Learning from a Different Culture

Change in Population Make-up of Japan

[Editor's Note: All charts referenced in this article are available in the print edition of STRIDE.]

Chart A shows the population of Japan in 1997 (actual figures) and in 2025 (a projection). In the 1997 line graphs, both for males and females, there are big dips for the 31-year olds indicating that fewer babies were born 31 years before. It may be interesting for Canadian people to know that this phenomenon is said to have resulted from an old Japanese superstition that those who are born in the Hinoe-uma unlucky years that come around every 60 years, live an unhappy life. Chart B is a projected population composition of the province of Ontario.

As is indicated in the chart, Japan will have a rapidly aging society in the years to come, to an extent that no other country has ever experienced. Therefore, the provision of some form of long-term care (LTC) is urgently needed, either by medical or care facilities or by home nursing. There is one thing that should be taken into account when thinking of nursing care in Japan. Unlike Canada, Japan has no employment system to use immigrants as care workers. The Japanese experts and scholars in the field have long advocated the introduction of such a system to Japan, but it has never been realized and will require many more years before it happens.

The Canadian experts may point out a defect in the immigrant employment system: that the foreign workers themselves get older and may contribute to the problem. It may be true but according to projections based on the present population make-up of Japan, its total population will be reduced by as much as 20% in the near future, after reaching its peak in two or three years. It is clear from Chart A that the biggest problem Japan will face is a shortage of manpower to take care of its elderly people. Therefore, population increase is the top priority for Japan. Of course this is a projection and we can't completely deny the possibility that Japan might have another big baby boom or establish an immigrant employment system rather soon as the experts advocate. However chances are slim and as far as we see the present population composition, Japan's population structure is unfavourably skewed at this time. Inevitably, providing proper LTC for the elderly is very important and the establishment of an immigrant employment system should accompany to achieve the goal.

Japanese LTC Provided by Hospitals

Chart C shows the ratio of hospital beds available per 1,000 population in Japan. (Source: the Health and Welfare Ministry, Japan) It clearly shows that there is enormous number of hospital beds in Japan. Canadian people will be surprised to know that these figures include mental hospital beds, at the rate of three beds per 1,000 people (based on population).

Meanwhile, the number of beds available at nursing homes was 437,985 as of October, 1999. Also at intermediate care facilities positioned between hospitals and nursing homes, 223,498 beds were available as of March, 2000.

The burden of hospitals to assume LTC has been reduced to some extent, after the introduction of the intermediate care facilities. Still, there were as many as 250,000 hospital beds used as LTC beds as of 2000. In terms of the hospital number, hospitals having such beds amount to about 2,500, one fourth of the total number of hospitals. In a nutshell, a large part of long-term care is provided by hospitals. Costs of services provided by hospitals are covered by medical insurance. Half of the premiums are assumed by companies and the other half by employees. Of an employee's monthly salary, 8.5% to 9.6% goes to the payment of these insurance premiums.

New System Adopted in Japan

Japan introduced the Nursing Care Insurance Scheme for the Elderly in April, 2000, in an attempt to redress the distorted Japanese practice of elderly care costs being covered by medical insurance. This system, proposed by the government and a committee composed of academics and experts, is aimed at elderly people who don't need to be hospitalized but rather need to be in a nursing home or receive home care. With this system, a correction hopefully is being made to the long-term care system in Japan. The LTC expenditures are now covered by nursing care insurance, which is a departure from the past practice of being covered by medical insurance.

This nursing care insurance scheme may be useful in Canada. Under the new system, costs of nursing care provided for elderly people at a hospital are covered by the social insurance system. So also are nursing home costs incurred, and fees paid to receive home nursing and household chore services. A care assessment system has also been set up to assess the degree of necessary public nursing care to be provided. In addition, the problem of “wealthy elderly people”, who earn more than a certain amount of income but were exempted from paying medical bills, has been corrected. Under the new system, they have to pay 10 percent of the bills.

Chart D shows the breakdown of the financial sources that support the nursing care insurance system. Of the total fund, 50 % is borne by taxes, including state, city or town taxes, 33 % is borne by premiums paid by the people of age 40 to 64, and 17% by those 65 years old and over. It should be noted that these figures do not represent the ratios of money one has to pay after receiving care, but rather those of insurance premiums paid to maintain the system.

As already mentioned, Japanese hospitals have assumed a large part of the responsibility of providing long-term care, partly because there were not a sufficient number of elderly care facilities, such as nursing homes and retirement apartment complexes as are available in Canada, to provide nursing care and a living space for them. Under these circumstances, nursing care expenditures have been covered by medical insurance. Some estimate says that costs for end-of-life care for the elderly account for 7.5% of the total expenditures incurred to accommodate patients in hospitals. (Source: Iryo Keizai Kenkyu Kiko, Medical Economics Research Center)

Thus, medical expenditures for elderly people have soared and so has the financial burden paid by taxpayers and companies, as is shown in Chart E. This is not a desirable situation for either taxpayers or companies. Obviously Japan can no longer afford to sustain the present system or to continue paying the rapidly growing medical bills for elderly people.

Universal Problem

With the aging of society, who is to assume the burden of increasing LTC costs is a very serious issue for both Canada and Japan. We must come up with fair and appropriate ways to share the burden. In that pursuit, the studies in Canada by Japanese experts needs to continue, as the use of what has been learned to date has materialized in the introduction of a number of new systems in Japan.

At the same time, the exchange of information and visits can also attune Canadian long term care professionals to some of the new solutions being developed and applied to the Japanese long-term care system.