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, the aging population is increasing the demand for care, and there are concerns about a shortage of personnel to provide public care services. To compensate for the shortage of public care services, an appropriate combination with informal care provided by family members and others is necessary, but the situation of family caregivers in Japan is also difficult. It is necessary to develop a foundation for supporting family caregivers, such as the application of social security, and in the long term, to support marriage among young people and the maintenance of family size to ensure the sustainability of elderly care for future generations.

The aging rate in Japan is projected to remain high for the next several decades. According to the Ministry of Internal Affairs and Communications' "Population Estimates," as of 2023, the population of Japan aged 65 and over was 36.18 million, and the population aged 75 and over was 19.57 million. In addition, the proportion of the population aged 65 and over to the total population was 29%, and the proportion of the population aged 75 and over was 15.7% (both as of February 2023).

Source: Created by the author

According to projections (medium fertility and medium mortality projections) by the National Institute of Population and Social Security Research (2023), while the elderly population will decline after peaking, its proportion of the total population will not decrease. The population aged 65 and over will reach 39.29 million in 2040 and 33.67 million in 2070. This will represent 34.8% of the total population in 2040 and 38.7% in 2070.

Furthermore, the trend in the population aged 75 and over and its proportion is noteworthy. The population aged 75 and over will reach 22.27 million in 2040, representing 19.7%, and 21.8 million in 2070, representing 25.1%. A higher proportion of the population aged 75 and over means an increase in the demand for long-term care. This is because the proportion of people who require long-term care (or support) increases once they reach 75 years of age. For example, looking at the proportion of people certified as requiring long-term care (or support) among those insured under the long-term care insurance system in fiscal year 2020, 1.4% of those aged 65 and over required support and 3.0% required long-term care, while among those aged 75 and over, 8.9% required support and 23.4% required long-term care (Ministry of Health, Labour and Welfare, "Report on the Status of Long-Term Care Insurance Business in Fiscal Year 2020"). As the proportion of the population aged 75 and over is expected to increase in Japan over the next few decades, the demand for long-term care is also expected to increase.

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

Amidst the anticipated increase in demand for long-term care, a major concern is the shortage of care workers (hereinafter referred to as "care staff") who will provide public long-term care services.

Looking at the current state of the long-term care labor market, securing the necessary personnel is not easy. According to the 2023 White Paper on Aging Society, the job-to-applicant ratio for long-term care workers in 2022 was 3.71, higher than the 1.16 ratio for all occupations. Meanwhile, a survey conducted in 2021 by the Long-Term Care Labor Stabilization Center targeting 18,000 businesses (with a response rate of 51.8%) showed that the turnover rate was slightly higher at 14.3% for facility-based care workers and home helpers combined, compared to 13.9% for all occupations. Furthermore, the same survey revealed that 63% of businesses felt they were experiencing a shortage of personnel (total of those reporting "severe shortage," "shortage," and "somewhat shortfall"). In addition, the training of care professionals is also in a poor state. According to a survey by the Association of Training Schools for Certified Care Workers, the enrollment rate of training schools in fiscal year 2022 was only 54.6%.

The number of care workers has been consistently increasing since the system was established in 2000, but it is still not keeping pace with the expected increase in future demand. As of 2021, there were 2.15 million care workers, but the number of staff needed, as estimated by the Ministry of Health, Labour and Welfare based on the projected amount of care services in the "8th Long-Term Care Insurance Business Plan," will be approximately 2.43 million in 2025 and approximately 2.8 million in 2040. With the working-age population decreasing due to the declining birthrate and aging population, a considerable number of staff will need to be secured, and it is unlikely that the shortage of care workers will be easily resolved.

In the face of the predicted chronic shortage of care workers, attention is being drawn to informal caregivers such as family members, friends, neighbors, and volunteers (hereinafter referred to as "family caregivers"). According to an OECD report summarizing the caregiving situation in 19 countries, informal care by family members and other caregivers has become indispensable in many countries, with family members and other caregivers accounting for a staggering 80% of total caregiving time (OECD, 2005).

In Japan, family caregiving is particularly prevalent. According to the 2022 (Reiwa 4) National Survey on Living Conditions, even in Japan, where the long-term care insurance system is well-established, 56.4% of "primary caregivers" are family members (spouse 22.9%, children 16.2%, children's spouses 5.4%, parents 0.1%, and other family members living separately 11.8%), and public care service providers account for 15.7%. As will be discussed in more detail later, given that families play such a significant role in caregiving and that an increase in the number of care workers is unlikely, support for family caregivers and other caregivers becomes crucial.

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

The situation for family caregivers in Japan is dire. As the population ages, family sizes are shrinking, leading to increased elderly-on-elderly care and a concentration of caregiving burdens.

First, let's look at the changes in family size among households with care recipients. According to the 2022 National Survey on Living Conditions, in 2001, "nuclear family households" accounted for 29.3% (of which "households consisting only of a married couple" was 18.3%), "single-person households" for 15.7%, and "three-generation households" for 32.5%. By 2022, however, "nuclear family households" had decreased to 42.1% (of which "households consisting only of a married couple" was 25%), "single-person households" to 30.7%, and "three-generation households" to 10.9%, indicating a shrinking of family size.

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 the age combinations of those requiring care and their "primary caregivers," the percentage of those where both are "65 years or older" increased from 40.6% in 2001 to 63.5% in 2022. Similarly, the percentage of those where both are "75 years or older" increased from 18.7% in 2001 to 35.7% in 2022. This suggests an increase in elderly-to-elderly care, such as elderly spouses caring for their elderly parents or elderly children caring for their parents.

On the other hand, there has been no significant change in the amount of time primary caregivers spend providing care. Looking at the percentage of primary caregivers living with their parents who provide care "almost all day" from the same survey, the percentage in 2022 decreased only slightly compared to 2001, when the long-term care insurance system was implemented (however, there was a slight increase for those requiring Level 5 care) (see table). Looking at the percentages by level of care required, the percentage of caregivers who provide care "almost all day" increases as the level of care required increases. In 2022, the percentage of those requiring support level 1 who received care "almost all day" was 3.1%, for care level 3 it was 31.9%, and for care level 5 it was 63.1%.

These data suggest that the amount of time spent on care has not changed significantly since the implementation of the long-term care insurance system, but the burden of care has relatively increased due to the rise in elderly-on-elderly care. It is also possible that the shrinking size of families has reduced assistance from caregivers other than the primary caregiver, leading to a concentration of the care burden. In recent years, there have been concerns that excessive caregiving burdens can lead to caregivers becoming depressed, abuse or injury to those receiving care, and in extreme cases, even caregiver-related murders such as murder-suicide (e.g., Yuasa 2023). Support for family caregivers and other caregivers has become an urgent necessity.

Policies for Supporting Caregivers in Japan

However, Japan's system for supporting family caregivers is not adequate. Japan's long-term care insurance system primarily aims to support the independence of those requiring care, and support for family caregivers is not envisioned as an objective of the system (Masuda 2022). Therefore, family caregiver support programs are positioned only as optional programs within the long-term care insurance community support programs, which are left to the discretion of each municipality.

The following three types of family caregiver support programs can be implemented by municipalities as optional programs: ① holding caregiving classes, ② monitoring elderly people with dementia, and ③ continuing family care support programs. ③, continuing family care support programs, are programs aimed at reducing the physical, mental, and economic burden on families, and include "health consultation and disease prevention programs," "holding caregiver exchange meetings," and "caregiving independence support programs" (Ministry of Health, Labour and Welfare 2016). However, challenges have been pointed out, such as the small number of municipalities implementing these programs and the lack of caregivers who meet the eligibility requirements (Masuda 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.

First, family caregivers are covered by social security just like regular employees. It is stipulated that "caregivers who provide care for one or more persons requiring care levels 2-5 at home for 10 hours or more per week, regularly for at least two days a week," are eligible for social security benefits. Furthermore, pension insurance and unemployment insurance premiums are paid by the long-term care insurance fund, which is the insurer for long-term care insurance, while workers' compensation insurance premiums are paid by the municipality. Subsidies are also provided by the long-term care fund for illness (medical) insurance premiums and long-term care insurance premiums.

Next, if family caregivers are unable to provide care due to illness or other reasons, they receive subsidies to cover the costs of hiring a service provider to do it for them. These subsidies can also be applied to caregivers taking time off to refresh themselves (Miyamoto 2016).

Additionally, family caregivers are guaranteed a leave system for caregiving. The "Act on Better Balance Between Family, Caregiving, and Work," enacted in December 2014, established three types of caregiving leave and leave systems: 10 days of caregiving leave, 6 months of family caregiving time (complete leave or reduced hours), and 24 months of long-term family caregiving time (reduced working hours on the condition that employees work 15 hours or more per week). All of these systems include legal provisions prohibiting dismissal (Masuda 2022).

Finally, the provision of caregiving allowances to those requiring care indirectly supports family caregivers. Caregiving allowances are cash payments. In Germany, those requiring care can receive not only services from professional providers (in-kind benefits) but also cash payments to cover the costs of care provided by family caregivers. When receiving cash payments, medical services that assess the need for care review the application and continuously monitor whether appropriate care is being provided. The amount of the payment is set according to the level of care required, but it is approximately one-half to one-third of the amount of in-kind benefits (Miyamoto 2016). Cash payments are a great help to family caregivers whose work is restricted due to caregiving responsibilities.

As described above, the German long-term care insurance system provides comprehensive support for family caregivers. Social security coverage and cash payments support those whose work is restricted due to caregiving. In addition, subsidies for alternative care make it easier for caregivers to take rest according to their physical and mental condition. The German long-term care insurance system is a valuable model for supporting sustainable 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: Created by the author

These problems can be mitigated in the short term by applying social security to family caregivers, as in Germany, or by subsidizing the cost of alternative care. However, in recent years, the lifelong single rate has been rising in Japan, and more people are choosing not to form families. Short-term measures targeting only those currently providing care may lead to further reductions in family size, potentially increasing the number of family caregivers who will face difficult situations in the future. While community-based integrated care has been promoted in recent years, if people are forced to concentrate on care within their families in addition to the aging population, the number of people who can provide care in the community will also decrease.

To prevent future difficulties, it is necessary to maintain and restore the family size that can take on the responsibility of elderly care from a medium- to long-term perspective. Possible ways to achieve this include supporting marriage among young people and increasing the supply of housing that can accommodate multi-generational living for those who wish to do so.

In order to make elderly care sustainable, a comprehensive family policy is needed that enhances support for family caregivers in the short term and supports family formation in the medium to long term.

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

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