By Shigeyoshi Itagaki / Yomiuri Shimbun Staff WriterThe Health, Labor and Welfare Ministry has compiled a plan aimed at reforming the nursing care insurance system in fiscal 2018. The plan calls for increasing the burden on people who receive large incomes, but does not include reforms to curb the provision of some services. Nursing care expenses are expected to double over the next 10 years due to the graying of society, yet some problems continue to be left for the future.
¥21 trillion in fiscal 2025
At a subcommittee meeting of the Social Security Council at the health ministry on Nov. 25, committee members leveled one criticism after another: “Nursing care services need to be cut if we are to maintain the system.” “We’re not really doing enough to pare down benefits.” Their frustration centered mainly on the reform proposal’s failure to tackle one area in particular: the downsizing of services for those in need of light care.
This fiscal year’s expenditures in nursing care will reach ¥10.4 trillion, some three times the amount spent when the system began in fiscal 2000. In fiscal 2025, when all baby boomers will have reached at least 75 years of age, the costs look set to reach ¥21 trillion. The so-called “big-boned policy” for economic and fiscal reform put forth at a Cabinet meeting in June 2015 urged “taking another look” at services for people in need of light care, with cost-cutting in mind.
In response, the subcommittee examined whether to remove “living assistance services” such as cleaning, cooking and shopping from the purview of nursing care insurance coverage for elderly people who live at home and require relatively little assistance, or that equivalent to Level 1 or 2 on the nursing care scale. The 1.53 million people affected would be expected to resort instead to “home assistance services” provided by local governments in cooperation with nonprofit organizations and others, leading to savings of ¥100 billion annually.
Not enough agencies
A senior official of the health ministry explained the reason for postponing the reform: “After looking into the matter, we judged regional authorities to be inadequately prepared.”
Of the home assistance services expected to be available, only 516 governments had services up and running as of July 2016, or about 30 percent of all local authorities. A person in charge of services in a municipality in Kanagawa Prefecture expressed relief at the postponement, saying, “If the system had suddenly changed, a lot of elderly people would have stopped receiving needed services.”
The issue was also becoming a political football. Late in September last year, when the debate over revising nursing care insurance was taking shape, the idea of dissolving the House of Representatives in January suddenly spread throughout the government and ruling parties. The government found it difficult to gain ruling party support for the plan to cut services because the elderly were likely to oppose the cuts, so party headquarters forced through a cautious view.
“We know it will have to be done, but now’s not the time,” a senior official of the ruling parties recalled thinking.
‘Can’t raise premiums further’
The failure to take action to curtail services invited considerable criticism. Insurance premiums will have to be raised if costs continue to increase at the current rate, with the current national average of ¥5,514 per month for nursing care insurance (for those 65 years and older) likely to increase to ¥8,165 per month in fiscal 2025. One member of the subcommittee said, “We can’t raise premiums any further.”
Expenses aside, some subcommittee members doubted the need for living assistance for those requiring no more than light care. They pointed out that it might even impede independence.
With the co-payment in principle set at 10 percent, an hour of living assistance services generally costs about ¥300. One person involved in home visits for nursing care in Tokyo remarked, “Most users think of this only as a chance for cheap housekeeping.” Gratuitous use of such a service may encourage the elderly to stop doing domestic chores, causing them to deteriorate physically and mentally.
Yet another criticism in the subcommittee held that the current revision simply takes money from those who have high incomes. This year, the debate about the system will move to departmental meetings on revising payments for services. Reforms that incorporate a long-term view and include topics left over from last year are hoped for, so that the system can be passed on to future generations.
Sorting out insurance coverage
Prof. Shuichi Nakamura of the International University of Health and Welfare, formerly the head of the Health and Welfare Bureau for the Elderly in the Health, Labor and Welfare Ministry, said: “Before the days of nursing care insurance, home helper services were mainly about doing domestic chores. When nursing care insurance came along, its use spread to the point of becoming essential for any elderly person needing assistance at home. So we can’t just economize on services through austerity. We need to sort out just where public insurance coverage should take us. Convenience stores and supermarkets are getting involved in the delivery of meals and foodstuffs. Private services that support living at home are developing. And people in the community are increasingly supporting one another. All these things need to be discussed.”
Higher income may mean greater burden
The proposed revisions are strongly oriented toward assessing hefty premiums on people with high incomes, based on “ability to pay.”
For those in the 40-64 year age bracket assessed for nursing care insurance, beginning in fiscal 2017 insurance premiums of workers with high incomes at large companies will increase in stages.
Up to now, insurance premiums for both employers and employees have been calculated mainly according to the number of employees in the company, imposing a relatively greater burden on small businesses with lower average salaries. The system will change so that the burden depends more on the total amount of compensation a company pays its employees.
At the same time, a government subsidy of ¥145 billion to the Japan Health Insurance Association, which enrolls employees of small businesses, will be lowered in stages.
Beginning in August 2018, co-payments for nursing care services will increase to 30 percent for elderly people with incomes comparable to those in the workforce. The threshold annual income for a person being assessed a 30 percent co-payment will be about ¥3.83 million for people living alone and ¥5.2 million for two people living together. The increase should apply to about 3 percent of the users, or about 135,000 people. In the scheme, co-payments will be at one of three levels, between 10 percent and 30 percent, depending on the user’s income.
The co-payment cap will also be revised. Currently the cap is ¥37,200 monthly for households paying residence tax that are considered to earn an ordinary level of income, but next fiscal year it will increase by ¥7,200 to ¥44,400. The revision will affect about 180,000 people.