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To contribute to the Italian debate on Long-term care, Percorsi di secondo welfare (Laboratory of the University of Milan) is consulting various international experts of this theme. At the moment, we interviewed Paula Blomqvist (University of Uppsala) on the situation in Sweden, and Heinz Rothgang (University of Bremen) about Germany. Now we asked Rie Miyazaki, Professor of Social Policy Studies at Ohtsuki City College in Japan, to answer key questions about Long-term Care in Japan, with reference to the Covid-19 crisis and its consequences.
The Long-term Care system in Japan
In Japan’s Long Term Care system – every person aged 65 years or older and middle-aged persons (aged 40-64 years) with specified diseases – are eligible for benefits based strictly on physical and cognitive disability. Long Term Care Insurance is provided to insured persons certified for support or care requirements according to their care needs and certification assessment.
The insurance benefits included in-home services (e.g., home visits/day services and short-stay services/care) andservices at facilities, including long-term care welfare facilities (also called special nursing homes), long-term care health facilities (also called geriatric health services facilities), and long-term care medical facilities (medical long-term care sanatoriums) without cash benefits or other direct benefits for family caregivers.
Dependent older adults can select and use provided facilities in-home, or community-based services according to their care needs. Care managers are actively involved in care plans and service arrangements. Individuals not eligible for long-term or support care may utilize preventive care services. Eligibility is assessed using a 74-item questionnaire based on activities of daily living, followed by a decision made by a long-term care approval board based on the initial computer decision, the home-visit report, and a medical doctor’s opinion. Seven levels of long-term care require certificates: support levels 1 and 2 and care needs levels 1 (least disabled) to 5 (most disabled).
The situation of ageing in Japan
The total population in Japan is 125,71 million people as of October 1, 2020. The population aged 65 and over is 36.19 million. The population aged 65 and over (percentage of the elderly) is 28.8%. By 2065, one in 2.6 people will be 65 and over, and one in 3.9 will be 75 years old and over. Aging is even evident among the labor force. As for employment rates by age group, rates in 2020 for ages 60–64, 65–69, and 70–74 have increased to 13.9 points, 13.2 points, and 10.5 points, respectively, compared to 2010, ten years ago 1. Regarding employment, around 30% of Japanese aged 60 and over responded “The number of days and hours I work has declined” due to the Covid-19 pandemic. While it is expected that the aging of Japanese society will continue, there is a requirement to provide employment opportunities addressing a wide range of needs among the elderly in Japan, and for initiatives enabling continuous employment while proceeding with Covid-19 prevention measures such as further promotion of smart working.
Japan is a super-aged society. According to OECD (2020), super-aged society refers to a society where more than 20% of their total population is 65 years or more. Italy – as Japan – is thus classified as a super-aged society (the ratio is 23.1%). It implies that aging is not only an immediate personal issue but also a salient factor in crucial public policies, such as pensions, health, and long-term care.
What is, in Japan, a potential explanation of a “super-aged society”? Some authors claimed the “working culture” – a deterioration of employment opportunities for young men. Thus, the consequences of the country’s aging and shrinking population include economic crisis, budgetary challenges, pressure on job markets, and depopulation of rural areas. According to Professor Miyazaki, “Japan has the highest aging rate in the world. Compared to the case in Italy, I think it might be less perceived among Japanese nationals. In Japan, the main family caregivers are the spouses of older frail adults rather than their working-age children. And working-age children quitting their job to care for their older parents rather than insufficiency of public LTC provision might be considered relevant social issues in Japan. The social issue above has repeatedly been perceived as public reports or white papers, but the strong countermeasures have not been conducted”.
Moreover, the connection with age, labor market, and technology also resides in investment in the silver economy. The silver economy is meanwhile flourishing, and Japan is at the forefront of robot development to face a declining labor force and to take care of its elderly. Moreover, the government’s efforts to address the demographic crisis have yet to succeed, and immigration has been limited. Tokyo is engaged in global health cooperation and succeeded in incorporating the concept of human security into sustainable development goals. It has also been active in international cooperation on ageing, with a focus on the Association of Southeast Asian Nations (ASEAN) region. A central, and most relevant, idea is the one of “age-tech”: technology making comfortable longevity accessible to all.
The Covid-19 pandemic: new policy trajectories?
As Professor Miyazaki declares, “Long Term Care in Japan suffers from insufficient LTC provision, both in public and private sectors”. Despite this, in Miyazaki’s words, “Japan’s LTC system has at least two main strengths. First, there is a National LTC Insurance system. Second, the citizens aged 40 overpay premiums based on the ability to pay principle and can receive LTC service in-kind, paying mostly 10% of their costs.” He also adds, “For Covid-19, not the public policy but the efforts of each LTC provider have been required. No major shift in LTC policy for Covid-19 has been identified. Since 2017, some policy changes for migrant LTC workers have been implemented, due to Japan’s scarce LTC labor force”.
Recently, a BBC newspaper recited, “low immunity against Covid-19 and a growing population of frail elderly is driving a surge in coronavirus deaths in Japan which had, for a long time, upheld some of the strictest pandemic restrictions”. Japan’s Long-term care insurance law has shifted to a more population-centric approach. Implementing “Kayoi-no-ba” group activities has been valued in Japan as a disability prevention initiative.
Among the most recent initiatives, the Kihon Checklist – a 25-item questionnaire – has been broadly used by health experts and researchers to assess frailty in Japan. A new 15-item questionnaire has been developed to identify frailty and other health-related problems in older people of 75 years and above. This will provide the necessary support to frail individuals at any healthcare facility in local communities. The increase in frailty prevalence in older people has been a concern during the Covid-19 pandemic. Home-based physical exercise programs are expected to be effective in frailty prevention. The utilization of information and communication technologies, social network services, and video calls has attracted attention to effective tools to facilitate communication for older people during the pandemic.
Suggested readings
Cabinet Office (2021), Annual Report on the Ageing Society, Summary, FY2021.
Miyazaki, R. (2019), Migrant care workers and care-migration policies: a comparison between Italy and Japan, in “Asia Europe Journal”, vol. 17, pp. 161–177, https://doi.org/10.1007/s10308-018-0528-3.
Ng, K. (2023), Low immunity, overwhelmed hospitals fuel Covid-19 deaths in ageing Japan, BBC.
OECD (2020), Health at a Glance: Asia/Pacific 2020, Report, Paris.