Long-term care policy reform in Japan

The implementation of Japan's Long-Term Care Insurance Scheme in April 2000 was the culmination of some 30 years of policy deliberation on aged care. Understanding the policy debate surrounding the Long-Term Care Insurance scheme and its financing arrangements requires an appreciation of rapid demographic and social change, especially in family structures and attitudes to caring for aged parents; but the pressures that population aging and economic downturn are placing on Japan's pension and health insurance systems also must be recognized. Even more generally, the delicate balance of political interests in Japan's central governing body, the Diet, has shaped the implementation of Long-Term Care Insurance as a forerunner to other reforms in social security and health insurance.     

Aged Care Service Delivery in Japan

Summary

The implementation of Japan's Long-Term Care Insurance Scheme in early 2000 presaged many changes in service delivery and much debate among service providers, different levels of government, academic analysts, and major media interests. The first part of this paper gives an account of the major changes in the organization of service delivery that have increased opportunities for private sector providers, including large corporations, and restructured contractual relationships between municipalities and providers in all sectors. New arrangements for client assessment, classification, care management, and extended service types are then outlined. An assessment is then made of the likelihood that the expected outcomes of the scheme will be realized, with the concerns of welfare professionals that the public welfare system is under threat juxtaposed with bureaucratic goals of liberalizing the provision of long-term care.     

The Productivity Commission Inquiry into Aged Care: A Critical Review

Abstract

The final report of the Productivity Commission Inquiry into Aged Care has recommended a substantial restructuring of Australia's aged care system to make it fairer, more responsive to the needs of individual consumers, and more sustainable in the context of population ageing. While acknowledging the necessity of a safety net and the needs of diverse groups, the recommended reforms continue to advance the neoliberal restructuring of Australia's health and welfare systems. This paper provides a critical examination of the context and key drivers for change, and considers the reception of the report within the aged care sector. While social workers are actively engaged in the aged care system, they are largely absent from the discussion in the final report. Nonetheless, the transfer of recommendations into actual policy provides an opportunity for social work to argue its unique contribution and potential in the delivery of aged care.     

Health System Reform and the Elderly: The Case of Israel

Abstract

Following the implementation of the National Health Insurance Law in January 1995, major changes have taken place in the provision of health services by Israel's sick funds and the way these services are funded. This article presents the principal changes that have occurred and assesses their impact on those aged 65 and older, using findings of a survey conducted one year after the law's enactment. While the findings show that the elderly's situation has improved in some areas, they also raise concerns that the elderly are having difficulty navigating the reformed health system and that they are not benefiting from the new competition among the sick funds.     

Sense of Need for Financial Support and Respite Services among Informal Caregivers of Older Americans

ABSTRACT

Financial support and respite services are two of the most frequently reported types of help that caregivers of older adults need. Using an expanded health behavioral model, this study examined the effects of predisposing, enabling, and needs factors on caregivers' sense of need for these two types help. Data were drawn from the 1999 National Long-Term Care Survey and included 1,058 caregiving dyads in the community. The results indicated that caregiver-related factors more than care recipient–related factors affected caregivers' sense of need to seek both types of help. The findings direct to two important implications for long-term care policy for and practice with older adults: improvement of service for caregivers and service delivery systems.     

Israel's long-term care insurance law after a decade of implementation

Israel's Long-Term Care Insurance (LTCI) law has been in effect for a decade. It is timely to review the effects of this legislation with a view to identifying possible directions for reform and lessons for other countries considering the introduction of a similar social insurance scheme. The paper considers the law's effects in terms of the size and characteristics of the beneficiary population, the coverage of the scheme, its financial standing, the rate of institutionalization of the elderly, the caregiving burden, the service delivery system, and the overall scope of long-term care services for the aged. Israel's experience has lessons for financing arrangements, target efficiency, service delivery arrangements, and the construction of the burden of care.     

Japan's Financing Systems for Health Care of the Elderly

The multiplicity of Japan's health insurance system fails to achieve equality among the different insurance groups of the sharing of the financial burden. This "horizontal" inequality is effectively offset by a unique redistribution mechanism established in 1982. However, there is no reserve fund so that savings can be accumulated for the greater financial need in the future. This will inevitably lead to a heavier financial burden for the future working generation or more utilization of the personal assets of the elderly. How to achieve "vertical" or intergenerational equality in financing the cost of health care for the elderly is the biggest social policy challenge for Japan.     

Community-Based System,Reports, and Substantiated Cases of Elder Abuse: Disparities Between Municipalities and Relating Factors in Japan

This study examines (1) the staffing and financial characteristics of systems for elder abuse detection and intervention in the municipal governments of Japan and (2) the relationship among the development of detection and intervention systems, the reporting rates of suspected elder abuse cases, and substantiated abuse rates in 927 municipalities across Japan. Progressive systems for the detection and intervention of elder abuse were significantly associated with a larger number of public officers than in non-progressive systems. Furthermore, greater rates of both suspected and substantiated cases of abuse were associated with progressive systems for elder abuse detection and intervention. Per capita annual expenditures on the comprehensive support project and the community general support center's catchment under the Long-Term Care Insurance (LTCI) program showed no significant association with the development of systems, the rate of suspected cases, or the number of substantiated cases. National social policy makers should examine strategies that would help municipalities assign sufficient staff to elder abuse detection and intervention programs.     

Social Inclusion as an Agenda for Mental Health Social Work

Summary

Following New Labour's election to office in the UK in 1997, policy initiatives have proliferated relating to mental health. Much of this policy innovation emphasises the social dimensions of mental health and distress, with an emphasis on employment and social inclusion. Paradoxically, this modernization of the mental health agenda comes at a time when mental health social work is struggling to establish its role and contribution within recently integrated health and social services. The paper considers whether New Labour's flagship programme, Mental Health and Social Exclusion, constitutes a “New Deal” for mental health, and whether it provides a perspective that will help mental health social work to define its distinctive contribution to integrated services.     

Long-Term Care Policy: Singapore’s Experience

Singapore, like many developed countries, is facing the challenge of a rapidly aging population and the increasing need to provide long-term care (LTC) services for elderly in the community. The Singapore government’s philosophy on care for the elderly is that the family should be the first line of support, and it has relied on voluntary welfare organizations (VWOs) or charities for the bulk of LTC service provision. For LTC financing, it has emphasized the principles of co-payment and targeting of state support to the low-income population through means-tested government subsidies. It has also instituted ElderShield, a national severe disability insurance scheme. This paper discusses some of the challenges facing LTC policy in Singapore, particularly the presence of perverse financial incentives for hospitalization, the pitfalls of over-reliance on VWOs, and the challenges facing informal family caregivers. It discusses the role of private LTC insurance in LTC financing, bearing in mind demand- and supply-side failures that have plagued the private LTC insurance market. It suggests the need for more standardized needs assessment and portable LTC benefits, with reference to the Japanese Long-Term Care Insurance program, and also discusses the need to provide more support to informal family caregivers.     

The Making of National Health Insurance in Britain and Canada: Institutional Analysis and its Limits

Scholars examining the development of health insurance reform programs from an institutionalist perspective have drawn attention to the importance of state structures and administrative capacities in shaping social policy outcomes. Focusing on the introduction of the British National Health Insurance Act of 1911 and the Canadian Hospital Insurance Act of 1957, I suggest that institutionalist analysis can obscure the historical record in three ways. Analysts may ignore the multiple institutional mechanisms that were available to policy makers at the time; they may overlook the contentiousness of policy battles; and they may underestimate the extent to which similar institutions have functioned in very different ways. In the case of Britain, I argue that national health insurance was part of a package of social reforms designed to halt the slide of Britain from a position of preeminence in the world economy. The introduction of Canadian health insurance coincided with an increased role for local and federal states in fostering economic development within the nation. Institutional structures, cultural values, and political power were all resources used within both states to create a consensus behind the new national agenda.     

Policy-Practice in Social Work: Models and Issues

Abstract

The emergence of policy—practice is a recent development in social work. In this article, policy—practice is defined as a direct social work practice mode with the potential to strengthen the social work profession's abilities to meet its century-long commitments of providing policy-informed services to those in need of them. At the same time, policy—practice advocates for and participates in policy implementation and change. This article examines policy—practice and places it within the context of the profession's historic cause—function debate and identifies several barriers that have complicated development. Most important, the article reviews five policy-practice models found in the literature: (1) social worker as policy expert, (2) social worker as change agent in external work environments, (3) social worker as change agent in internal work environments, (4) social worker as policy conduit, and (5) social worker as policy itself.     

Households’ precautionary behaviors—the effects of the introduction of National Health Insurance in Taiwan

By reducing risk of large out-of-pocket medical expenses, comprehensive social health insurance may reduce households’ motivation to engage in precautionary behaviors such as saving, procurement of private insurance, and spousal labor-force participation. We use the natural experiment provided by the 1995 introduction of National Health Insurance in Taiwan to examine these effects, using pre-existing differences in access to health insurance (tied to the household head’s and spouse’s joint employment status) to identify the effects of increasing insurance coverage. We find that comprehensive health insurance has a statistically significant and large effect on household savings, but no significant effects on purchase of private accident insurance and spousal employment.

Parallel Process Issues for Lesbian and Gay Adoptive Parents and Their Adopted Children

ABSTRACT

This article is a case study that examines the failures of the social welfare system in failing to prevent homelessness. This article chronicles one family's homeless experience and examines the social policies and programs that affected them. The authors make recommendations for further research and policy implementation for vulnerable populations.     

Does Health Insurance Premium Exemption Policy for Older People Increase Access to Health Care? Evidence from Ghana

Aging in Sub-Saharan Africa causes major challenges for policy makers in social protection. Our study focuses on Ghana, one of the few Sub-Saharan African countries that passed a National Policy on Aging in 2010. Ghana is also one of the first Sub-Saharan African countries that launched a National Health Insurance Scheme (NHIS; NHIS Act 650, 2003) with the aim to improve access to quality health care for all citizens, and as such can be considered as a means of poverty reduction. Our study assesses whether premium exemption policy under the NHIS that grants non-payments of annual health insurance premiums for older people increases access to health care. We assessed differences in enrollment coverage among four different age groups (18–49, 50–59, 60–69, and 70+). We found higher enrollment for the 70+ and 60–69 age groups. The likelihood of enrollment was 2.7 and 1.7 times higher for the 70+ and 60–69 age groups, respectively. Our results suggest the NHIS exemption policy increases insurance coverage of the aged and their utilization of health care services.     

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.     

Welfare and Welfare to Work in the United States

Summary

Despite social work's historic ambivalence toward income support programs, the policy changes introduced by the TANF welfare to work program demand the profession's attention. Although social workers are not directly responsible for the administration or implementation of the program, many serve TANF clients whose lives have been affected by these changes. Tracing social work's historic but reluctant involvement with income support, this paper urges the profession to respond to the challenges posed by the TANF program in a more systematic way and to contribute more effectively to the wider task of poverty eradication.     

Promotion of Sexual Health in the United States

Abstract

The United States has been experiencing a severe sexual health crisis in the last decade. This paper reviews these sexual health challenges and discusses a major initiative and a “Call to Action” that was launched by the U.S. Surgeon General in 2001 to promote sexual health. This led to several initiatives to overcome obstacles that were preventing the development of a sound, scientifically based public health policy to promote sexual health. This paper specifically outlines the components of the Sexual Health Program housed at the Morehouse School of Medicine's National Center for Primary Care, including the National Advisory Council and the National Consensus Process.     

Interpersonal Helping Skills,by Eldon K. Marshall,P. David Kurtz,and Associates. Jossey-Bass Publishers,San Francisco, 1982. $35.00. 682 Pp.

Abstract

Courses in international or comparative social welfare have many benefits, but require a framework for systematic comparisons between countries. This article presents an institutional political process model for studying social welfare policy comparatively. The principal elements of the model include each country's societal values, government institutions (operationalized as the role of interest groups), policy goals, and system implementation (type of welfare system). The model is demonstrated through a comparison of the dissimilar social welfare systems of Sweden and the U.S.