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Two perspectives on a gray tomorrow

by Jeff Kingston

CARING FOR THE ELDERLY IN JAPAN AND THE U.S.: Practices and Policies, edited by Susan Orpett Long. Routledge: London, 2000. 358 pp., $100.

By the year 2025, some 26 percent of Japan’s population will be over 65 years old, meaning that society and families will need to cope with the various needs of 32 million aged people. Since I plan to join that group by then, it is encouraging that there are strong advocates of better preparation and improved care for the elderly and a government that appears willing to innovate and make this a priority in social policy.

This book presents an array of papers on a broad range of elderly-care issues ranging from government policies, cultural constraints and care provision to dealing with dementia on an individual level. One can only hope that the progressive perspectives espoused here are incorporated into formulating and implementing elderly-care initiatives over the coming decades.

The implementation of the Kaigo Hoken (Long Term Care Insurance Law, 1997) is welcomed by most of these contributors as a significant advance in the way Japan has approached the problems of dealing with elderly care. These papers were written before its implementation in April, 2000 and the postponement of premium collection forced by then Liberal Democratic Party executive Shizuka Kamei in late 1999. Here the new law is assessed in terms of its departure from previous government policies and its innovativeness on an international level. Rather than following the Scandinavian social-welfare model, the Kaigo Hoken scheme is more of a market-based social-insurance policy that minimizes bureaucratic interference and provides vouchers for the purchase of health-care-related services.

In contrast to a similar German plan implemented in 1994, the Japanese system has a much lower threshold for eligibility, higher allowances, less rigorous assessment and no cap on spending growth. Unlike the German plan, recipients receive no cash. Instead, they get vouchers that can be redeemed at approved care providers ranging from hospitals to nonprofit organizations. Kamei argued to no avail for a cash system that would effectively allow recipients to pay family members for services rendered. Various advisers to the Ministry of Health and Welfare lobbied against such a provision because it would merely perpetuate the shouldering of care-provision responsibilities by female members of the household.

Indeed, one of the goals of Kaigo Hoken is to relieve wives, daughters and daughters-in-law of this burden and to update government policies to take account of recent demographic and economic trends. The new law is a recognition that the family has been overburdened by the absence of government initiatives concerning elderly care and that it has also changed considerably in the postwar decades. In addition, too many women have been forced to sacrifice their careers and health to the rigors of elderly care because of the absence of support services. Belatedly, society has recognized the costs and folly of assuming that the family and its female members would naturally serve as the foundation of elderly care in a context of considerable transformation in the family and in women’s participation in the labor force.

The Kaigo Hoken program collects premiums from all Japanese people with incomes, after the age of 40, and in turn provides them with institutional or community-based long-term care in the event of an age-related disease or disability. This has removed the stigma of “social welfare” from those seeking to use the system. In addition, there will be less of an economic incentive than existed until 2000 to hospitalize elderly people (covered by health insurance) rather than placing them in nursing homes (rigorously screened with costs linked to income). This will hopefully rescue many old people from unnecessary levels of care in dismal hospital wards.

The rub is that poorly prepared local governments are implementing this system, costs will most likely vastly exceed projections and there may not be enough of the needed community-based services in certain areas because not all market opportunities will be exploited. This means that there will be a period of confusion and inadequate service that may rob the system of public confidence and near-certainty that premiums will rise sharply to meet the costs of a system lacking effective cost-control provisions.

Kiyoshi Adachi further complains that the Kaigo Hoken reflects the same pattern of exclusionary paternalism that is typical of central-government policymaking. It is telling that neither the Japanese people nor local government were systematically consulted in the drafting of the new law. Adachi favors a participatory welfare system that allows citizens to join in the planning and decision-making processes of policymaking.

In her introduction, Susan Orpett Long reflects on the political responses to social change, arguing that “the definition of aging as a social problem is thus not an objective crisis of demography, but a crisis in the significance of biological aging, family relationships, and relations between individuals and the state. In the past, families might be expected to incorporate multiple meanings of care, the physical and the interpersonal. Providing nursing care, giving financial support, and maintaining the social meaning of life of an old person converged historically in the family. As this has come to be challenged in government programs and private circumstances, some people have advocated a return to the era of family caregiving for the elderly. Yet to do so is to disregard the tremendous demographic and social changes that have led to more active and more independent lives for longer periods for many older adults, and to longer periods that the elderly live with debilitating diseases that leave them dependent on others.”

The unprecedented stress on families, and women in particular, related to long-term elderly care in both the United States and Japan reveals both differences and striking similarities in how people in both nations are coping. The popular image of Americans dumping their elderly into institutions is shown to be wide of the mark, while family-based care in Japan falls well short of the desired ideal. Culture plays a significant role in shaping elderly-care policies: For the Japanese, there is a strong preference for a predictable and secure system while Americans prefer flexibility and contingency planning. In Japan there is a tendency for sustained, reciprocal, intergenerational assistance, while in the United States children tend to help parents only after a crisis.

As for public-policy implications, Ruth Campbell and Berit Ingersoll-Dayton argue that “the more ‘crisis-oriented’ American experience has not produced a unified ground swell for a comprehensive national policy of relief for caregivers. In the U.S., the emphasis on the individual leads Americans to assume their situation is unique to their family, whereas in Japan the more institutionalized role of family care and the daughter-in-law’s responsibility, in particular, make it seem more like a societal problem.”

This excellent volume approaches this societal problem from various angles and points out the difficult choices that lie ahead for both nations and for all of us and our families. The authors deserve kudos for tackling such a complex issue with perspicacity and sympathy. Their book serves as a tribute to the Abe Fellowship Program and Center for Global Partnership that funded research and facilitated workshops leading to its publication.

One can only lament that it is priced for libraries.