Long-Term Care Insurance in Japan

Abstract

Among all the industrialized countries, Japan has the fastest rate of population aging and the highest life expectancy at birth. It is projected that the proportion of elderly people will reach 35.7% in 2050. In this demographic environment, Japan launched a social insurance program for long-term care for the elderly in 2000. What were the forces that led Japan to establish a long-term care program for elderly people? What are the provisions for financing, benefits, and service delivery? What aspects of policymaking in developing such a program are unique to Japan? This article presents answers to these questions.     

Differences in Facilities' Acceptance of Patients Under Long-Term Care Insurance in Japan

Abstract

Objectives. In April 2000, Japan launched a public, long-term care insurance (LTCI) plan for elderly people who need support. This study describes how medical support for the elderly is delivered at LTCI care facilities in Japan now and gaps between system goals and current activity. Recommendations are made for enhancing the implementation of LTCI.

Methods. We mailed questionnaires to all health service facilities for the elderly (HSF) and special nursing homes for the elderly (SNH) located in the Kyushu area of Japan, asking whether they would accept patients with nine specific conditions.

Results. We found that HSFs, which are required to employ a full-time doctor and are reimbursed at a higher rate, accept significantly fewer patients with four conditions that need medical support than are accepted by SNHs, which are not required to employ a full-time doctor.

Discussion. In this study, we find discrepancies between system goals and current activities at LTCI care facilities. For the Japanese LTCI system to work well in the limitation of medical resources, we must understand how it really works and to reform the system continuously.     

Differences in facilities' acceptance of patients under long-term care insurance in Japan

OBJECTIVES: In April 2000, Japan launched a public, long-term care insurance (LTCI) plan for elderly people who need support. This study describes how medical support for the elderly is delivered at LTCI care facilities in Japan now and gaps between system goals and current activity. Recommendations are made for enhancing the implementation of LTCI. METHODS: We mailed questionnaires to all health service facilities for the elderly (HSF) and special nursing homes for the elderly (SNH) located in the Kyushu area of Japan, asking whether they would accept patients with nine specific conditions. RESULTS: We found that HSFs, which are required to employ a full-time doctor and are reimbursed at a higher rate, accept significantly fewer patients with four conditions that need medical support than are accepted by SNHs, which are not required to employ a full-time doctor. DISCUSSION: In this study, we find discrepancies between system goals and current activities at LTCI care facilities. For the Japanese LTCI system to work well in the limitation of medical resources, we must understand how it really works and to reform the system continuously.     

Emergence and evolution of co-operatives for elderly care in Japan

To cope with the unprecedented speed of aging, Japan launched the quasi-market reforms in social welfare policy and the long-term care insurance system introduced competition amongst various kinds of service providers in 2000. Co-operatives have been actively involved in service provision for elderly care combining their business dimension with associational one. There existed distinct patterns of emergence and evolution of co-operative elderly care from grass roots. Consumer co-ops started to train consumer members as care-givers and entered the care business while health co-ops made a substantial investment to build facilities and manpower for elderly care as a natural extension. Workers co-operatives were organized to provide elderly care to the increasing number of care receivers.     

Nearby Nature and Long-Term Care Facility Residents

Abstract

As the population in North America continues to age, long-term care facilities for housing the elderly are likely to become even more important. Because one of the primary foci of these facilities is on sustaining and enhancing quality of life while eventually helping patients and families cope with the dying process, both the physical and social environments are critical to the facilities' success and the users' well-being. Healing, or restorative gardens and other designed green spaces have been suggested by many academics and practitioners as important components of these environments, yet there has been relatively little systematic research on the use and benefits of nature in this context. Do elderly residents of long-term care facilities benefit from access to outdoor areas? What are the design characteristics that are most important for this unique population?

Forty elderly residents of three different urban long-term care facilities were interviewed about the importance of outdoor green spaces and views within the facility, their use of the facility's outdoor spaces, benefits they derive from those spaces, and barriers to using the spaces. Facilities differed both in terms of the amount of nature in their outdoor spaces and in the design of, scale of, and access to those spaces. Results show that overall residents place a high value on access to green spaces and derive a number of benefits from these spaces, yet they spend relatively little time in these settings. Barriers to greater use of outdoor spaces included physical limitations, lack of staff assistance, and design issues. Implications for the value of nature spaces in long-term care facilities are discussed, along with specific design recommendations.     

Caught Between Love and Money: The Experiences of Paid Family Caregivers

This paper considers the experiences of family home care providers, paid an hourly wage by California’s In Home Supportive Services program to care for disabled or elderly relatives. These caregivers are unique in that they provide care in what Arlie Hochschild calls the “third sector” of social life, where norms and responsibilities tied to work and family intersect. Drawing on in-depth interviews and ethnographic observations of family home care providers, we find that providers perceive their paid caregiving as deviant behavior that violates social norms surrounding family care, i.e. that people should not be paid for the care of kin. Family caregivers manage the norm violation associated with their carework by offering “accounts” that 1) emphasize the tasks and skill associated with caregiving and 2) by framing their carework as a public good that benefits the larger community. These accounts allow family providers to distance themselves from the norm violation of receiving a wage for care and to reconstruct their actions in a positive light.     

We Can Run But We Can't Hide:

Long-term care costs are not covered to any significant extent by public or private insurance. As a result, nursing home patients often must use their entire life savings to pay for their care and once impoverished turn to welfare in the form of Medicaid, the federal-state health care program for the poor. Private-sector solutions, such as private long-term care insurance, should expand to play a larger role but cannot solve the whole problem by themselves. Reform of the Medicaid program to make the means test less onerous would be desirable, but this approach would retain the welfare stigma. What is needed is a public insurance program to which everyone would contribute and earn the right to benefits when they need them without having to prove impoverishment. Any public insurance program should leave a substantial role for the private sector. Public costs of a social insurance program would be high but not unaffordable, especially since society will incur most of these costs even without an expanded public program.     

Implementing public policies and services in rural Japan: issues and problems

While the sharply increased services for the elderly in the revised Gold Plan--announced in 1994--are noteworthy, implementation of the revised Plan is expected to present numerous issues and problems, particularly in the rural areas of Japan, because of unique circumstances such as depopulation and the presence of a disproportionately large number of elderly; geographical and physical isolation; a conservative and tradition-bound political climate; and conservative attitudes of the elderly. This article examines the current state of policy implementation, identifying issues and problems that are being encountered in the rural areas of Japan. Such issues as economic and family life, health care, and service delivery for the elderly are examined.     

Implementing Public Policies and Services in Rural Japan

While the sharply increased services for the elderly in the revised Gold Plan-announced in 1994-are noteworthy, implementation of the revised Plan is expected to present numerous issues and problems, particularly in the rural areas of Japan, because of unique circumstances such as depopulation and the presence of a disproportionately large number of elderly; geographical and physical isolation; a conservative and tradition-bound political climate; and conservative attitudes of the elderly. This article examines the current state of policy implementation, identifying issues and problems that are being encountered in the rural areas of Japan. Such issues as economic and family life, health care, and service delivery for the elderly are examined.     

Future of Long-Term Care Financing for the Elderly in Korea

ABSTRACT

With rapid aging, change in family structure, and the increase in the labor participation of women, the demand for long-term care has been increasing in Korea. Inappropriate utilization of medical care by the elderly in health care institutions, such as social admissions, also puts a financial burden on the health insurance system. The widening gap between the need for long-term care and the capacity of welfare programs to fulfill that need, along with a rather new national pension scheme and the limited economic capacity of the elderly, calls for a new public financing mechanism to provide protection for a broader range of old people from the costs of long-term care. Many important decisions are yet to be made, although Korea is likely to introduce social insurance for long-term care rather than tax-based financing, following the tradition of social health insurance. Whether it should cover only the elderly long-term care or all types of long-term care including disability of all age groups will have a critical impact on social solidarity and the financial sustainability of the new long-term care insurance. Generosity of benefits or the level of out-of-pocket payment, the role of cash benefits, and the relation with health insurance scheme all should be taken into account in the design of a new financing scheme. Lack of care personnel and facilities is also a barrier to the implementation of public long-term care financing in Korea, and the implementation strategy needs to be carved out carefully.     

Computer-Based Case Management for the Elderly

A combination of economic, demographic, and political factors is pressuring health care providers into improving discharge planning and long-term care services for their clients, particularly the elderly and poor. Case management, with its emphasis on patient assessment, monitoring, and program evaluation, is one tool increasingly adopted to accomplish these goals. This paper examines the application of computer technology to case management and describes a computerized, hospital-based case management program for the elderly.     

失能老年人长期护理的需求规模评估、费用测算与经济效应预测

伴随着失能风险的增加,老年人长期护理问题成为人口老龄化研究的新课题.基于CHARLS等相关数据,改进Markov模型,测算2020—2060年失能老年人长期护理需求规模及费用,并预测经济效应,结果表明:(1)老年人数量呈倒"U"形增长趋势,并于2048年左右达到顶峰,约为4.34亿人;失能老年人呈逐年上升趋势,于2060年达到1.84亿人.(2)失能老年人长期护理费用由2020年的3906.57亿元增长到2060年的44973.16亿元,增长11.51倍,其中轻度、中度和重度失能老年人长期护理费用分别增长8.92倍、15.55倍和21.17倍.(3)老年护理劳动力需求量预测显示,由90.33万人上升到228.98万人,增长2.54倍;机构养老护理型床位需求量预测显示,由241.03万张增长到553.11万张,增长2.29倍;老年护理市场直接经济增量预测显示,由3906.57亿元增长到44973.16亿元,增长11.51倍.基于此,本文提出包括坚持"以制度为基础、以服务为核心、以救助为兜底、以法律为准绳"的基本原则,建立失能动态监控机制,完善养老服务财政补贴制度等政策建议.     

Global Convergence: Aging and Long-Term Care Policy Challenges in the Developing World

Aging around the world poses a global challenge in eldercare. This challenge is particularly felt in low- and middle-income countries (LMICs), where population aging outpaces the development of aged care policies and services. This Perspective highlights the phenomenon of global convergence in several unsettling trends and challenges shared across LMICs. These include the weakening of informal family care systems for the elderly, growing need for formal long-term care of the frail and disabled who can no longer be adequately supported by family members, and mounting pressures for policy responses to tackle these societal challenges. It is argued that policymakers should take a proactive stance. That is, when family care for the elderly falls short and family caregivers are increasingly under strain, the government should step in and step up support to fill in the gap by developing appropriate policies and a continuum of long-term care services that are accessible and affordable for the majority of older people in need. Three general principles are then suggested with regard to long-term care provision, financing, and quality assurance, which transcend national borders and can be used to guide long-term care policymaking across LMICs.     

In sickness and in health: A qualitative study of elderly men who care for wives with dementia

It is estimated that approximately 1,000,000 elderly men care for spouses with Alzheimer's disease or other forms of cognitive impairment, yet we have only a limited understanding of their work, and central questions arise. What do men caregivers do, and what meanings do they ascribe to their work? What are their distinctive strengths and vulnerabilities, and what can we learn about men and caregiving from their stories? This qualitative study was based on in-depth, open-ended interviews with 14 elderly men who are primary caregivers to wives with dementia. All interviews were taped, transcribed, and manually coded. The resulting information then underwent analysis from which three major themes emerged: feelings of isolation and invisibility of their care work, a style of caregiving that jointly utilizes management and nurturing, and feelings of commitment, responsibility, and devotion.     

Public Policy Implications of Elderly Interstate Migration to Oregon, 1985-1990

Abstract

Several Oregon counties received a noticeable influx of elderly migrants from other states during the 1980s. Oregon policy regarding taxes, land use, and long-term care is examined for possible influence on migration. Models of elderly migration are examined for insight into how public policy influences migration, and previous research regarding the effects of elderly migration on public policy is reviewed. Data regarding disability and financial vulnerability among elderly by migration status are analyzed for possible influence upon public policy.

Change in the population aged 65 and older mirrored state and national patterns for 1980 to 1990 and 1990 to 1999. Interstate elderly arriving in attractive counties reported a low prevalence of disability and financial vulnerability, indicating a low risk of demanding public assistance. Interstate elderly arriving in population centers reported a relatively high prevalence of disability but a low prevalence of financial vulnerability. This may suggest that Oregon's long-term care policy influenced elderly migration.     

State Discretion and Medicaid Program Variation in Long-Term Care

Summary

Although federal statutes and regulations establish the broad parameters within which state Medicaid programs operate, the federal government grants states substantial discretion over Medicaid and Medicaid-funded long-term care. An appreciation of resulting cross-state variation in Medicaid program characteristics, however, has been lacking in the ongoing debate over whether the federal government should further devolve responsibility for caring for the poor and disabled elderly to the states. To better inform this discussion, therefore, this article documents considerable variation, not only in terms of Medicaid program spending and recipients, but also in terms of strategies chosen to reform long-term care services and financing. Since there is little doubt that states take full advantage of current levels of discretion, advocates of devolution may want to reassess their views to consider whether existing variation has resulted in inequities addressable only through more, not less, federal involvement.     

The home care industry: strategies for survival in an era of dwindling resources

The home care component of our long-term care system is increasingly being recognized as the preferred alternative to institutional care for the frail elderly and disabled. Dwindling resources, both human and financial, are likely to have a deleterious effect on home care. Findings from a 1987-88 survey of paraprofessional home care workers of the frail elderly in New York City are used to draw implications for the home care industry. The scope of problems inherent in the industry imply that changes are necessary on both the micro and macro levels; the article concludes with recommendations for both levels.     

The Home Care Industry

The home care component of our long-term care system is increasingly being recognized as the preferred alternative to institutional care for the frail elderly and disabled. Dwindling resources, both human and fmancial, are likely to have a deleterious effect on home care. Findings from a 1987-88 survey of paraprofessional home care workers of the frail elderly in New York City are used to draw implications for the home care industry. The scope of problems inberent in the industry imply that changes are necessary on both the micro and macro levels; the article concludes with recommendations for both levels.     

The Gender Politics of Human Waste and Human‐as‐Waste: Indonesian Migrant Workers and Elderly Care in Japan

Significant decline in mortality and fertility rates has led to a rapid aging population in many parts of the globe. Coupled with a decrease in caring for one's senior parents at home, this condition creates a crisis in elderly care. Most studies on elderly care in Japan, the country with the highest percentage of senior people in the world, employ theoretical approaches rooted in the fields of aging and migration studies. This article offers a new perspective by not only focusing on the voices of the Indonesian women migrant care workers in Japan by way of in‐depth interviews, but also intersecting feminist and waste studies in its analysis. This different theoretical approach allows this article to argue that the politics of disposability in the ‘global care chains’ is a gendered and ‘affective’ phenomenon. Drawing from Jaggar's ‘emotional hegemony’ and Saraswati's ‘affective structure’, this article shows that emotions matter in constructing the disposability of these migrant workers and elderly people, particularly within the capitalist currents that drive the gendered supply chains.     

Future of long-term care financing for the elderly in Korea

With rapid aging, change in family structure, and the increase in the labor participation of women, the demand for long-term care has been increasing in Korea. Inappropriate utilization of medical care by the elderly in health care institutions, such as social admissions, also puts a financial burden on the health insurance system. The widening gap between the need for long-term care and the capacity of welfare programs to fulfill that need, along with a rather new national pension scheme and the limited economic capacity of the elderly, calls for a new public financing mechanism to provide protection for a broader range of old people from the costs of long-term care. Many important decisions are yet to be made, although Korea is likely to introduce social insurance for long-term care rather than tax-based financing, following the tradition of social health insurance. Whether it should cover only the elderly longterm care or all types of long-term care including disability of all age groups will have a critical impact on social solidarity and the financial sustainability of the new long-term care insurance. Generosity of benefits or the level of out-of-pocket payment, the role of cash benefits, and the relation with health insurance scheme all should be taken into account in the design of a new financing scheme. Lack of care personnel and facilities is also a barrier to the implementation of public long-term care financing in Korea, and the implementation strategy needs to be carved out carefully.