John C. CAMPBELL
TOWARDS AN INSURANCE FOR LONG-TERM CARE? WHAT THE FRENCH SHOULD LEARN FROM THE JAPANESE, THE GERMAN, AND (A LITTLE LESS) FROM THE AMERICAN
John C. CAMPBELL (University of Michigan and The University of Tokyo)
Long-term care for frail older people is an increasingly significant policy issue in all advanced nations. Everywhere the number of old people who need assistance is increasingly rapidly, while social changes have decreased the ability of families to provide care on their own. France already has a comprehensive long-term care system, and it is currently thinking about expanding it to make this policy the fifth official risk for the social security system, along with pensions, unemployment, health and family policy.
Japan is the most interesting case for long-term care because it is the oldest country in the world, and a decade ago it initiated a large-scale program. Germany, which is the second-oldest country, also has an important program on a somewhat smaller scale. Both can provide potential lessons, and in a negative sense so can the United States.
That is, in this area as in so many others, it is the US that is the odd man out. France, Germany, and Japan have all installed large-scale, systematic programs based wholly or in part on mandatory social insurance, in which younger people and older people all pay premiums and/or taxes, and older people with physical or cognitive disabilities are eligible for benefits regardless of income or family situation. Most of those assisted live at home rather than in an institution, In the US, public benefits are restricted to low-income people and mostly pay for nursing home care; middle class people must fend for themselves (at least until they become poor due to the high costs).
This year, as part of President Obama’s health care reform, the US decided to try a new program of long-term care insurance that is run by the government but is voluntary, called the CLASS program (it stands for Community Living Assistance Services and Support though it offers a cash benefit). Many experts are doubtful that enough people will sign up to make the program workable, but in any case we can hope that it is a first step for the US.
Second, while the other three countries all cover older people in nursing homes in similar ways, France and Germany on the one hand and Japan on the other hand have taken a fundamentally different approach in care for older people who live in the community. France and Germany offer both formal services, such as home helpers, and cash allowances that can be used to recognize and encourage caregiving by family members. Japan offers only formal services, not cash. It is not that it does not wish to support family caregivers—on the contrary, providing relief for heavily burdened spouses and children was one of the main goals of the program. But the choice of methods is different.
That is, many Japanese believe that the key problem for family caregivers is the physical burden and emotional strain of the work. Simply giving them money does not solve this problem; some may use it to hire some untrained person to help, but for the most part the wife, daughter, or daughter-in-law continues to provide most of the care. The Japanese idea is that formal services will actually take on a share of the real work.
It is interesting that in Japan the service which is even more popular than home help is adult day-care. The frail older person comes by van to a center, where she engages in activities, has a meal and a bath, and interacts both with the professional staff and the other clients. Today 1.6 million people, or 6 percent of the age 65 population, use day care, usually 3-4 times a week. It makes a big difference in their lives and in the lives of their families. There is some day care in France and Germany but the numbers who use it are relatively low
Third, the countries that offer cash allowances, France and Germany, differ in how they do it. German older people who pass the eligibility screening can freely elect a cash allowance, which is about half the value they could get if they elected services, and they can freely decide how to use it. The authorities do not give them advice or ask about it, although they do come and check every six months. In France, a committee of experts devises a care plan of what services the client needs; she can then decide, for example, whether to employ a trained caregiver or pay a family member (though not a spouse) to provide care in their home. The client has to obtain receipts for any of these services.
The German and then the French system seem to offer the most choice to the older person, since they has the option of paying a family member. Japanese older people do not have that choice, although they can freely choose among different kinds of services, which are readily available almost everywhere in Japan, and they can also choose which agency will provide the services. They are assisted by a care manager, who gives them advice and oversees the services they get. If they do not like the service they are getting, or for that matter their care manager, they can terminate them and move on.
All three of these approaches are reasonable solutions for the problem of increasing numbers of frail older people and declining traditional supports. All three are universal, meaning that everyone is eligible, although in France the amount of the benefit is adjusted to income. All three recognize that the burdens of caregiving should be shared between the family and society at large—that is, the government—rather than left up to individuals and families except for poor people, as in the United States.
Of course all such programs are expensive, and difficult to maintain in times when public resources are short. However, the experiences of Germany and Japan indicate that costs can be controlled, and in fact the chaotic and largely private approach in the United States actually consumes more resources.
As to which of the three systems is preferable, it is partly a value choice. The Japanese approach does have many advantages. In a sense it is more efficient, because unlike cash, which everybody wants, people typically use services like home help and day care only to the extent they really need them—most Japanese actually use only about half of the services they could. And more importantly, the broad expansion of services has really made a difference in the lives of frail older people and their caregivers, and it well prepares Japan for the future when there will be still more old people, and less family support available.
In this era of intense fiscal constraints, a major expansion of long-term care programs is not likely in any of the developed nations, but the underlying problems will only intensify over time and demand attention from policy makers.
Tokyo, June 2010
John C. Campbell, Professeur émérite de l’université du Michigan, est actuellement chercheur invité à l’Institut de gérontologie de l’Université de Tokyo. Ses recherches portent sur les politiques publiques. Il travaille essentiellement sur le Japon, souvent dans une perspective comparative, ces derniers temps, principalement sur les politiques sociales, notamment le système de santé et le nouveau système d’assurance publique et obligatoire pour la dépendance.
Parmi ses nombreuses publications, on peut citer : How Policies Change: The Japanese Government and the Aging Society, Princeton, N.J.: Princeton University Press, 1992. Japanese edition, 1995; (avec Naoki Ikegami). “Long-Term-Care Insurance Comes to Japan.” Health Affairs 19:3 (May-June, 2000), 26-39.