Culture, No.10  Feb. 2, 2012


From benefits to rights

Photo : Ueno Chizuko

Ueno Chizuko

Japan has entered the period of a “super-aging society” the likes of which no country has ever experienced. As of 2010, Japan’s percentage of elderly (those aged 65 or above as a percentage of the total population) reached the world’s highest level of 23.1%, and is expected to exceed 27% in 2020.

The progress of population aging simultaneously gives rise to the challenge of nursing care. In fact, the number of people with conditions requiring long-term care (defined as “a condition assumed to require care on a continual and regular basis for all or part of basic movements in daily activities”) has been increasing in Japan, along with extended nursing care periods, higher degrees of needed care and increasing numbers of people with multiple physical or psychological conditions requiring long-term care or combinations of these requiring long-term care.

When the human body remains in one position over a long period, it develops what are called pressure ulcers, in which the skin becomes necrotic due to insufficient blood supply in the part of the body contacting the surface supporting the body. When the ulcer stage progresses and the tissue layers are severely damaged, even the bone can sometimes become exposed and protrude to the surface, causing the patient severe pain. Areas where pressure ulcers develop are also susceptible to infection-causing bacteria. Many patients have also died from infectious diseases, including pneumonia and tuberculosis. Until not so long ago, these were typical scenarios in Japanese nursing care.

However, the level of Japan’s nursing care has now advanced and there is an established aim of avoiding pressure ulcers. Great progress has taken place in measures for preventing aspiration pneumonia, and sanitation standards, nutrient levels and medical standards in Japan are extremely high. These are outcomes of the country’s sophisticated economic development since the end of World War II. Japan has realized a rare society in the world, where even those with severe physical or mental impairments and with conditions requiring long-term care can conduct their lives with attentive nursing care.

Two systems have underscored the realization of such a society.

One is the public pension system. For the elderly to receive nursing care, more than anything they need economic strength. While there are certainly defects in the system, including the problem of pension accounts disappearing, caused by the Ministry of Health, Labor and Welfare’s mismanagement of pension records, if these systems were not established, elderly people with no income would have no choice but to depend on their children to get by. This can be considered a reason why pensions have changed the relations between aging parents and their children.

The other system is long-term care insurance, put into effect in 2000 as a structure by which society as a whole supports those in need of long-term care. This can be seen as a system worthy of Japan boasting internationally.

Looking overseas, there are two types of long-term care systems. One is the method typically seen in Scandinavian countries by which taxpayer money provides all the funds necessary for nursing care. The other is Germany’s method, by which insurance premiums are collected from citizens. Though Japan is seen as copying the German method, this is actually not the case. Japan has adopted a proprietary compromise system in which it finances 50% of the cost of long-term care through tax money and the other 50% from insurance premiums.

Among all the strong points of Japan’s long-term care insurance system is that the upper usage amount limit is set far higher than in the German system. Another strength is its redistributive effect among regions with different population aging rates, which is enabled by the incorporation of tax money. A further advantage is that its adoption has led to achievement of a transformation of awareness among those in long-term care service.

Before this system was introduced, long-term care service was administered using tax money. Governmental bodies (municipal governments) also decided on the legality of usage of the service by potential users. Under such circumstances, there was a strong sense that receiving nursing care was an authority-issued benefit, while at the same time people receiving nursing care were attached a social stigma of being poor. For some time after the long-term care insurance system commenced, some users were even concerned about their reputation and disliked nursing care helpers parking their cars in front of their houses.

This mentality has, however, gradually subsided and been replaced by a buildup of a sense of entitlement in which people feel it is not bad to receive the service since they are paying the insurance premium. In time, it came to be taken for granted that those requiring long-term care could independently select and receive the types of service they need.

This system also produced significant economic benefits. Financial resources for the first fiscal year after the system’s enforcement were approximately 4 trillion yen, while it was said that the size of the market, including relevant peripheral industries, was around four times the amount of the financial resources for the system; i.e., a 16 trillion yen market was created. Amid the prolonged economic recession, this has generated excellent job opportunities, especially for middle-aged and older women thought to have trouble obtaining employment.

Moreover, nursing care had traditionally not been viewed as labor, but rather was something that women conducted at home for free; placing an immensely heavy burden on them. At the time the system went into force, one Liberal Democratic Party (LDP) politician said, “In Japan, we have a beautiful tradition among children of nursing their elderly parents.” Such comments reflected the opinions of those with no knowledge of the realities of nursing care.

The long-term care insurance system was not originally intended as a system for those receiving nursing care but rather for the purpose of mitigating the burden of those conducting it. In fact, the system has greatly alleviated the burden on nursing caregivers in middle-class families. For this reason, the system can be seen as advantageous for voters belonging to the generation more likely to nurse their elderly family members. From here forward, it is also necessary to remake this system from one for family nursing caregivers to one for the happiness of the elderly themselves.

The world notices the sustainability of Japan’s long-term care system

The aged population is expected to continue to grow in the future. In line with this, the number of those requiring long-term care will also increase, as will those who need higher levels of care. This will create greater need for long-term care, which in turn will necessitate larger social welfare costs.

However, politicians are unwilling to take steps to impose new burdens on the public. The Council on Fiscal and Economic Policy under the LDP administration was in fact oriented toward curbing social welfare costs. Long-term care insurance is revised once every three years, and with each past revision the system has become more difficult for the public to use.

For example, restrictions are imposed on the use of services available. In compliance with the rule that people other than the service user are not entitled to receive services, clothes of family members living with a user may not be put in the washer together with those of the user. When food is being prepared for a user, food for family members living with the user may not be prepared together. The numbers of such restrictions have been increasing in long-term care insurance. If the size of the financial resources does not change with the growing needs, services will naturally become inadequate at meeting such needs. I am deeply concerned about the possibility of this “hollowing out” of the system progressing in the future.

Another problem is that working conditions in the field of nursing care have not improved. Those engaging in the long-term care business at long-term care facilities work under harsh conditions, including night shifts once every three days. It is not uncommon for their after-tax monthly salary to be below 200,000 yen. Such workers are unable to develop their own future prospects and scores of them continually leave the profession. In fiscal 2010, their turnover continued to rise, to almost 20%.

Many of the welfare vocational schools established in series in the early 2000s are under-enrolled. It is said that this is not because the number of young people seeking to engage in the long-term care business is decreasing, but because their parents are opposed to it since they feel there is no future in such professions. This translates to a pervasive contempt for the care giving profession in society.

In the future, we will have to serve growing needs of the elderly and at the same time improve working conditions in the field of long-term care as well as social recognition of the field. To do this, it is obviously considered essential to increase the number of financial resources for long-term care benefit expenses.

There are two ways to expand these financial resources. One is to increase the aggregate amount of insurance premiums. To achieve this, it may be possible to raise premiums currently imposed on people aged 40 or over or to lower the eligible age for the insured.

The other way to adjust long-term care insurance’s finances is to increase the amount of input from taxes, in which case allocation from national finances to long-term care benefit expenses may be possible. However, this may be difficult considering the already overstrained finances in all areas. With this in mind, another option is to raise taxes.

Japan’s national burden ratio, which is the ratio combining the tax burden and social security burden ratios, is substantially lower than that of other Organisation for Economic Co-operation and Development (OECD) member countries. With respect to consumption tax in particular, some European countries have rates around 20%. In light of this, I think there is sufficient room to raise tax rates in Japan.

Looking at many of the opinion polls conducted on the Japanese public, approximately 60% of respondents feel they would be content with a higher burden if it were for realizing a more secure society. This shows that the social consensus for raising taxes has already been obtained, but there is a problem with an unreliable government in its use of collected tax money. The government should put forth a sincere response to this reality, prepare funds to finance the cost of providing sufficient service and supporting better working conditions, and consolidate sustainable systems as soon as possible.

At the present, we tend to look at advanced nations when we think of aging populations. In fact, East Asian countries, including China and South Korea, are faced with graver situations. China’s pace of population aging exceeds that of Japan as a result of its government’s “one child” policy. Chinese are therefore now attentively watching how the situation will unfold for Japan’s long-term care insurance system. Japan currently has an international mission to make this excellent system sustainable.

Living in the “post-family era”

Not only the system but also the societal system itself needs to be reviewed.

People develop greater individual differences as they grow older, which is manifested in the body and mind as well as in family structure and social status. While respecting the individual rights of children is often advocated in the field of education, it is the elderly who, in my view, actually claim their individual autonomy.

If we think in that way, screening the elderly based on their age is mere nonsense. I believe we need to build a mechanism that enables people who have come to need long-term care to receive sufficient welfare services regardless of their age, and at the same time allow those who are healthy to have opportunities to work, also regardless of their age.

However, unless a fundamental change is made to the societal structure in Japan that encompasses, among other things, lifetime employment and the seniority system in which age correlates to job position, the possibility of the elderly becoming part of the workforce will not increase. With the enactment in Japan of the Equal Employment Opportunity Act in 1986, gender discrimination in employment was supposedly eliminated. In the same manner, an “age discrimination act” needs to be created to eliminate age restrictions during recruitment.

Keiko Higuchi, representative of the Women’s Association for a Better-Aging Society, once said that human beings now have a lifespan of 100 years. From the present age onward is an era in which people will live actively until around age 70-80.

If that is true, people should be allowed to make a fresh start several times in their lives. In 2006, Prime Minister Abe Shinzo launched a “re-challenge society” initiative aimed at helping youth who to obtain secure jobs, or the unemployed, to have another try. That is exactly what is hoped for.

Though annuities are a support to senior citizens, they are not enough. For that reason, I would like to recommend that they make a living through “multiple incomes” in which small amounts of earnings are accumulated.

For example, they may choose to work as a nursing care helper for three days a week, teach haiku at a culture school once a week and sometimes take part in for-profit volunteer activities. To enable such a lifestyle, I hope we can realize a society where anyone with incentive and ability can freely be employed regardless of age or gender.

Finally, I think that another way of referring to the “super-aging society” may be the “post-family era.” Until now, spending old age within a family has been an ideal happy life. However, with such advancement of longevity, separation from spouse by death or divorce may be unavoidable, while children live on their own, away from their parents. Many people have the misfortune to spend the rest of their lives as single people. The reason why my book titled Alone In Your Old Age (in Japanese; Houken Corp., 2007) became a bestseller was probably because many people recognized that living one’s old age alone can happen to anyone.

It is simply an illusion to think that people can spend their life with their family even when they are in their 80s or 90s. The people who will support our older years will then be our friends and acquaintances as well as reliable nursing caregivers. Viewed in this light, Japan’s long-term care insurance system will become a savior for the elderly that allows them to spend their older years at an enriched level.

Translated from “Kaigohoken-seido wa cho-koreishakai no kyuseishu (Japan’s Long-term Care Insurance System is a Savior in the Super-aging Society),” Voice, January 2012, pp. 80-84. (Courtesy of PHP Kenkyusho)