In the scheme of the long-term care insurance system, all municipalities in Japan were required to create a business plan in fiscal year 1999 and have done so for the first period of the plan, which is the five years from 2000 to 2004. One of the basic directions of this plan is organisation of a support system for the both the healthy elderly and the elderly requiring care on a community basis at the municipal level. In the scheme of the long-term care insurance system, various business entities including private companies can participate in in-home care service business by meeting certain requirements.
Municipalities are the main operators of the long-term care system and are the insurers, managing the insured 65 years of age and older, issuing insured certificates, providing payments for insurance benefit expenditures etc.
Municipalities are expected to play many roles in the long-term care insurance system and are able to flexibly structure the system at their discretion. The idea that society as a whole should look after older people is admirable, but the newly launched system is seriously flawed in a number of ways, and the front lines of care for the elderly continue to be the scene of almost daily tragedies . The problem of senior care is now one that confronts Japanese society as a whole, and it is not a matter that can be taken care of merely with the introduction of the new public insurance scheme.
A problem with the new system is the process of assessing the need for care. The first stage of assessment consists of having an evaluator mark answers to a questionnaire on a sheet that is fed into a computer. The obvious inadequacy of this mechanical approach is supposed to be remedied through a second stage of assessment by local committees, but it will be hard for these panels to make up for the shortcomings of the basic approach.
Another problem with the new system is that it focuses entirely on the condition of the elderly people requiring care, neglecting the condition of the family members who have been providing it. Just because a person's care requirements are "light" under the scheme's standards, that does not imply that the burden on the person's family in terms of time, effort, and money is necessarily a light one.
An issue is the choice between care and care in the home. One purpose of the new insurance system is to promote care in the home so as to reduce the number of cases of "social institutionalised" (where people are kept in hospitals not because of their medical care needs but because they cannot receive adequate non-medical attention at home), thereby reducing total medical care expenses. For the elderly person receiving care, living in the familiar environment of the home is probably preferable, but for family members the mental and physical strain of looking after someone, even a close relative, around the clock may in some cases be unbearable.
In general terms there is a very strong movement among lobby groups and the general public to foster principles allowing the elderly and disabled to have more say in determining their own living conditions and relating to the decision-making and payment for healthcare services -i.e. a move away from government directives that take these decisions away from the people affected.
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