Japan’s Long-Term Care Insurance Program as a Model for Middle-Income Nations
are preferable to institutional care for all but the most serious cases. But if institutional care comes to be seen as normal by the public and if an increasing number of public or quasi-public nursing homes—orworse still, hospital owners— band together to protect their interests politically, it will be difficult to change course and adopt more rational programs. Another case that is at present a worry in many nations is the importation of immigrants from less-developed nations to provide care, as is the case in Austria, Italy, Singapore, and so on. In most cases, these are untrained women, often with dubious immigration status, who live in the household to provide full-time care for a frail elder and cook and clean for the family as well. As their numbers grow, tricky problems emerge: quality of care, issues of fairness and exploitation, abuse on both sides, a stunting of the development of more professional long-term care, and demands for heavy and growing government subsidies of the practice. These problems are hard to deal with when a big constituency of families has a vested interest in the system. Some high-income nations have tried to regularize recruitment, training, and employment conditions of migrant caregivers, but without much success so far. Japan is unusual in the extent to which it relies on trained careworkers employed by agencies in providing long-term care. An advantage of early establishment of a formal long-term care system in middle-income nations is that training and certification programs can be built up gradually as demand expands. Initiating a Good Long-term Care System Is Good Politics and Good Economics It might be thought that there would not be much pressure for long-term care programs in nations with few frail older people needing care. However, the problem of caring for them is not a worry only for government. Even at an early stage in population aging, it is acutely felt by more and more ordinary citizens who are concerned about what will happen to their parents and ultimately themselves— some combination of leading a miserable life and imposing great burdens on family members. Virtually, everyone would welcome any help that a new program would provide. The earlier a long-term care system is started, the lower is the cost. When the number of qualifying older people is relatively low, and traditional family supports are still working fairly well, the demand for public programs will not be very high. Moreover, when no public services had previously been available, even modest benefits will be welcomed. The government can decide a decade or more later whether coverage or benefits should be upgraded. Initiating a Good Long-term Care System Is Good Public Policy Early adoption of long-term care makes sense from the government’s point of view for three reasons: • If care for frail older people—qualitatively different from other social problems—can be handled by a dedicated system, the health care system can focus on acute care and prevention, while other social programs can concenUniversal Health Coverage for Inclusive and Sustainable Development http://dx.doi.org/10.1596/978-1-4648-0408-3
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