled to
utilize home care services and facility services in accordance with their own needs and
desires without feeling a sense of reluctance, regardless of their income level and family
situation.
The second is to integrate
the two existing systems for the elderly, the welfare system and the Health Service System
for the Elderly, removing the wasteful overlap between these systems.
The third is to encourage
diverse private-sector businesses to enter this market so as to respond to the rapidly
increasing demand for long-term care services. Under the conventional welfare system,
there has been a mechanism in which municipal governments choose service providers and
contract with them to deliver services.
9 The
average cost of a stay in hospital (about $3,800 a month) is 1 .8 times more than that of
a stay in special nursing home(about $2,100 a month) . All dollar values in this article
are based on January 1, 1998 exchange rate of 130.62 yen to the dollar.
Therefore,
the municipalities have tended to preferentially choose service providers run either by
the municipalities themselves or organizations which are funded by the municipalities,
instead of private-sector service providers which the municipalities are not familiar with
.
The long-term care insurance system,
however, will abolish the system of contracting by the municipalities in order to have the
same conditions for public- and private-sector service providers for competition. This
will enable elderly people and their families to choose freely from among service
providers, regardless of whether they are public or private, and private businesses can
enter into the market without hesitation.
The fourth is to introduce
the concept of "care management" in order to provide a variety of services in
conjunction with one another to meet the desires of the elderly. Many elderly people and
their families tend to remain isolated at home and they are extremely in short of
information as to what type of care to receive and what type of service providers are
available. Even if they know the existence of such providers, much negotiation with them
and formulation of programs are needed to actually receive services from them. This task
requires a great deal of time and patience.
As a result, in the new
system as shown in Table 6, the elderly in need of care and their families can have their
care plan formulated by the professional of their choice and have him or her coordinate
the services based on the plan. The system will reimburse the cost incurred for this work.
Insurers
The insurers are the
municipalities. In Japan, the medical care insurance system is uniform in principle
throughout the country. The needs for long-term care services, however, vary greatly
according to the ratio of cohabitation with elderly parents and the perspective of local
residents on family care giving. Thus, the long-term care insurance system must reflect
the characteristics of local communities in its benefit design and the level of premium
payment to some extent.
Municipal governments alone
will not take responsibility for this new system, but the national and prefectural
governments, which have been conventionally sharing the costs under the welfare system for
the elderly and the Health Service System for the Elderly, will bear a part of the total
expenses. Insurers of medical care insurance and insurers of pension insurance will
collect long-term care insurance premiums on behalf of the municipalities.
The
Insured
All people age 40 and older
will be required to participate. For people
under 40 years of age, who need long-term care, care services will be provided through the
existing welfare system designed for people with disabilities.
Those who are insured will be divided into
two categories, using 65 years of age as the demarcation line. Those senior citizens age
65 and older will be allowed to receive insurance benefits, if they have a condition
requiring long-term care regardless of the cause. They will pay premiums through the
municipalities in which they live. Those whose age is between 40 and 65 will be allowed to
receive insurance benefits only if their conditions are caused by illnesses associated
with aging (e.g. cerebrovascular strokes and early-onset dementia) despite the fact that
their condition will require long-term care10. These people will pay
premiums through the medical care insurance system in which they are enrolled.
Insurance
Benefits
Insurance benefits cover both
home care services and facility services as shown in Table 7. In addition, the cost of
so-called care management services (i.e. the cost of designing care plans and coordinating
services by a care manager) will be reimbursed. To receive insurance benefits, the insured
person must be assessed by the municipalities first concerning his or her need to receive
insurance benefits.
10 The
reason the long-term care insurance system covers only those age 40 and older and uses 65
years
of age as
the demarcation line is that this system was designed to reorganize and integrate the
welfare
system for
the elderly and the Health Service System for the Elderly from the perspective of
long-term care
for senior
citizens. There were people who believed that it would be technically difficult and
inappropriate
to classify
the risk of a condition requiring care by age. However, for the reason mentioned above, it
was
decided for
the time being to cover long-term care for the elderly under the new system. Whether we
should lower
the age limit of those covered or not will be an important issue after this system is
This
determination is solely based on the insured person's physical and mental conditions.
Different from the conventional system, neither the family situation nor the income of the
elderly person and his/her family is reviewed for this purpose.
Insured persons who are
entitled to receive insurance benefits through this process are classified into five to
six categories according to their needs for care or the severity of their condition. The
level of insurance benefits varies among these categories. At present, we are considering
benefit levels of about 2,300 dollars per month for the most severe category and about 500
dollars for the mildest category. Within this range, the insured can freely combine
different types of home care services, such as home care aid services and home-visit
nursing care, and may be eligible to receive reimbursement.
Table 8 shows the benefit
model example of the new system11
This case is a person who
cannot turn over in bed by himself or herself, and needs help for some activities of daily
living. He or she also needs home-visit personal care late at night and medical
management. The person is living with his or her child. In this model, the insured can use some services almost every day. All of these services will be covered by the benefits
of the public long-term care insurance. One characteristic of this model example is that
it has incorporated multiple short (10 to 30 minutes) visits per day around the clock. A
conventional home care aid typically visits a patient two to three times a week, staying
for two to three hours each time to do household work such as making meals for two days
and cleaning the house. These services have not been very useful for the elderly who need
physical assistance. The new system aims to provide truly useful services to those who are
in need of care by focusing on the provision of physical assistance such as diaper changes
and position changes.
The level of services illustrated in the
model example is expected to be covered by the public long-term care insurance. When the
insured desire more frequent visits or additional services such as meal delivery, they can
purchase them out of pocket or have
implemented.
11 This model example is shown in the 1998 Annual Report on Health and Welfare, p. 240 their expenses covered by a private
long-term care insurance policy that they buy.
Copayment
Concerning users' copayment,
the insured will be reimbursed for 90% of the expenses for the services that are covered
by insurance benefits; in other words, the users' copayment is 10% of expenses. If the insured person is admitted to a facility,
he or she will be responsible to provide the copayment for meal expenses in addition.
Financial
Scale
Using 1995 prices for the
purpose of this estimate, the total expenses of welfare and Health Service System for the
Elderly spent for long-term care of the elderly was 16.1 billion dollars in 1995. By 2000
when the infrastructure development by the New Gold Plan ends and the long-term care
insurance system starts, this amount is expected to grow to 32.2 billion dollars12. Since elderly people in
need of care will continue to increase in number, this amount is expected to reach 52.8
billion dollars by 201012 (See Table 9). The long-term
care insurance system will cover these expenses excluding the users' copayment. The system
will be funded 50% by premiums and the remaining 50%by tax. The national, prefectural and
municipal governments will share the expenses with at a ratio of 2:1 :1 .
Insurance
Premium
Though the average insurance
premium will vary depending on the income of the insured, it is estimated to be 19 dollars
per month in 2000 and 27 dollars per month in 2010, as shown in Table 9. The actual
premium charged to the insured will be divided into one for the elderly and another for
those age between 40 and 65 as follows:
In the case of an elderly
insured person: The municipal governments will set approximately five premium levels,
depending on the income level of the elderly and deduct the relevant premium from the
person's pension at the source.
12 These flgures are
calculated based on the price index of 1995 without making adjustments for inflation.
In the case of an insured
person age between 40 and 65: The premium level will be slightly different, depending on
medical care insurance plan in which the insured person is enrolled. In the case of
medical care insurance for employees, one-half of the long-term care insurance premium
will be borne by the employer and in the case of the National Health Insurance, the same
will be borne by the national government. Thus, in reality, the amount of the long-term
care insurance premium to be borne by the insured will be about one-half that of the
elderly. All of the premium collected by medical insurers will be pooled into the Social
Insurance Medical Fee Payment Fund, which, in turn, will distribute the funds to
municipalities. The amount of funds distributed to each municipality will be set so that
each municipality receives approximately an equal percentage of the total cost of benefits
for that municipality. This way, the gap in funding, which would be inappropriate to place
on the shoulders of the insurers (such as the aging ratio), will be corrected (See Table
10).
Significance and Challenges of Recent Policies on Long-Term Care for the Elderly
The long-term care insurance
system has not yet been implemented, and therefore, it is impossible to evaluate its
results at this moment. However, the very fact that the two policies (namely the Gold Plan
and the public long-term care insurance system) have been adopted since the late 1980s
indicates the change in people's perspective about long-term care for the elderly from the
issue which should (can) be solved within the family to the issue which needs solution
through the entire society's efforts. It seems anachronistic to launch such a new
entitlement program as the public long-term care insurance system, when budget cuts of
social security programs are one of the prominent issues arising from the aging of the
population. However, this has become possible because of changes in people's perspectives.
The examples in which these
changes are typically reflected in the long-term care insurance system are the abolishment
of the conventional allocation system, the adoption of respect for choices made by the
elderly as a basic principle, and rejection to introduce the cash benefits systeml3 .
The following questions have
been frequently raised by foreign researchers: Why didn't Japan introduce the cash
benefits system under the public long-term care insurance system? Shouldn't we appreciate
family members' care giving as long as people pay premiums? Don't we expect swelling
expenses, because if family members' care giving is not appreciated, every one uses
non-family care services?
These questions appear at the
first glance to be reasonable from the viewpoint of maintaining fairness between people
receiving family care and people receiving non-family care or from the viewpoint of being
afraid that expenses may increase beyond control. These opinions indeed were expressed to
some extent in the course of discussions about creation of the long-term care insurance
system. However back then, most of the people who were in favor of the cash benefits
system did not base their opinions on the reasons mentioned above, but rather on the idea
that the long-term care should be ethically given by family members (especially daughters
and daughters-in-law) and that such care should be properly appreciated in order to avoid
losing such ethics. These opinions were primarily advocated by the elderly age group and
rural residents. Nevertheless, these traditional opinions faced strong criticism from the
people supporting feminism, who stated that those opinions would compel only women to give
long-term care. Women's organizations asserted that the current situation is that people
who try to use non-family care services suffer severe criticism from their relatives and
neighbors as misdirected people who do not take care of their parents and parents-in-law.
Those organizations further expressed their concern that under these circumstances, the
conventional concept of family care could persistently remain if the cash benefits system
would be created.
In the end the establishment
of the cash benefits system was shelved. The reason for this is that the people who
thought the cash benefits system would be the opposite of the trend toward burden-sharing
of long-term care in the society as a whole, cash benefits system for other reasonsl5
13 A
beneficiary or family member receives cash as a benefit, when the beneficiary chooses care
given by
the family
instead of services provided by non-family service providers.
considering
the present status in Japan, became dominant14 along with the people who opposed to the
Another significance of
recent Japanese policies on long-term care for the elderly is the impact on national
economy. On one hand, the introduction of the public long-term care insurance brings about
a negative effect of increasing public burden mainly shouldered by the working generation.
On the other hand, it generates substantial growth of the long-term care service industry
through the process of externalizing family labor. The most important factor regarding
anxiety about post-retirement life among Japanese people is the issue of who will care for
them when they are in a condition requiring care. Senior citizens have saved considerably
high amounts of money, which are said to be the world's highest level, because of such
worry. Long-term care insurance is hoped to play a role in eliminating anxiety about
post-retirement life. It isexpected that long-term care insurance will improve consumption
propensity of the elderly, leading to the expansion of domestic demand.
According to Professor Ohmori
of Osaka University, the overall economic effect achieved by the creation of public
long-term care insurance is expected .to be an increase of GDP by 1.3% by offsetting the
negative effect caused by expanded publicburden through the expansion of the long-term
care service industry and consumption by the elderly among other effectsl6
However, it seems there is a
certain prerequisite for realizing such an economic expansion effect; the benefit levels
of public long-term care insurance are fairly high so that senior citizens can rely on the
insurance and thus spend money free from worries.
14 The trend toward the burden-sharing of, long-term
care in society as a who[e has been rapidly becoming
dominant, as
the quantity of long-term care services has been increasing. It is predicted that within a
short
period after
the launch of the public long-term care insurance, prerequisites which deny the cash
benefits
system will
change, and that the negative effects of not having the cash benefits system will
gradually .
expand, as
was pointed out by foreign researchers. The issue of having the cash benefits system will be
debated
again at that time.
15 Other oppositions include an opinion that
providing the cash benefits system would only end up with
becoming
a mere means of lavishing money without any guarantee of improving the care level for the
elderly
and an opinion that the financial scale of the system would further expand, resulting in a
heavier cost burden.
16 Takashi Ohmori, The Impacts of Long-term Care
Insurance on Japanese Economy, Nippon Keizai
Shimbun,
October 17, 1997.
As
the aging of the population is in motion, inevitably, the burdens for taxes, pension,
public medical care insurance and the like have been rapidly increasing especially among
the current working generation. Therefore, it is impossible to maintain the considerably
high benefit levels of public long-term care insurance, if public funds, including taxes
and premiums, are continuously distributed in the traditional manner.
A considerable amount of
public funds have been spent for public infrastructure programs, such as the construction
of roads and ports. These programs, however, are no longer expected to have a greater
impact on the Japanese economy than in the past, and the government has been criticized
for funding the programs that primarily benefit vested interests and are thought to be
useless. It is now the time to start investing the funds in new industries, such as health
care, to reflect the aging of the society.
It is also important to
determine the priority among social security programs, such as those for pension, medical
care and long-term care.
In the process of
prioritization, the alleviation of more serious risks such as disabilities and illnesses
should be recognized as being more important than the mere income increase in terms of
relieving the worries of the elderly and effect on the national economy. These approaches
will make it possible to maintain the benefit levels at which people do not have to feel
worries about public long-term care insurance and medical care insurance.
Final discussion of this
paper is the challenges in implementing the long-term care insurance systeml7 Currently, various
preparatory activities are underway toward the
implementation of the system in April of 2000. They include preparation of standards for
assessment for the eligibility status, training of manpower who will be involved in
assessment, and identification of needs for the purpose of calculating insurance premiums,
in addition to the development of long-term care service infrastructure based on the New
Gold Plan. One of the present concerns is whether the sufficient quantity of long-term
care
17 Other
challenges which aren't discussed in this article are explained in the following article : Naoki
lkegami, MD,
Public Long-term Care Insurance in Japan, JAMA, 1 997; 16: 1 31 0-1 314.
services
in response to the demand will be provided or not, once the insurance system is
implemented. Though the infrastructure is being developed at a rate faster than that for
the New Gold Plan, there are wide variations in the level of infrastructure developed
among different geographical areas. It is expected that it is unavoidable to have some
shortages in some localities initially after the implementation. However, it seems
shortages will disappear in the medium term as seen in Germany, because the fund pool of
long-term care insurance is anticipated to promote the entry of private-sector businesses
into this market.
Another concern is whether or
not assessments for the eligibility status will be done accurately and speedily. In
Germany, there were cases where people could not receive insurance benefits for a long
time due to the delay in the assessment process partly because of the short preparation
period up to the implementation of the system. In addition, many of German people who are
insured submitted requests to review their eligibility status partly because it was said
that the decisions were greatly different depending on the assessors. In Japan as well,
there are many preparatory activities needed for such a short lead time as two years,
leading to potential danger of experiencing similar situations. Since the preparation
period is limited, it is impossible to expect the flawless start of the system in the year
2000. What is important is to establish standards which will serve as the basis for
assessing the condition requiring care through transparent procedures, and to
energetically train assessors.
Another concern is how to
assure the quality of long-term care services. Long-term care services are offered to
people who are in a tense condition as an elderly in need of care and his or her care
giver. How to assure the quality of care is an important issue.
While it is expected to see
the entry of many businesses into this market in the future, the risk that vicious
businesses will cause troubles, such as abuse, scammed work and fraudulent reimbursement
claims will increase. It is necessary to seriously consider how to prevent or minimize
these problems and to improve the quality ofservices provided by businesses.
It will be possible to assure
a certain level of quality through care management and regulations of prefectural
governments. However, it seems necessary to develop and introduce superior and more
effective methods, including the ombudsman and an approach to evaluate the quality of
long-term care services by third parties as seen in the US.
Conclusion
It is not a long time ago
when the issue of long-term care began to be the society's serious interest in developed
countries. In Japan, we are now indeed facingthis historically new challenge through the
establishment of such policies as the Gold Plan and the public long-term care insurance
system. This is a challenge under the harsh conditions, including the progress in the
aging of the population and absence of the hope for dynamic economic growth. Thus, the
future prospect of this challenge is unclear. However, as long as there is no panacea for
the social security system in the aged society, the policies our country is currently
adopting seem to be one of the influential approaches to the long-term care issue which is
difficult to be solved by the elderly and their family members alone.
A variety of trial and error
will be repeated in the future in implementing these policies. However, Japan will be able
to give various lessons to other countries through such experiences.
