Japan's financing system 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.     

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.     

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.     

Mental health and the aging: A review of the literature for clinical social workers

This article is a review of the literature on recent trends in mental health services to the elderly. The focus is on clinical services to elderly living outside of mental hospitals but includes services to residents of community nursing homes and homes for the aged. It is concluded that there is currently a non-system of services failing to meet present mental health needs. Current restrictive government reimbursement policies and national health insurance proposals are focused on treatment for acute episodic illness. This orientation does not permit a broader preventive perspective or a comprehensive mental health care approach.     

The importance of employer sponsorship in the long-term care insurance market

Medicare and Medicaid are major sources of long-term care payments and thus will bear much of the burden from the growth in long-term care service use. The large future demand for long-term care services is of great concern among policymakers due to its expense and the use of public program dollars. It is argued that the individual purchase of long-term care insurance can help alleviate the increasing financial pressure on public programs responsible for the majority of longterm care financing. However, consumers have shown little interest in insuring against the high costs of long-term care. This analysis examines the effect of several factors on the decision to purchase a long-term care insurance policy: knowledge and attitudes of long-term care insurance and the long-term care financing system, the perceived risk for longterm care, financial planning behavior, and the availability of long-term care insurance. The interim results indicate the factor most likely to affect the decision to purchase long-term care insurance is access to employer-sponsored long-term care insurance. This suggests tht the availability of affordable and high quality coverage is more important than demand-side factors such as awareness of long-term care insurance and a perceived greater risk for long-term care.     

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.     

Physician case-by-case assignment and participation in Medicare

The prospect of budget cuts in Medicare is likely to result in less generous reimbursements from Medicare and thus affects physicians' willingness to accept Medicare patients with the reduced payments. This study examines physicians' decisions about case-by-case assignment and participation in Medicare in relation to Medicare reimbursement generosity. A two-part model is applied to a database from a national survey of physicians. The results indicate that reimbursement generosity from private insurance relative to that from Medicare negatively affects physicians' assignment rates, implying that the elderly's access to health care and/or the financial burden is likely to be jeopardized by further reductions in Medicare reimbursements.     

Domesticating insurance,financializing family lives: the case of private health insurance for children in Finland

This article explores the domestication of a financial instrument that is much used in contemporary Finland, but that most of its users do not primarily think about in terms of being a financial instrument: the private health insurance for children. In Finland, all children are covered by social insurance and are entitled to free public health service with very low costs, if any. Yet, some 40 percent of families want to supplement this service with private products. Many fear that the popularity of the private health insurance for children contributes to a vicious circle that ends up weakening the legitimacy of, and the service given by, the public health sector; inequality in the face of health risks threatens to be aggravated, as well. Therefore, this financial instrument has become an object of political controversy. The main question of the article is: how do economic, political and moral valuations become intertwined in the domestication of insurance? The concept of ‘domestication’ is found helpful for analysing the pragmatics of valuation and for appreciating the dynamics and the heterogeneity of forces at play when financialization influences everyday life. The study argues that when financial instruments are appropriated they are also transformed; thus, they should not be viewed as homogeneous tools that have similar effects in all contexts of use. The main empirical materials studied are interviews with families with and without private health insurance policies for their children.     

Medical Utilization and Health Expenditure of the Elderly in Taiwan

The present analysis, based upon data from the 1989 Taiwan Labor Force Survey, includes two parts. First, the determinants of physician visits and hospitalization by the elderly are analyzed according to the behavioral systems approach, and, second, variation in health expenditures among the elderly are examined using the Tobit model with sample selection. Findings show that elderly with good or poor health conditions are less likely to use medical services than the frail elderly and that married elders are less likely than the non-married to use medical care. The higher the educational level, the lower the probability of using formal medical services, and elderly who have health insurance are more likely to use formal health care than those who have no health insurance. The elderly who live with their children are less likely to use formal medical services than those who do not live with their children. Finally, among the elderly who have used formal health care, individual health expenditures are influenced primarily by three factors: health condition, health insurance, and residential location. Implications for Taiwan's relatively newly established national health insurance program (effective April 1, 1995) are discussed based upon the findings of this research.     

Protecting the economic health of the poor in India: Are health mutuals the right medicine?

In addition to government‐sponsored health insurance schemes (GSHIS), many microfinance institutions (MFIs) and community‐based organizations (CBOs) in India have started microinsurance health insurance schemes. These include health mutuals for the benefit of their members. This article explores these as an alternative health‐financing model in India. A literature search produced 926 relevant publications. After applying advanced search options and removing duplicates, abstracts of 324 papers were read and then 47 papers reviewed, and finally 29 were included in this review. Five key themes emerged: (1) “Health for all” arguments and opportunities in favour of micro health insurance schemes; (2) micro health insurance products; (3) impact of micro health insurance schemes; (4) systematic irregularities and regulatory framework; and (5) innovation. We also look at the emerging market patterns that will define micro health insurance products. Health mutuals can effectively provide mass health protection to the poor and not so poor through efficient business models, bespoke benefit packages and multiple payment plans. They can reduce financial vulnerability and improve health outcomes. While GSHIS can cover a substantial tranche of expected health‐related costs, the balance can be supplemented through innovative financial products that reduce financial risk.     

Financing Reform for Long-Term Care

The way the nation provides for the financing and delivery of long-term care is badly in need of reform. The principal options for change are private insurance, altering Medicaid, and 110 FROM NURSJNG HOMES TO HOME CARE public long-term care insurance. This article uses the Brookings-ICE Long-Term Care Financing Model to evaluate each of these options in terms of affordability, distribution of benefits, and ability to reduce catastrophic out-of-pocket costs. So long as private insurance is aimed at the elderly, its market penetration and ability to finance long-term care will remain scverely limited. Affordability is a major problem. Selling to younger persons could solve the affordability problem, but marketing is extremely difficult. Liberalizing Medicaid could help solve the problems of long-term care, but there is little public support for means-tested programs. Finally, universalistic public insurance programs do well in meeting the goals of longterm care reform, but all social insurance programs are expensive and seem politically infeasible in the current political environment. The way the nation provides for the financing and delivery of long-term care is badly in need of reform. No other part of the health care system generates as much passionate discontent as does long-term care. At the heart of the problem is the absence of any satisfactory way to help people anticipate and pay for long-term care. The disabled elderly find, often to their surprise, that the costs of nursing home and home care are not covered to any significant extent by Medicare or private insurance. Instead, they must rely on their own savings or, failing that, turn to welfare in the form of Medicaid. At a national average cost of $40,000 a year for nursing home care, long-term care is a leading cause of catastrophic out-of-pocket health care costs for the elderly. In addition, despite the strong preferences of the disabled for home and community-based services, current financing is highly skewed toward care in nursing homes. While the debate over long-term care reform has many facets, it is primarily an argument over the relative merits of private- versus publicsector approaches. Differences over how much emphasis to put on each sector partly depend on values that cannot be directly proved or disproved. Some believe that the primary responsibility for care of the elderly belongs with individuals and their families, and that government should act only as a payer of last resort for those unable to provide for themselves. The opposite view is that the government should take the lead in ensuring comprehensive care for all disabled older people, regardless of financial need, by providing comprehensive, compulsory social insurance. In this view, there is little or no role for the private sector. Between these polar positions, many combinations of public and private responsibility are possible.     

Depression screening,education, and treatment at the workplace: A pilot study utilizing the CDC Health Scorecard

Depression is a significant health issue for many Americans, ranking among the top worksite issues resulting in referrals to Employee Assistance Programs (EAPs) with prevalence rates in the working population of more than 6%. This study was part of a larger statewide assessment conducted using the Centers for Disease Control and Prevention (CDC) Worksite Health Scorecard. The purpose of this study is to examine the number of Kentucky workplaces currently offering screening, education, and treatment related to depression. The study also aims to compare the number of Kentucky workplaces offering these elements by size and industry type. The one-time, cross-sectional assessment surveyed a random sample of 1,200 worksites to examine worksite offerings of screening, education, counseling, management training, and health insurance coverage related to depression. Results showed that the majority of worksites do not provide employee depression screening, education and counseling, management training on identifying warning signs of depression, or comprehensive treatment and follow-up for employees with depression. Smaller worksites (<250 employees) were even less likely than larger companies to provide screening, education, counseling, training, and insurance coverage for depression. Increasing the provision of these wellness components at the worksite has potential to improve the quality of life for employees and reduce the financial burden to employers.     

Mortgage and Lending Instruments Designed for the Elderly

This paper explores the elderly homeowner's need for maintenance/rehabilitation-of-dwelling loans and outlines potential mortgage instruments for which the elderly might qualify in order to obtain modest, modern homes. A delineation of lifestyle, income and psychological factors contributive to the housing-inadequacy of the nondestitute elderly, is presented. This is followed by a discussion of location change stimulated either by housing-dissatisfaction or a desire for family closeness and the resultant financial burden of mortgage payments, taxes, utilities, and assessments. The final section presents mortgage plans available through HUD to address the problems presented and recommendations concerning mortgage plan policy. Key concepts: -Mortgage -Elderly Homeowner -Reverse Annuity Mortgage -Housing-inadequacy -Housing-dissatisfaction -Adult Child Elderly Parent Interaction     

Expanding the focus of health insurance education for Medicare beneficiaries

Health insurance education plays an important role in helping consumers make informed decisions about their need for supplemental coverage. This article reviews findings on the knowledge of Medicare beneficiaries about their health insurance coverage. Then, current health insurance education programs are examined with regard to their ability to meet the needs of a competition-based public policy. Barriers outside the control of individuals that impede the growth of the long-term care insurance market are identified and the need for an alternative, broader form of health insurance education is suggested. Changes in the scope and content of health insurance education are proposed that would educate the elderly to their own needs as well as the larger policy issues. An expanded model of education based on the concept of the Swedish study circle is discussed to illustrate the possibility of combining individual knowledge and public debate about complex social issues.     

Understanding the diverse needs of the Medicare population: implications for Medicare reform

Meeting the health care needs of millions of elderly and disabled Americans is central to the debate over Medicare's future. Using data from a nationally representative survey of 3,309 beneficiaries, Medicare's most vulnerable beneficiaries were profiled, examining variations in coverage, satisfaction, access, and financial difficulties. A substantial portion of the Medicare population--two thirds--were found to have health problems or low incomes. The analysis found that about 40% of beneficiaries with incomes below the poverty level, in fair or poor health, or with ADL limitations, have difficulties paying their medical bills or getting needed health care. Medicare's disabled, under-65 beneficiaries are at even higher risk: nearly half (47%) have health care access problems or deal with financial hardship due to medical bills. The diverse needs and experiences of the Medicare population are underscored, providing new insights into the challenge of maintaining or improving protection for those with greatest need while assuring the long-term fiscal viability of the program.     

Expanding the Focus of Health Insurance Education for Medicare Beneficiaries

Health insurance education plays an important role in helping consumers make informed decisions about their need for supplemental coverage. This article reviews findings on the knowledge of Medicare beneficiaries about their health insurance coverage. Then, current health insurance education programs are examined with regard to their ability to meet the needs of a competition-based public policy. Barriers outside the control of individuals that impede the growth of the long-term care insurance market are identified and the need for an alternative, broader form of health insurance education is suggested. Changes in the scope and content of health insurance education are proposed that would educate the elderly to their own needs as well as the larger policy issues. An expanded model of education based on the concept of the Swedish study circle is discussed to illustrate the possibility of combining individual knowledge and public debate about complex social issues.     

Using the Medicare buy-in program to estimate the effect of Medicaid on SSI participation

This article assesses the importance of receiving supplemental health insurance on participation in Supplemental Security Income (SSI) for the elderly. The implementation of the Qualified Medicare Beneficiary (QMB) program offered a substitute for Medicaid, and expanded health insurance eligibility to a higher income level. Using a sample of elderly respondents aged 66 to 75, I find that the QMB program reduced SSI participation. More than half of the QMB participants were previously covered by SSI and Medicaid. The calculations suggest that the QMB program was not as expensive as it might first appear because of reductions in SSI expenditure.     

The Relationship Between Life Satisfaction Among Wives and Financial Preparedness of Households in Japan

The wealth gap between the rich and poor is widening and contributing to Japan’s shrinking middle class. This study examined concerns about the future and life satisfaction and their association with household financial preparedness (e.g., savings, investments, life insurance) among married women in Japan. Double-hurdle models assessed the probability of having savings and the amount of these savings, using the sample from the 2006 Japanese Panel Survey of Consumers (n = 1,206). Supporting earlier works from several other countries, concerns about the future were positively associated with the probability of having supplemental life insurance. Moreover, life satisfaction levels were positively associated with the probabilities of having savings, investments, and supplemental life insurance and with the amount of the investments. The findings suggest economic inequalities among women could widen in the future, as those who have and are expecting to have more financial resources are more likely to be prepared for future financial needs than those who do not.     

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.