Sustaining Elder Care and Supporting Family Caregivers

Japan faces a shortage of care workers, and families will likely continue to shoulder an essential share of caregiving. To ensure that older adults receive adequate care across future generations, we need to pursue the optimal balance between the long-term care insurance system and family caregiving.

• Outlook for Population Aging and Long-Term Care Demand
• Shortage of Long-Term Care Workers and the Role of Family Care
• Circumstances Facing Family Caregivers
• Policies for Supporting Caregivers in Japan
• Insights from Germany’s Long-Term Care Insurance
• Medium- to Long-Term Responses for Elder Care

Outlook for Population Aging and Long-Term Care Demand

In Japan, population aging is driving up demand for long-term care, and shortages of personnel to provide public care services are a growing concern. To compensate for shortfalls in public services, an appropriate mix with informal care provided by families and others will be necessary. At the same time, the circumstances facing family caregivers in Japan are difficult. Alongside strengthening the foundations for supporting family caregivers—such as expanding social security coverage—we also need, over the longer term, to support marriage among young people and maintain family size so that the sustainability of elder care can be secured across future generations.

Over the next several decades, Japan’s old-age ratio is projected to remain high. According to the Ministry of Internal Affairs and Communications’ Population Estimates, as of 2023 Japan had 36.18 million people aged 65 and over and 19.57 million aged 75 and over. People aged 65+ accounted for 29% of the total population, and those aged 75+ for 15.7% (both as of February 2023).

Source: Compiled by the author

According to projections by the National Institute of Population and Social Security Research (2023; medium-fertility/medium-mortality scenario), although the number of older adults will peak and then decline, their share of the total population will not. The 65+ population is projected to be 39.29 million in 2040 and 33.67 million in 2070, accounting for 34.8% of the population in 2040 and 38.7% in 2070.

Particularly noteworthy are the trends for those aged 75 and over. This population is projected to reach 22.27 million (19.7%) in 2040 and 21.80 million (25.1%) in 2070. A higher share of people aged 75+ implies greater demand for long-term care, because the proportion certified as requiring support or nursing care rises sharply at these ages. For example, in FY2020 the share of insured persons under the long-term care insurance system who were certified as needing support or care was 1.4% (support) and 3.0% (care) among those aged 65+, compared with 8.9% (support) and 23.4% (care) among those aged 75+（厚生労働省「令和2年度介護保険事業状況報告」）. Given that Japan’s 75+ share will continue to climb over the coming decades, long-term care demand can be expected to increase as well.

Source: Compiled by the author, based on the 2001 edition and the 2022 edition of the Ministry of Health, Labour and Welfare's "Basic Survey on the Basic Survey of the National Life"(厚生労働省『国民生活基礎調査の概況』の2001（平成13）年版、及び2022（令和4）年版).

Shortage of Long-Term Care Workers and the Role of Family Care

With long-term care (LTC) needs expected to grow, a key concern is the shortage of personnel to deliver public LTC services (hereafter, “care workers”).

Current labor-market conditions suggest that securing the necessary workforce will not be easy. According to the 2023 White Paper on the Aging Society（2023〔令和5〕年版『高齢社会白書』）, the effective ratio of job openings to applicants for care workers in 2022 was 3.71, far higher than 1.16 for all occupations. A 2021 survey by the Care Work Foundation of 18,000 providers (51.8% response rate) found a turnover rate of 14.3% for facility-based care staff and home helpers combined, compared with 13.9% across all occupations. In the same survey, 63% of providers reported feeling understaffed (“severely understaffed,” “understaffed,” or “somewhat understaffed”). Training pipelines are also under strain: according to the Association of Training Schools for Certified Care Workers, LTC training schools filled only 54.6% of their seats in FY2022.

Although the number of care workers has risen steadily since the system was launched in 2000, it still lags projected demand. As of 2021 there were 2.15 million care workers. Based on projected service volumes in the 8th Long-Term Care Insurance Plan（第8期介護保険事業計画）, the Ministry of Health, Labour and Welfare estimates that about 2.43 million will be needed in 2025 and about 2.80 million in 2040. With the working-age population shrinking due to low fertility and population aging, a substantial increase in staffing will be required—making it unlikely that the shortage will be resolved quickly.

Against this backdrop of a likely chronic shortfall, attention is turning to informal caregivers—family members, friends, neighbors, and volunteers (hereafter, “family and other informal caregivers”). An OECD report covering 19 countries indicates that informal care has become indispensable, with about 80% of total care hours provided by family and other informal caregivers（OECD, 2005）.

In Japan, family caregiving is particularly prevalent. Even today, with the LTC insurance system firmly established, the 2022 Comprehensive Survey of Living Conditions（2022〔令和4〕年版『国民生活基礎調査』） shows that 56.4% of “primary caregivers” are family members (spouse 22.9%, child 16.2%, child’s spouse 5.4%, parent 0.1%, non-cohabiting family, etc. 11.8%), while 15.7% are service providers under the public LTC system. As discussed later, given families’ large role in caregiving and the limited prospects for rapidly expanding the formal workforce, supporting family and other informal caregivers is essential.

Source: Compiled by the author based on on the 2022 Comprehensive Survey of Living Conditions（2022〔令和4〕年版『国民生活基礎調査』）

Circumstances Facing Family Caregivers

In Japan, the situation of family and other informal caregivers is severe. As population aging advances and household size shrinks, older-to-older care and the concentration of caregiving burdens are increasing.

First, consider how household composition has changed among households that include a person requiring care. According to the 2022 Comprehensive Survey of Living Conditions（2022〔令和4〕年版『国民生活基礎調査』）, in 2001 nuclear-family households were 29.3% (of which couple-only households were 18.3%), single-person households were 15.7%, and three-generation households were 32.5%. By 2022, nuclear-family households had risen to 42.1% (including 25% couple-only), single-person households to 30.7%, while three-generation households had fallen to 10.9%—evidence of smaller family units.

Source: Compiled by the author based on on the 2022 Comprehensive Survey of Living Conditions（2022〔令和4〕年版『国民生活基礎調査』）

Next, looking at age pairings of care recipients and primary caregivers, the share that are both aged 65+ increased from 40.6% (2001) to 63.5% (2022); the share both aged 75+ rose from 18.7% to 35.7%. This points to growth in care provided by an older spouse or by an older adult child to an aging parent—that is, older-to-older caregiving.

At the same time, the time primary caregivers devote to care has changed little. Among co-resident primary caregivers, the proportion providing care “almost all day” has only slightly declined from 2001 (the year the LTC insurance system took effect) to 2022 (with a slight increase at Care Level 5; see table). By care-need level, the higher the level, the greater the share of caregivers reporting “almost all day.” In 2022, “almost all day” was 3.1% at Support Level 1, 31.9% at Care Level 3, and 63.1% at Care Level 5.

Taken together, these data suggest that care time has not decreased since the introduction of LTC insurance, while older-to-older care has risen, increasing the relative burden on caregivers. As families have become smaller, assistance from non-primary family members has likely declined, further concentrating the burden. In recent years, excessive caregiving strain has raised concerns about caregiver depression, abuse or injury of care recipients, and—in the most extreme cases—murder–suicide linked to caregiving（for example, 湯淺 2023）. Supporting family and other informal caregivers has become an urgent priority.

Policies for Supporting Caregivers in Japan

Japan’s framework for supporting family and other informal caregivers is, unfortunately, far from comprehensive. The long-term care insurance (LTCI) system is designed primarily to support the independence of care recipients, and family caregiver support is not envisaged as a system goal（増田2022）. Consequently, within the LTCI’s community support projects, caregiver-support programs are positioned only as discretionary services that each municipality may choose whether or not to implement.

Municipalities may offer three types of discretionary family-caregiver support projects: 1) Caregiving classes/workshops, 2) Monitoring programs for older adults with dementia, and 3) Family Care Continuation Support—a set of programs aimed at reducing caregivers’ physical, psychological, and economic burdens, including health consultation and disease-prevention services, peer exchange/meet-ups for caregivers, and caregiver self-reliance support（厚生労働省2016）. However, challenges have been noted, such as few municipalities implementing these programs and very few caregivers meeting eligibility criteria（増田2022）.

Insights from Germany’s Long-Term Care Insurance

Germany’s LTCI provides useful reference points. From the outset, care provided by family members has legal priority over external services（ドイツ社会法典11編3条）. Accordingly, Germany’s system includes measures to ensure that family and other informal caregivers can continue providing care without becoming cut off from social life. The main supports are social insurance coverage, subsidies for substitute (respite) care, care-leave schemes, and cash benefits paid to care recipients.

Social insurance coverage. Family and other informal caregivers are covered as if they were in regular employment. Caregivers who, at home, provide 10+ hours per week of care on at least two days per week to one or more persons certified at Care Levels 2–5 are eligible for coverage. Pension and unemployment insurance contributions are paid by the long-term care fund, workers’ accident insurance by the municipality, and subsidies are provided toward health-insurance and LTCI premiums.

Subsidies for substitute (respite) care. When family caregivers are unable to provide care due to illness and other reasons, grants are available to pay providers for temporary substitute care; these subsidies can also be used for respite vacations to help caregivers refresh（宮本2016）.

Care-leave schemes. Under the 2014 Act on Better Reconciliation of Family, Care, and Work, caregivers are entitled to 10 days of short-term care leave, six months of family care time (full leave or reduced hours), and up to 24 months of long-term family care time (reduced hours while working 15+ hours/week). All three carry statutory protection against dismissal（増田2022）.

Cash benefits to care recipients. In addition to in-kind services from professional providers, care recipients may choose a cash benefit and use it to finance care by family and other informal caregivers. The medical service that conducts care-need certification also reviews eligibility for cash benefits and monitors ongoing care. Benefit amounts depend on care level and are typically about one-half to one-third of the value of in-kind services（宮本2016）. For caregivers whose paid work is constrained by caregiving, these cash benefits offer significant support.

Taken together, Germany provides robust support for family and other informal caregivers: social insurance coverage, usable cash benefits, and respite subsidies that make it easier to rest according to one’s physical and mental condition. Germany’s LTCI offers valuable guidance for sustaining family caregiving.

Medium- to Long-Term Responses for Elder Care

Given rising care needs and workforce shortages, Japan will need to combine public LTC services with informal care in appropriate ways. As we have seen, family and other informal caregivers face older-to-older care, concentrated burdens due to shrinking household size, multi-care (one person caring for multiple recipients), and multiple roles (balancing care with employment and earning).

Source: Compiled by the author

In the short term, these problems can be alleviated by extending social insurance coverage to family caregivers and subsidizing substitute care—as in Germany. However, Japan’s lifetime non-marriage rate has been rising, and more people are not forming families. If we focus only on short-term measures for today’s caregivers, continued shrinkage of family size could leave more caregivers in severe difficulty in the future. Although community-based integrated care is being promoted, if people are forced to concentrate care within families amid demographic aging, the pool of community actors will also decline.

To prevent future difficulties, Japan needs a medium- to long-term strategy to maintain or restore family size sufficient to take on elder care. Possible avenues include supporting marriage among younger adults and expanding the supply of housing that enables three-generation co-residence for those who want it.

In short, to make elder care sustainable, Japan needs a comprehensive family policy that both strengthens short-term support for family caregivers and supports family formation over the medium to long term.

(Published with additions and revisions in the August 2023 issue of "EN-ICHI FORUM")

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