名古屋学芸大学健康 ･ 栄養研究所年報

創刊号

２００７年

《Review》

The long term care insurance system in Japan−Significance of nutritional preventive care−
Akihiro IGATA M.D.＊

Introduction
As a chief member of the council of the ministry of health, labor and welfare of Japanese government, I
have been deeply engaged in the institution and its revision of the long term care insurance in Japan, in 2000
and 2005 respectively. In this paper, its background, history and development, and revision, especially fromthe nutritional aspects, will be presented and discussed.

The institution of the long term care insurance in Japan 2000
Japan has become one of the countries with the longest life-expectancy in the world in a short period. As
the creation of the ideal longevity society is the biggest task of mankind, ever experienced, many advanced
countries have been focusing their efforts to create a new social system, suitable for the longevity society. To
this end, we were obliged to establish an ideal longevity society by ourselves.

The introduction of the new long term care insurance in 2000
The institution of this insurance system was one of these trials towards the ideal longevity society in future,to establish a system responding to the society’s major concern about care for aging, whereby citizens can beassured that they will receive suitable care and be supported by society as a whole. This insurance system wasenacted, toward the satisfactory service delivery for every elderly person.
As a new policy of Japan, it was undertaken to separate long term care from medical one, to establish awelfare system as a first step to device the structure of social security.

Structure of the long term care insurance system in JapanThe long term care insurance system in Japan is one of three major national programs for the elderly andaged people, along with the ones for pension, and for medical care. All Japanese citizens over the age of 40
should pay premiums.
Benefits can be paid to handicapped elderly people older than 65, and to special young people, who arehandicapped from those diseases, that closely relate to aging. Insurers shall be local municipalities. Sincemany systems in Japan had been controlled by Japanese central government, the new system is controlled by
local authorities.
＊ President; Nagoya University of Arts and Sciences

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Before its start, all social care services had been given by legal relief-measures to limited people. After
its institution, one became able to choose the services, as one’s right by paying premiums.
Now, each municipality must provide care- or support- requirement certification, based on the screening
judgment, through analysis by computer system. The benefits for the long term care service are classified assupport-required (preventive benefit), or care level from class 1 to 5, according to need for help.
This new system has many advantages, comparing with those in other countries.
The care or support in this system is not “relief to handicapped aged people”, but promote independence.
Thus, the concept of welfare was changed to “promotion of independence.” This new concept is definitely
written in article 1 of the long term care insurance act.
In general, the insurance system should be supported only by premiums of all users, similar to the one inGerman system. However, in the system in Japan, the half of total expense is supported by public fund (25%by the central government and another 25% by local municipalities.). On the contrary, total expense of longterm care is supported by public fund in many northern European countries. Therefore, our system has bothadvantages of the pure insurance system obviously in Germany and the one of northern European countries.
The users must pay one tenth of all benefits i.e. total expenses of given services. Since the start of the newsystem, the number of users had increased rapidly especially those requiring slight care or slight support, sothat the number of the users of support level and care level I became about double in 2005 within 5 years.
This rapid increase means its high reputation, but it also means drastic increase of the total expenses. In
fact the total expense grew from 3.6 in 2000 to 6.8 trillion yen in 2006.
Accordingly, a steep growth in premium will be expected in the current system in that the sustenance of
this system, has become an urgent issue to be solved. (Fig. 1)

Revision of the long term care insurance system in 2005
Japan has undertaken the first major revision of its long term care insurance system in 2005, based on theexperience of 5 years according to the legal obligation.
It should be stressed that this revision is
not an entire renewal of the law, but its naturaldevelopment and growth based on the successand excellent results of 5 years’ experience.
At the same time, it is also important that thefiscal sustenance of this system became anurgent problem, as this system is supported by
the insurance premiums and the public fund. If
the cost of the system continues to escalate atits current rate, the program would have to raise
its premiums or to raise the financial support
by the public fund in order to remain fiscallybalanced. For the latter, the possible procedures
are now discussed, to raise the consumption tax
as the exclusive financial source of this systemor to expand the premium-supporting people tothe younger generation, older than 30. Anyway,

Figure 1 Overview of the revision of the long-term care insurance
system66

The long term care insurance system in Japanthe sustenance of this system is now the most urgent problem to be solved.

The cardinal points of this revision 2005 were as follows:
1) Improvement of the regional care level.
With the establishment of “regional comprehensive support center” in every town and village with a populationof more than 20,000, where nurses, social workers and care-managers should cooperate as the cardinal staff topromote the regional care services in those regions, toward “aging in native places”.
2) Incorporation of the more preventive care as a major service component.
The physical exercise or training, nutritional care and oral care became to be enforced.
3) Intensifying the relation with other social insurance systems, such as medical insurance and public pension
scheme.
4) Averaging the expenses between institutional care and home care.
Now, the users have to pay the accommodation cost, including that of diet, so that the difference in both cares,
will be equalized.

Establishment of the new prevention benefits
The new preventive cares were introduced, so that people slightly requiring support or care, would notassume a condition requiring support or care, on the basis of their situations. In this revision, prevention ofbedridden state was the most urgent problem, so that the suitable physical exercise or training should be includedin the benefits. Those who are able to live in independence should continue to live without any support, so thatthe support should be limited to find the possible activities for them to help to live in independency.
Oral sanitary care is also an important benefit, for the prevention of aspiratory pneumonia, which is oneof the frequent cause of death of aged people. As the third point, the nutritional preventive care was introduced
to avoid mal-nutrition or to raise the low protein-level in blood of the aged people.

Nutritional aspects of the version 2005
As a cardinal benefit for preventive care, a new nutritional care was incorporated. This service is identicalwith that in the general health promotion projects for the elderly people.
Through many surveys, it became clear that the albumin level in blood of aged people was low in general.
The percentage of the elderly people with lower albumin level in blood, lower than 3.5gr./ dl was found to
be in about half of the ones both in institutional care and at home. The deficient nutritional conditions might
jeopardize the self independency with high quality of life.
In recent years, the dieticians were aware of the need and balance of food, to prevent the life-style-relateddiseases. For their prevention, some restrict ions on salt, total energies, fat or cholesterol intake etc wereadvised.
Now, among aged people, it became clear that some deficiency of nutrition prevails, both under institutionalcare and at home. This new data suggested that the insufficient food intake was more urgent in addition to itsbalance.
The low albumin level in blood is induced not only by deficient served food, but also by anorexia orby mal-absorption from the intestinal canal. Now, the dieticians should aware of all factors, except for the67

calories of served food. The nutritional care for aged people should prevent the life style-related diseases, andin addition, avoid the malnutrition.
Through the introduction of new preventive nutritional care in the long term care insurance system, theresponsibilities of the dieticians become more and more important, to avoid to have the orderly people fall inbedridden state.
Many dieticians had focused their efforts to offer the enough nutritional elements as the food. However,now, they must be aware, how much the elderly people can eat, and how much it can be absorbed, especiallyfor the aged people, The dieticians should face to these new problems.

Health Promotion Plan Japan 21
In accordance with the rapid increase of elderly and aged population in Japan, the health promotion
became one of the most urgent problems, to guarantee a healthy and happy aged society. Japanese government
proposed the Health Plan Japan 21 in 2000 for the subsequent 10 years
Thus Japanese government proposed it following the excellent example of American healthy people plan
1990.
This plan contains many items, with concrete quantitative goals to be achieved within 10 years. Someare for physical exercises, including walking, and sports, playing etc, for example, it is recommended to walk
additionally 1000 steps every day.
In nutritional aspect, some goals are proposed, to prevent the life-related diseases i.e. restrictions on salt
intake and fat-intake. The intake of vegetables is recommended to 350 gr/d.
Percentage of the people, who are aware of body weight control, is now 60%, which should be raised to90% after this plan. In addition, the percentage of people, who do not take breakfast, should be suppressed toless than 15%
The implementation of this reform package of the long term care insurance was carried on, based onthese backgrounds. Anyway, we must always be aware of the health promotion to create a happy and healthy
longevity society. Thus nutritional aspects should always be kept in mind in the long term care.

Conclusion
The long term care insurance system was introduced smoothly in 2000. It was the first step to create themost ideal longevity society by ourselves under the interest of the whole world.
The preventive nutritional care, incorporated in this system in its version 2005, is now under the socialconcern. It became important to be aware of mal-nutrition, in addition to the prevention of the life-relateddiseases.
The nutritional science in Japan had succeeded in the control of Beriberi with success. Next, it had succeeded to cope with the malnutrition after the end of the World War II. The dieticians in Japan became awareof the control of any life-style-related diseases. Now they have faced the new problems in the care of elderly
and aged people. The nutritional science became again the indispensable problems in the matured society.

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The long term care insurance system in Japan

References
1)

Long term care insurance system in Japan (Revision) 2005 : Ministry of Health Welfare and Labor

2)

IGATA A. Toward a society with maturity and harmony : Arch Gerontol Geriat 1994 ; 19 : 203-211

3)

IGATA A. Creation of the ideal society for long life : Some challenges in Japan. Geriatr Gerontol Int 2005 ; 5 : 229-233

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