At the moment, Japan has a lower percentage of older people than the United States and most European nations, but it has the most rapidly aging population in the world. In Japan, people over 65 will constitute 25 percent of the entire population around the year 2010, approximately a decade before the United States attains the same percentage.
But while the U.S. struggles with the question of how to organize and finance long-term care, as exemplified by the recent report of the U.S. Bipartisan Commission on Comprehensive Health Care -- the Pepper Commission, Japan has announced a 10-year health care and welfare plan for its elderly.
The Golden Plan, as it is called, was issued last December, and its budget was announced a few months later.
Once again, Japan is No. 1, enjoying the longest life expectancy in the world and developing a plan to meet the needs of its growing older population ahead of time.
Japan has been preoccupied by the challenge of dealing with an aging work force and rising health care costs, while compensating for its limited resources. Its population, half the size of this country's, lives in a land smaller than the state of Montana and depends primarily upon the outside world for its resources and energy. The nation has devoted a great deal of political and intellectual energy to exploring the consequences of an aging society. In 1982, the Japanese Economic Planning Agency issued a report called "Japan in the Year 2000" that included a special focus on the elderly.
The Golden Plan proposes a major shift from long-term institutionalized care in hospitals and the few nursing homes to home programs, combined with geriatric rehabilitation facilities, to provide care while reducing costs. The bill would cost $43 billion over a 10-year period, an amount nearly four times the public-sector spending on similar services during the 1980s. Part of the money would come from income-adjusted fees for the home-care support. Implementation would come at the municipal level to enhance local control and sensitivity to residents.
At present, approximately 700,000 Japanese, or 4.6 percent of the population, are 65 and older and so severely disabled that they are bedridden or require constant supervision in long-term-care facilities. Of these, 42 percent are in general hospitals (including geriatric), 20 percent in skilled nursing facilities, and 36 percent at home. By the year 2000, the Golden Plan would retarget these figures to 12 percent, 24 percent and 35 percent, respectively, with the remaining 28 percent treated at newly created geriatric rehabilitation centers. The plan calls for construction of 280,000 beds in these centers to accommodate a predicted 1 million disabled elderly by the year 2000.
To insure that the family remains an effective provider of care for the elderly, the plan proposes a threefold increase in government-employed visiting homemakers, a 12-fold increase in respite care centers and a 10-fold increase in day nursing homes. There would be 10,000 emergency home care support centers to assist the elderly and their families with problems like the agitation or wandering that can occur as symptoms of dementia, and the burnout that care givers feel. Each round-the-clock center, with two nurses and eight volunteer counselors, would serve an area with as many as 2,100 elderly, including up to 100 who require constant supervision.
In 1984, the Japan Economic Planning Agency estimated that it cost $16,000 annually to care for a disabled elderly person in a nursing home, but only $3,300 at home (or $7,700 if family labor is also counted, which usually means work performed by women).In the United States, our principal national long-term-care policy is spelled w-o-m-e-n. American women remain the principal care givers to older persons. This is true in Japan, as well. Thus, in both countries, the ultimate success of whichever plans are adopted will depend on the changing character of the family. Japanese women are beginning to move into the labor force in growing numbers, as American women already have.
Women of both countries continue to work a double shift, doing their regular job, a necessary part of the two-paycheck family in America (and increasingly so in Japan), and then meeting care-giving needs at home.
Both nations have populations that are steadily aging. Japan is acting on the challenge with all deliberate speed. The U.S. is not.
Robert N. Butler is Brookdale Professor of geriatrics and adult development at the Mount Sinai Hospital in New York City. Masako M. Osako is a gerontologist in Chicago and an international representative of the Well-Aging Association of Japan.
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