Journal of the National Institute of Public Health 2010 Vol.59 No.4 p.372 −379

＜ Review ＞
The Current State and Future Development of the Long-term Care
Insurance System in Japan
Takako TSUTSUI
Department of Social Services, National Institute of Public Health
Abstract
The Long-term Care Insurance System (LTCIS), a societal system of mutual assistance for elderly care, was established inJapan in 2000 in response to the increasing number of elderly requiring care. In this system, each municipality acts as an insurerand calculates long-term care insurance premiums by investigating the number of elderly requiring care and the total cost ofservice. However, as the number of service users increases and that the number of younger insured decreases, the ﬁnancial
burden on municipalities and citizens, particularly on the younger generation, has increased dramatically. Therefore, the system
is currently being reformed in terms of optimization of beneﬁts, certiﬁcation, and care management; the improvement of longterm care quality; and the promotion of prevention measures to secur stable revenue sources. On the other hand, problems
such as changes in the beliefs of insurers (i.e., local governments), service providers, and care managers, combined with adecline in service quality from providers and care managers, have complicated the matter. A fundamental reform is required,and concrete reform measures for the improvement of integrated community care and its service supply are being considered.
This paper an overview of a Government-sponsored report on the community-based integrated care system in Japan. The future
outcome of the LTCIS will also be discussed in this paper, leading hopefully to an interesting insight for other Asian nations
facing similar challenges concerning long-term care for the elderly.
Keywords： long-term care insurance; care needs certiﬁcation; community-based integrated care system(accepted for the publication, 22nd December 2010)

Ⅰ．Introduction
As the population ages, the number of elderly requiring
care has increased and the overall period of care has been
prolonged. In Japan, long-term care needs will only continue
to grow. A change in family structure has promoted theestablishment of the Long-Term Care Insurance System(LTCIS). Family members used to provide care, but theincreasing number of nuclear families has necessitated theuse of outside caregivers 1)-3). Before the introduction of the
LTCIS, all public ser vices were provided by agencies orcharitable organizations designated by the government, andindividuals had limited choices, if any, between providers.
Many recipients also felt a “stigma” attached to these
services, because their use implies poverty of the absenceof family members able to act as carers.
The LTCIS was introduced to overcome such problems
and is characterized by the following three points. First, itaims not only to provide personal care to the elderly, but also
to support their independent living through the provisionof appropriate home-based nursing services and household
assistance. Second, it is a user-oriented system, where users
can choose their care services directly from many providers.
Third, it employs a social insurance system in which thebalance of beneﬁts and expenses are made clear.
Ten years have passed since this system was founded,and there are still a number of problems to be resolved. For
example, each municipality acts as an insurer who calculates
long-term care insurance premiums by investigating thenumber of elderly requiring care and the total cost ofservice. However, as the number of service users increases
and the number of younger insured citizens decreases, theﬁnancial burden on municipalities and citizens, particularlyon the younger generation, increases dramatically.
Therefore, to meet the growing care needs and maintainthe care-supply system in the community, it is important

Address for correspondence: Takako Tsutsui
2-3-6 Minami Wako-shi, Saitama-ken 351-0197, Japan.
Email: tsutsui@niph.go.jp

372

J．Natl．Inst．Public Health，59（4）：2010The Current State and Future Development of the Long-term Care Insurance System in Japanto secure stable funding sources. Also, for efficiency andfairness to the municipalities (i.e., the insurers), as wellas to the citizens, it is necessary to realize the appropriate
administration of the Long-Term Insurance Project Plan,
Long-Term Care Benefits, Care Needs Certification, andCare Management. In addition, a central concept of thesystem is the citizens’ responsibility to follow preventive
services for the elderly in the Community Project for LongTerm Care and preventive care beneﬁts in the LTCIS, which
differs from the health care policy in Britain, where the useof public consciousness about self-care is maximized4).
The government has not reached a national consensus on
preventive services yet, which has resulted in alimiteduseuse of them 5,6). Additionally, preventive care benefits in
LTCIS are provided to the elderly who have been certiﬁed
to be in Support Levels. However, these preventive carebenefits, dif ferent from care benefits (designed for theelderly in Care Need Levels), are to be actively undertakenby the elderly so that they can change their life patterns
and prevent their physical conditions from deteriorating.
Thus, the preventive care benefits require the elderly tochange their behavioral patterns by, implementing, forexample muscle training and by eating balanced meals.
On the other hand, with care beneﬁts such as home-based
nursing services, service users are passive and no positive
involvement is required. Thus, there is a clear difference
between receiving preventive care benefits and carebenefits. Unfortunately, the elderly who wish to use LTCI
does not necessarily agree with the concept of an autonomic
decision in order to improve life patterns. Therefore, theyusually prefer care benefits to preventive care benefits. In
the beginning, Japanese government aimed at promoting
the kind of self-care that can be found in British healthpolicies; however, such an orientation has not necessarily
been accepted by the public.
Despite the great amount of fund injection, the system
has failed to yield results, and this seems to reﬂect citizens’
lack of awareness. The government is currently promoting
a project to rationalize Care Needs Certification5), but thisprogram has not achieved adequate results because thewillingness of insurers to par ticipate in such programs
is not homogeneous. Care Needs Certification has been
designated as an administrative requirement of local
governments 9). However, the quality of the cer tification
varies substantially according to the locality. For example,
the incidence rate of Leg Paralysis, one of the Care Needs
Certiﬁcation items, is 90% in one city versus 20% in another9).
In the inter est of fair ness, the gover nment hasreconsidered the cer tification items, has attempted toclarify the process of decision-making involved in the Care
Needs Certification system, and has promoted a series of

new texts about Care Needs Certiﬁcation in 2009. However,ser vice users and care managers still do not completely
understand the Care Need Cer tification system or theitems considered during the cer tification process. Poor
communication from the government, whose duties havebeen extended to include the national elderly care insurance,
combined with political pressures toward the government
in charge at the time, have led to a revision of the new texts
in favor of the old ones10). The incompatibility between the
new Result Cer tificates issued from April to September
2009, and the measures concerning the validation processof the certiﬁcate that was implemented one year before, hascreated a potentially catastrophic situation.
The LTCIS is an insurance that covers the risk of needing
long-term care, and therefore it provides services especiallyto the elderly requiring care. The provision of long-term careservices through insurance benefits is an attempt to reducethe burden on families who used to provide all the care to theelderly. However, some research have indicated that the use ofsuch services doesn’t reduce the burden on the family 11),12) andthat the impact on the family was really different according
to the type of services used by the elderly 13)-16).
The main expectation for this system is the possibility
to enable -through the global assessment of the users
physical and mental condition, as well as the evaluation of
the family care resources and the living environment- theimplementation of a care management program that allows
the user to be more independent. However, it seems thatsome difficulties remain regarding the monitoring of thesystem and the satisfaction of the users’ family 17). Also, there
is a problem in Japan regarding the care managers’ lack ofcompetence and some problems of objectivity towards thesystem 18),19). Between 2000 and 2005, 328 providers abuse
the system by submitting false reimbursement receipts,
which represented a loss of 5.5 billion Yen20).
Although this situation was problematic for the NationalDiet, it was advantageous to the Democratic Par ty ofJapan. From the Democratic Party of Japan’s point of view,
increasing the awareness regarding fairness issues may
potentially result in a loss of support for their party. Hence,
the new Democratic Party-led government of Japan started
cash-based allocation reforms including an increase in
April 2010 of the ‘child allocation’ 21), even though ﬁnancing
prospects are still uncertain in terms of financing 22). The
self-centered doctrine of the pursuit of one’s own happinesswithout any consideration for others is called me-ism. It
seems that many users of the LTCIS are followers of thisme-ism doctrine. Indeed, The elderly and their families
who ask care managers to provide them with a higher levelof care need than they require, receiving better benefits,
and care managers who falsify results in response to theirJ．Natl．Inst．Public Health，59（4）
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373

Takako TSUTSUI
requests, are becoming too common.
In Japan, the government intended to provide a fairer
Care Needs Certification system and certification items,
but critics of the system were not silenced. The main
explanation is that the newly elected Democratic par tyof Japan showed an ochlocratic attitude toward this meism and made what some may consider a poor judgment
regarding the insurance system. Japan was the first
country computerize the primary decision on Care Needs
Certiﬁcation to a computer (System of Primary Decision) 3).
This was supposed to result in a political closure thatwould earn ever yone’s approval, particularly by making
citizens understand, for the first time, the scientific basis
underpinning the decisions. The system of primary decisionmaking gathers data directly from the field. By placing
this information into a logical structure, Japan built an
unprecedented evidence-based care system23).
Event though this system is highly considered worldwide,
the Japanese citizens’ understanding of the system isstill remarkably poor 24). Moreover, irrespective of how
reasonable the system is, if the data, which are thought toprovide a direct window into the health conditions of theelderly, are distorted from the start by the me-ism of caremanagers, who are the investigators for the Care Needs
Cer tification (commissioned by the local government),
it is not surprising that fair results cannot be obtained.
For the proper functioning of this system, citizens should
possess a strong sense of ethics and realize the importanceof obtaining fair results. This sense of ethics is precisely
what we are aiming for. The LTCIS, which was foundedon this philosophy, has earned the citizens’ recognitionand provides more universal ser vices. However, after 10
years, a new issue has arisen: the necessity to make people
understand the implications of establishing a long-term careinsurance system as a social insurance. The goal here is a
drastic transformation of the citizens’ understanding of thelong-term care insurance and the social security system.
This drastic transformation was promoted from 2006
following revisions of the long-term care insurance system
in a new report on community-based integrated care. This
repor t notably predicted the outcomes of the LTCIS in
2025. The report also contained many suggestions, such as
establishing a grant for research in the ﬁeld of communitybased integrated care, which have been accepted by the
Ministry of Health, Labour and Welfare. A set of concretemeasures regarding the current state of community-based
integrated care and the services provided by this system aredetailed in this report and are currently under consideration.
The content of this report will now be presented, reviewed,
and observations on the future of the LTCIS will be drawn.

374

Ⅱ．The current situation of the LTCIS in Japanand predictions for 2025
In this section, the current situation in Japan in terms of
population demographics, and the changes anticipated by2025 will be discussed. The second topic will concern thepossible implications of the current and future sustainabilityof the LTCIS.
A sharp increase in elderly individuals needing care
Approximately 4,847,000 people have Care Needs
Certiﬁcates (or have a support level), which is about twice
as high as it was at the time of the introduction of the system(2,180,000 individuals)25),26). This increase is particularly
signiﬁcant for elderly with a low Care Need (support level
and Care Need level 1). In other countries, individuals
with these lower levels of care needs are not qualified toreceive beneﬁts, but in Japan they are covered by the longterm care benefit system. This huge population of lowlevel care recipients is becoming a threat to the long-termsustainability of the LTCIS.
In 2025, the elderly population over the age of 65 years ispredicted to exceed 36,000,000 individuals (30 % of the entire
population). This is also the year in which the majority ofthe postwar generation of baby-boomers will reach the ageof 75 years or older (The National Institute of Populationand Social Security in Japan Research 2009). The increasein the number of elderly obviously means an increase in thenumber of individuals with Care Needs Certiﬁcates. Indeed,
4.7 % of the population aged 65 – 74 years have received
Care Needs Certiﬁcates, a rate that doubles to almost 29.0 %among those aged over 75 years (see Figure 1) 27).

Figure 1. Population over 65 and the proportion of people who
received Care Needs Certiﬁcates27).

Correction of intra-regional disparity
According to the Estimation of the Population’s Evolution
in Municipalities published by the National Institute ofPopulation and Social Security in Japan Research (2009)
regarding the evolution between 2005 and 2025 of the
population over 75 years old, the following statements
are true: in 6.4 % of the municipalities, this population

J．Natl．Inst．Public Health，59（4）：2010The Current State and Future Development of the Long-term Care Insurance System in Japan
will decrease; in 46.8 per cent of the municipalities, it will
increase by 1–1.5 times. Moreover, regarding the more urban
regions, in 12.1 % of these municipalities this population will
increase by 2.5 times; in 6 % of them, this population will
increase by 2.5 to 3 times; in 2.5 % of the municipalities, thispopulation will more than triple27).
In 2025, even though the total population will mostly
remain unchanged, the facts that the population over 75
years old will increase considerably within urban regions,that this population will eventually decrease in somemunicipalities, and that in all of the other places between
these two extremes, the aging of the population will evolveat a different pace, can only lead to an era in which policies
and measures are not national but are adapted to thediversity of each municipality. In other words, maintaining
the stability of the LTCI system (which has already become
an insurance system adapted at the local community level)at a uniform and national level would be very difﬁcult.
The need for service assessment
According to the estimation of the national assembly onsocial security, depending on whether the benefit amountis revised or maintained in its current state, long term care
will require between 19 and 24 trillion yen in 2025 (presently
7 trillion yen are required)28), while the total medical careexpenditures are predicted to increase to 66 trillion yen (seeFigure 2).

associations recognize the necessity of lowering the amountof the beneﬁt seems difﬁcult.
Even though the concept of an insurance system thatcovers the needs and expectations of ever yone is largely
promoted during the establishment of any system based onsocial solidarity (such as social insurance), it is not feasible,
even theoretically. Thus, it seems necessar y to examine
carefully the efficiency and contents of the long-term care
ser vices. The only solution is to establish a system that
does not cover ser vices of poor quality. The government
has tried to suppress services of poor quality by creating
a quasi-market for long-term care ser vices. However, theactual situation has led to the need to check and monitor themarket in order to detect problems such as false claims forreimbursement using the long-term care insurance and toassess the quality of services.

Ⅲ．The current state of the new Japanese caresystemFigure 2. Predicted changes in social security beneﬁts, including
medical care and long-term care insurance in Japanbetween 2004 and 2025.

Community-based integrated care system
Even with market supervision and the non-reimbursementof poor quality ser vices, the increasing long-term careexpenses are still very high. To foster understanding among
the population and make them behave more responsibly,
it was necessary to build a system that answers the needsof the ser vice users and that treats ever y individual with
dignity. The system that arose from these ideas was theCommunity-based Integrated Care System, established 5
years ago5).
The goal of this system is to allow a person who needs
long-term care to stay at home as long as possible, andto provide an environment that allows such individuals topreser ve their own lifestyle for as long as possible. Thissystem was built for the safety of the citizens, to provide
individualized and appropriate ser vices (i.e., medical andsocial care) inside a community and to allow the provision ofthese services in any circumstances within approximately 30
minutes. Of course, in order to build such a system, drastic
reforms of the ser vices, human resources, remunerationof long-term care, and the LTCIS are necessar y, but thegreatest reform concerns the transformation of the citizens’
perception of life at old age29).

If we intend to maintain long-term care expenses at aconstant level, reducing the amount of the benefit is anecessity; however, as stated above, the government’s
attempt to create a more fair system has failed because of
the practitioners’ associations: most of their clients being ina low level of care need, any decrease in the beneﬁt amountwould mean a considerable loss of profit. Making these

Creating and administering the new system
The state promoted a system in which the social solidarity
transcends generations, is focused on coordination within
the medical system, and which is aimed at the developmentof a continually administrated LTCIS19). However, the state
is now supporting and rebuilding the system of mutual care,such as volunteer activities and services between residents

Data between 2004 and 2008 were obtained from Japan National
Institute of Population and Social Security33). Estimates for 2025 arederived from the Japan Cabinet Secretariat28).

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375

Takako TSUTSUIof the same area, which has always existed in Japan. This
does not mean that the design of the system is based onan unrealistic and nostalgic vision where neighbors help
each other, but it is rather the result of citizens no longer
being able to be the main caregivers to an increasing elderly
population. From one point of view, we might say thatchoosing this system was an agonizing decision.
Before establishing the LTCIS, the neglect of elderly
individuals was an impor tant social issue. Therefore,
only 10 years ago, Japan started a publicity campaign for
the implementation of the LTCIS entitled, ‘From care by
family to care by society.’ Promoting a system of integrated
community care based on self-care and social solidarity
care just a few years after this campaign was a politicalmove which, although it may appear to be similar to theGerman approach, actually has a very different foundation:
Germany chose from the beginning to establish a public
insurance system that would not replace, but complete, theold system of care provided by the family. In this system,
the care-recipient can choose to receive care from a healthprovider, or from their family. Even if family care is chosen,
they still receive an allowance. In contrast, in Japan, there is
no allowance for the family carer because social insurance
is only available for care provided by a care provider, andnot for care provided by a family member 2). In terms ofﬁnancing, the German model is funded entirely by insurance
premiums, whereas in the Japanese model, half of thefinancing is derived from taxes at the national, prefecturaland municipal level (accounting respectively for 50%, 25%
and 25% of the tax funding).
In a Japanese society that could no longer afford to cover
all the long-term costs of care, relying upon family care again
did not offer much choice. To achieve this major overhaul
toward an insurance system in which family carers fill a
crucial position, Japan would have to implement generously
the kind of measures that can be found in Germany tosupport family carers: provide nursing allowances, secure
a possible rotation of nurses, pay the pensions of familycarers, and provide advice and opportunities for learningand consulting.
However, winning the population’s approval for this major
overhaul will likely be a difficult task. It is interesting toconsider the situation in the United States, which becamea reference for these reforms in all kinds of ﬁelds. The selfcare system provides a basis for nursing and medical care.
For this reason, in some states, the long-term care services
available to the public actually exceeded the demand.
On the other hand, the population of Japan probably
does not want a strong but expensive welfare state such as
those in the Nordic countries. Neither would they agree to
implement a system that is based on family carers, as used376

in Germany. It is also likely that they would refuse a system
based on self-care as is found in the United States. This
may explain why Japan would prefer a restructured social
solidarity care system.

Ⅳ．Prelude to the reform of the LTCIS
Elements and functions of the community-based
integrated care system
The prelude to the drastic reforms that will break thecontinuity of the LTCIS star ted in 2006. At this time,
the Chiiki Houkatsu Shien Center (Community-based
Integrated Care Support Center), the cornerstone of thecommunity-based integrated care system, was founded, andmany reforms for the realization of care in the community
system were implemented. These reforms opened a paththat led to the actual structure of the community-based
integrated care system. Until now, the Chiiki Houkatsu
Shien Center has been building a support network withformal and informal care resources in order to integrate
health and social ser vices so that users receive seamlessand comprehensive care. However, the amount of careresources varies greatly between municipalities. Therefore,
an integrated care system, which should provide continuousand comprehensive care, and the roles of volunteers inthese systems also differ. However, the approach to building
such a network is still unclear from the perspective ofgovernment-backed schemes. The center was unable todeliver ser vice that was adequate for an integrated caresystem. Accordingly, the government star ted a model
project in 3 municipalities in 2009 and 57 municipalities in2010 to evaluate new ways of building such networks. The
aim of the project was to ensure that the centers understandthe care and support needs required by the elderly in theirregion by surveying each household about factors such ascomposition and income, whether the citizens live alone,
prevalence of diseases such as dementia, Activities of Daily
Living scores, support needs, and residential amenities30)
At the policy level, the actual reform represents a drastic
political change because it involves re-discover y of theindividual’s capacity, which hardly exists at present, to help
each other inside a community (mutual care)31).
The deﬁnition of the terms ‘self-care,’ ‘mutual care,’ ‘social
solidarity care,’ and ‘public care’ mentioned in this paper canbe found in ‘Chiiki Houkatsu Care Kenkyukai Houkokusho(Research Report of Community-based Integrated Care in
Japan)27). Brieﬂy, self-care represents the idea that one canwork by oneself or live by oneself on one’s own retirement
income, and that one can maintain good health by one’s own
means. Mutual care refers to the mutual care delivered byinformal carers. Social solidarity care is also a kind of mutual

J．Natl．Inst．Public Health，59（4）：2010The Current State and Future Development of the Long-term Care Insurance System in Japancare, but delivered in a system similar to social insurance.
Public care is the kind of care delivered to individuals
in great distress, when self-care, mutual care, or social
solidarity care is ineffective, and only after fulﬁlling several
conditions regarding income, living standards and familial
situations.
Broadly speaking, the United States may be considered
to represent a system based on self-care. On the other
hand, in France, Italy, and more recently England, self-careand mutual care are the core of the system. Germany andneighboring countries are slightly more dependent on asocial solidarity care system, while countries in northern
Europe use a sophisticated public care system.
Aim of the community-based integrated care system inJapan
Recently, along with the promotion of care by family
members, it seems that in countries like France or England,
the system of self-care and mutual care is being reviewed(self care)32). If we classify generally, we can say that Japan
used to be close to the German model but is now, throughexpressions like ‘support of mutual care,’ aiming to replicate
the model used in the Nordic countries.
From now on, we can expect numerous studies on thepossibility of earning the comprehension and support ofthe population toward this new system, and at the sametime preser ving peace and safety in the community.
However, without waiting for the results of these studies,
the community-based integrated care support center, whichis actually the core of the system, was founded in 2006.
According to recent evaluations, far from reaching the goal of
the government to support and re-structure the mutual caresystem, it appears that the new long-term care services, suchas that provided by small-sized institutions and group homes
specializing in dementia, are not adequately functional.
These results illustrate the dif ficulty in structuring acommunity care system in which the government (stateor local) inter feres publicly. The core of this system is
supposed to be the spontaneous and natural activities ofcommunity residents acting on their own free will. The oldsystem of mutual help that used to exist in the community
has been replaced by a social solidarity care system basedon social insurance. The actual attempts to reverse theprocess through an interference of the state does not seemvery appropriate, and certainly does not match the original
concept of natural and spontaneous mutual care.
After accomplishing an unprecedented nationwide projectwith the implementation of a long-term care insurance
system, it is important to consider whether the next coreof the system will be “self-care”, ”mutual care”, “ social
solidarity care” or “public care”31). This decision will be ofhigh consequence for all countries.

Ⅴ．Conclusion
This paper summarized the current state and future
development of different parts of the LTCIS. Japan is actuallyconfronted to ﬁnancial issues of public funding because the
LTCIS is becoming an integrated care system where needs
for care ( in quality and quantity) are gradually increasing.
Japan is aiming at community-based care that includes theﬁelds of medical care, public health, and welfare; however,in order to succeed, it is necessar y to consider training
human resources to be ﬂexible to the variety of care needs
and to adapt to the structural transformations of services.
Japan and other Asian countries that are also influenced
by Confucianism probably have common issues when they
face the problem of an aging population. The studies that are
being conducted in Japan regarding the implementation ofpolitical measures, as well as the structural transformationof human resources in the ﬁeld of long-term care, are very
useful for Japan itself, and may be a valuable experience forother Asian countries.

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日本では，高齢者の介護を社会全体で支え合う仕組みとして，2000 年に「介護保険制度」が創設された．この制度では，介護保険料は，保険者である市区町村が地域内での介護を必要とする高齢者の数や介護サービスの利用料から算出することとされてきた．
しかし，昨今は，サービス利用者の増加や少子化に伴う若年の被保険者の減少によって市区町村，住民，若年層の負担が激しいことから，この制度の安定的な運営と財源の確保が課題となっている．このため，日本では「給付，認定，ケアマネ
ジメントの適正化」や，「介護サービスの質の向上」，「介護予防施策の推進」といった視点からの制度改革が実施されているが，被保険者ならびにサービス供給事業者，ケアマネジャーの質やモラル低下の問題，サービス供給体制上の連携の問題等が発生しており，改革は難航している．
これらの問題の抜本的な解決を図るため，政府は，これからの日本が目指すべき地域包括ケアシステムと，これを支える
サービス等の在り方を記した報告書を発表した．
本稿では，この報告書を概観しながら，日本の介護保険制度の現状とこれらからの展望について考察した．なお，この内容は，高齢者の介護という，同様の課題に直面しつつある，他のアジア諸国にとっても有益な内容となるものと考える．
筒井孝子

J．Natl．Inst．Public Health，59（4）：2010

国立保健医療科学院福祉サービス部[ 平成 22 年 12 月 22 日受理 ]379