Vol 378 September 24, 2011
2011; 378: 1183–92
September 1, 2011DOI:10.1016/S0140-6736(11)61176-8See
1094 and 1106See
DOI:10.1016/S0140-6736(11)61098-2This isthe fourth in a
of six papers about Japan’s universalhealth care at 50 years*Co-lead authors
Department of Health ServicesResearch, Graduate School of Human Care Sciences,University of Tsukuba, Ibaraki, Japan
(Prof N Tamiya MD,A Nishi MD)
; National Instituteof Population and SocialSecurity Research, Tokyo, Japan
(H Noguchi PhD)
Departmentof Society, HumanDevelopment, and Health
(A Nishi, Prof I Kawachi MD)
,and Department of GlobalHealth and Population
(Prof M R Reich PhD)
, HarvardSchool of Public Health,Boston, MA, USA; Departmentof Public Health, GraduateSchool of Medicine
,Department of Global HealthPolicy, Graduate School of
Japan: Universal Health Care at 50 years 4Population ageing and wellbeing: lessons from Japan’slong-term care insurance policy
Nanako Tamiya*, Haruko Noguchi*, Akihiro Nishi, Michael R Reich, Naoki Ikegami, Hideki Hashimoto, Kenji Shibuya, Ichiro Kawachi, John Creighton Campbell
Japan’s population is ageing rapidly because of long life expectancy and a low birth rate, while traditional supports for elderly people are eroding. In response, the Japanese Government initiated mandatory public long-term care insurance(LTCI) in 2000, to help older people to lead more independent lives and to relieve the burdens of family carers. LTCIoperates on social insurance principles, with beneﬁts provided irrespective of income or family situation; it is unusuallygenerous in terms of both coverage and beneﬁts. Only services are provided, not cash allowances, and recipients canchoose their services and providers. Analysis of national survey data before and after the programme started showsincreased use of formal care at lower cost to households, with mixed results for the wellbeing of carers. Challenges tothe success of the system include dissatisfaction with home-based care, provision of necessary support for family carers,and ﬁscal sustainability. Japan’s strategy for long-term care could oﬀer lessons for other nations.
Populations in developed countries are ageing rapidlyand Japan’s is ageing the quickest. In 1950, Japan had avery young population; in 1990, only about 12% of Japanese people were aged 65 years or older, which isabout the same as in the USA in 1990, and well below theUK and other developed nations.
However, the postwarbaby boom was followed by sharply decreasing birthrates, while life expectancy rose.
By 2010, the number of people aged 65 years and older had almost doubled from15 million to 29 million—23% of the population and thehighest proportion in the world.
The absolute number of older people will soon level oﬀ, at about 40 million, butthe number of younger people will continue to fallrapidly.
Accordingly, Japan’s population will have thelargest proportion of old people in the world in 2050,when 40% of its population will be over 65 years of age.
This demographic situation means that Japan’sexperiences so far and its prospects for the future holdimportant lessons for policy makers in other nations,since they will soon be facing similar situations.How do older people in Japan compare with those inother countries in terms of income, health, and livingarrangements? In a 2005 international survey
of peopleaged 60 years and older, 57% of Japanese people said theyhad no economic problems, compared with 36% in theUSA, 33% in Germany, and 18% in France. The averagedisposable household income of the 65 years and oldergroup in Japan is 86% of that of the 18–65 age group,compared with an Organisation for Economic and Co-operation and Development (OECD) average of 82%.
Japanese public pensions are somewhat lower than thosein many European countries, but the average income of Japanese older people is fairly high because many of them work—about 30% of men aged 65 years and older,compared with 22% in the USA (and even lower inEurope).
Moreover, many have large savings.
Thus,Japanese older people are well oﬀ on average, althoughincome inequality is high and a sizeable number(especially older single women) have to rely on publicassistance or support from relatives.
The same cross-national survey
reported that 85% of Japanese people aged 60 years and older had noimpediments in their daily life, compared with 65% orless of American, German, and French people. Althoughthis survey is based on subjective criteria, Japan doeshave the highest healthy life expectancy (HALE) at birth(73 years for men and 78 years for women).
Additionally,83% of Japanese women aged 65 years survive until80 years, 3% higher than in any other country (70% inthe USA and 72% in the UK).
This good health in olderpeople was accomplished despite Japan spending muchless than the USA and UK on medical care.
In 1960, more than 80% of people aged 65 years andolder were living with a child.
The last time that 70% of older people lived with a child in the USA was in 1860.
In the mid-1990s, the corresponding number for northernand western Europe was 15% of the 60 years and olderpopulation.
Living arrangements in Japan have changedsubstantially. In the 2010 census,
the proportion of older
Search strategy and selection criteria
We used quantitative and qualitative data from academic published work to review theeﬀect of the long-term care insurance system in Japan. We searched PubMed and Webof Science (Thomson Reuters)
for studies published between 1990 and 2011, with theterms “insurance, long-term care” or “health services for the aged” in combination with“Japan”. All the 193 publications in PubMed and 164 publications in Web of Science writtenin English were judged to be relevant to our report on the basis of the context of theirevaluation of the long-term care insurance system in Japan, and were reviewed. Otheracademic published work, grey literature, and book chapters for related information(eg, demography, public policies, and health-care ﬁnancing in Japan, and long-term caresituations in other countries) were included when relevant.