2. Shifts in Welfare Policy Due to the New Kaigo hoken hô

As I have mentioned above, there is a social need for some sort of system to provide care for the elderly in Japan. Particularly, in more concrete public policy terms, the reasons for proposing the Kaigo hoken-hô and its aim could be summarized as follows (Ihara and Amaike 1997: 2-3):
__First, regardless of family situation and income level, elderly people should be entitled to utilize home care services and institutional services according to their own needs and wishes, without feeling any reluctance. Further, the independence of the elderly should be fully supported by this new system. Second, the two systems presently existing - the elderly welfare system and the national medical insurance system for the elderly - should be integrated with the new law in order to create a unified care system for all elderly people above the age of 64. Third, the law should encourage the private sector to play an active role as a service provider in this integrated system. These services are currently supported by the public and semi-public sectors. Fourth, the idea of "care management" which is a rather new notion in Japanese health care, should be introduced in order to provide a variety of services required by the elderly
__On the one hand, generally speaking, all of these aspects relating to the care of the elderly are very much welcomed by the Japanese public. On the other hand, the law itself as well as these four positive aspects have also been criticized (Mainichi Shinbun 09.10.1997: 5). In the following, I would like to point out several unique changes or shifts in the concept of social welfare expressed by this law which, according to my analysis, can be clearly recognized as shifts in a positive or negative way:

"From status to contract" through service industries

I used this very popular phrase invented by a famous legal historian, Sir Henry S. Maine (1888: 165). He coined this phrase to explain social trends in the legal status of the individual from ancient to modern times. A shift from "status to contract" is exactly what the Kaigo hoken law effects.
__The former Rôjin fukushi-hô [Law for the Welfare of Elderly] promulgated in 1963, provided administrative measures (sochi) for the care of the elderly in order to make arrangements of various welfare services such as home help services, day services, and short stay services for the elderly including the providing or rental of special appliances such as wheelchairs, canes, and hearing aides for daily use. Sochi also applied to the admittance of elderly care to institutions. Sochi were basically decided by local authorities, but, legally as well as administratively, they were not regarded as claim or right of the elderly person in need of services or institutionalization (see Ogasawara et al. 1997: 52-53). In order to gain the benefits of sochi, private information relating to family relations, income, or other property matters would eventually be disclosed. Those elderly who needed sochi and were recognized as an "object" of welfare services would be taken care of by the social welfare system of the government. In the Rôjin fukushi-hô, tax money was used for the support of needy people. However, as a matter of fact, people were feeling reluctant about obtaining that "status".⁴ With the new Kaigo hoken-hô, the notion of this sochi was abolished. A shift from state responsibility to individual care by the establishment of an insurance system can be clearly recognized in this law.

"From family to society" through mutual assistance

Both care and social assistance supplied by the Japanese welfare systems have had a negative image and faced difficulties because of the traditional emphasis on family care. Usually those who receive welfare services are categorized as poor and without family support, and this has been one of the reasons why people have been reluctant to be in that "status" and become an "object" of socialized welfare services. Until very recently - and still today in many Japanese rural areas - the family has taken care of their elderly members (Kimura 1988: 175-186). Therefore, it is quite an embarrassment for many elderly to receive public welfare services, particularly if they live alone and are separated from their family.
__A recent article on elderly life that appeared in the Asahi-Shinbun (16.12.1997: 26; 17.12.1997: 34) reported these strong ethical and moral sentiments of the elderly against utilizing social welfare services. The people interviewed expressed traditional attitudes like "a parent has to be taken care of by their children's family members, particularly by the wife of the eldest married son". Recently, however, it has become more and more difficult both in urban and rural communities to care for elderly family members due to changes in the function of the family. Further, statistical data show that there is a rapid increase not only in elderly parents but in elderly children as well.
__The new law stresses the positive idea of insurance as a mutual assistance framework so that people would not feel any reluctance to utilize it. All people beyond the age of 40 are required to pay premiums from their income to prepare for the possibility of being taken care of after they have reached 65 years of age. This is a practical solution to cope with the possible increase in the number of elderly who might not be taken care of through the family or relative networks of support.
__According to the Report on the Survey Concerning Aging issued by the Prime Minister's Office in January 1998, only 38% of the middle-aged (40-59 years of age), and 46% of the elderly (beyond 60 years) responded that if family members became bedridden, he or she should be taken care of by other family members. By contrast, around 47% of the middle-aged and 31% of the elderly expressed the need to utilize public welfare services or even institutions in case of a bedridden family member. However, in the case of ordinary care for the elderly, only 9% of the middle-aged group and 10% of the elderly responded that they needed to be institutionalized rather than utilizing public welfare services in their home environment (Sômuchô Chôkan Kanbô Kôrei Shakai Taisakushitsu 1998).

"From state to individual" through community support

According to the Kaigo hoken-hô, each individual will be supported in his or her care by community-based local agencies. As mentioned above, emphasis is not put on the government to intervene for the care by application of "Sochi", but on each individual to utilize community-based care services after having consulted a care-manager. Furthermore, the law encourages the use of private sector organizations in the community which are usually business-oriented welfare services. It is a totally new notion for many Japanese to utilize these services which many people would otherwise not have been able to afford.
__In my opinion, this shift from welfare as a state obligation to individual choice with regard to the care-provider can be recognized in a very positive way. It signifies a very dramatic change in Japanese welfare legislation.⁵

"From bureaucrats to the people" through public deliberation

The official statement of the Ministry of Health and Welfare assures us that as soon as the new long-term care system as a mutual assistance insurance mechanism supported by local governments and communities is well understood by the people, elderly people will be ready to claim their rights and utilize this system in a positive way. However, there must be a change in the mentality and attitudes of welfare bureaucrats as well as the people in the local community in order to accomplish this objective.

"From tax to insurance" through cost-sharing

The new law proposes a shift in expenditure from tax money to insurance money in order to share the cost for the care of the elderly. Therefore, the biggest problem many people will have with this new system would be expenses which are expected to increase in the future.
__Even though people will have to pay premiums for this insurance, they will not have a chance to utilize this service if a particular criteria is not met. Even if people are lucky enough to be grouped into the standard-care category after having passed an evaluation process, they will still have to pay around 10% of the total cost as a user fee. This means that the Japanese will pay an insurance fee, tax money, and a user fee. One of the mechanisms to collect money for insurance premiums is automatic deduction from pension incomes through the administrative channel of local governments.
__Cost-sharing for the benefit of elderly care is naturally a good idea. Nonetheless, there are many people who have worries by saying "hoken atte mo kaigo nashi", which means "there is an insurance system but no services will be available" due to the different level of services according to the situation in each local community.

3. Bioethical Approach to the Long-term Care Insurance Law

Bioethics is an interdisciplinary subject relating to the value judgment of life and death in the social and human environment (Kimura 1986: 248-249). It embraces various traditional disciplines like biomedical sciences, ethics, law, philosophy, religion, or public policy. Various grassroots movements of the 1960s dedicated to civil rights, women's liberation, consumer protection, patient's dignity, and other human rights were the creative force behind the formation of bioethical ideas. In this socio-cultural context, it seems obvious to me to look at the issue from four different angles which reflect bioethical ideas (Kimura 1987). These are (1) the public policy perspective, (2) the human rights perspective, (3) the equality perspective, and (4) the "do-no-harm" perspective.
__The public policy perspective can be usefully employed as a good criteria in analyzing bioethical aspects in the making of new laws regarding issues such as organ transplants, the definition of brain death, or guidelines for genetic tests. The Kaigo hoken-hô should also be scrutinized in this public policy perspective.
__From the time the law was proposed to the House of Representatives (139^th Session) on November 29, 1996, there has been much deliberation among the general public on the long-term implications of this policy. One criticism was that the law focuses on elderly persons who need care, while someone who might become disabled at a younger age would not be covered. According to the law, from age 40 people are required to pay a compulsory premium, but benefits will, in principle, only be given from the age of 65 after undergoing a qualifying evaluation by an expert. Only in exceptional cases, those younger persons who became ill and disabled as a result of the biological aging process may also receive benefits. This clearly is injust from the perspective of the younger generation.
__One focus of the public debate during 1997 was one of the most basic issues of the system, i.e., whether the benefits should be funded by an insurance system or a taxation system. If the principle of mutual support is fundamentally important, it is quite obvious that a taxation system is much better suited because it is fairer.
__However, without sufficient exchange of opinions among the public, the insurance system was finally adopted by policy-makers as the better choice. The reason for this was that almost all political parties refrained from pursuing tax raising-policies in the face of general elections. In a sense, then, the Long-term Care Insurance Law became a victim of political compromise, and, in my opinion, a great opportunity to reconsider fundamental notions of public policy with regard to mutual care for needy people was lost.
__Care should be provided as a commitment of the social community regardless of age and generation, and be based on the needs of disabled people and their family. The government, however, insisted that cases covered by the Welfare Law for the Disabled should not be integrated into the Long-term Care Insurance Law.
__The human rights perspective can be used to analyze legislation, as it is essential to have criteria whether a certain law will have positive or negative implications regarding the dignity and rights of the people. In the Long-term Care Insurance Law, there are several key expressions such as "support", "care", "welfare", "choice", "service", "mutual support", "cost-sharing", and "independence". However, there is not a single word expressed as to the "rights" of the person in need of services. This law still strangely bears the sense of obligation and a paternalistic welfare-state flavor usually practiced by Japanese bureaucracies. If it is truly important to support the independence of the elderly, as is exactly stated in this law, one has to recognize, first of all, the right of the elderly persons as individuals to have access to various services mentioned in this law as an extension of their constitutional rights.
__An equality perspective is an essential element in the process of value judgment when one looks into details of the law's application. There is a possibility of inequality in service provision, reflecting differences in the conditions of local communities. For example, even though the care-manager of a particular community may be able to make plans for the elderly, home care or even institutional care might not be available due to the lack of human resources. This is an unequal and unethical situation which might lead to the creation of "migrant social welfare recipients" moving around from one particular area to another in search of local communities that provide adequate services.
__One of the problems relating to the equality perspective is the gender issue. Japan is a strongly male-oriented society in which around 85% of the home care-givers are still women. Ironically, several Japanese feminist groups have rejected the idea of cash payment for full-time care-giving at home. They felt that such cash payment could be a plot against women, confining them to the home and depriving them of their social, business, and professional opportunities.⁶ The final decision of not providing cash payment to full-time home care-givers also deprived male family members of being in such a care system on a full-time basis. Obviously, the equality principle is violated with this law. Equal treatment should be accomplished to all possible and available care-givers in the family.
__The "Do-No-Harm" perspective can also be regarded as one of the criteria in making value judgments on issues related to bioethics. Here the main problem is that those who have been paying insurance premiums might not necessarily get care services later in life.
__Usually, insurance means that the payers will get benefits whenever they are in a particular situation (such as sickness, unemployment, etc.) because they have been paying to insure against a future risk. In this sense, the new law is not implementing an insurance at all. This is simply harming the insured who expect to receive proper services when they will need them. The Long-term Care Insurance Law does not automatically guarantee care because it imposes a barrier of qualifying standards. In addition, it is not clear whether an appeal can be filed within a particular time limit.
__An additional problem for the elderly can be seen in the current situation in which most hospitals accept elderly patients who have difficulty managing by themselves at home. In Japan, this hospitalization for the elderly occurs very often due to the lack of vacancies in appropriate elderly institutions and is usually called "social hospitalization" (shakaiteki nyûin) because it is not meant to cure a disease, but rather to care for the elderly patient in an institutional setting but which is eventually consuming great amounts of medical resources (Kôseishô; 1997a: 175). Following the application of the Long-term Care Law, these patients will be eventually discharged. This will cause tremendous harm not only to the patients themselves, but also to their families, if there is no system prepared for the care of these elderly.

4. The Kaigo hoken-hô in the Public Policy Process: ___The Citizen's Positive Role in Making Proposals

I briefly mentioned above that the bioethical public policy perspective played a significant part in the making of the Long-term Care Insurance Law. In this section I will focus on this point by introducing the activities of civic action groups initiated by conscientious people in the process of making this law.
__There was a high degree of open debate and public policy-making relating to this law that caught the attention of many people because it was believed to have various implications for Japan in the 21^st century in political, economic, social, and family terms. The media usually reports issues such as elderly care in the social or family and women's feature sections. In the case of this law, however, there were many articles of support or criticism that appeared on the front pages of national newspapers. The topic became headline news on radio and television programs with reports on the political, economic, financial, and government issues focusing around this bill. Thus, it evolved into one of the most crucial political issues in Japan that integrated all existing systems for welfare and medical care in local communities.
__As the legislative body, the Diet itself had a series of special sessions by inviting experts in the Welfare and Health Committees on the issue of long-term care. Further, special public hearing sessions were even held in cities outside the capital region.
__In my opinion, however, the formation of a citizen's social action group in order to support the fundamental idea of long-term care insurance was even more remarkable. This group was established in 1996 and named Kaigo no Shakaika o Susumeru Ichimannin Shimin Iinkai (Ten Thousand Citizens' Committee to Realize a Public Elder-Care System; in the following abbreviated as KSSISI). It has made tremendous efforts to make concrete and positive proposals for the legislating process of the law. Among other things, the group presented policy alternatives, made recommendations, administered surveys on elderly care, sent questionnaires to Diet members on the proposed law, and collected resources, documents, and drafts related to the law. KSSISI's name reflects the purpose of this organization, as founding members planned to gather 10,000 citizens to join this committee with a membership fee of 10,000 yen. They suggested that this national organization would raise a 100 million yen fund to support activities which allow for an input from the ordinary Japanese citizen's point of view on the care of the elderly.
__In the statement on the establishment of KSSISI, the emphasis was obviously on citizens' input to influence the making of the law and presenting positive proposals on various points such as the following: 1) Citizen's participation in the policy-making process to plan for care-related infrastructure; 2) assurance of receiving services by setting a target year in order to avoid the situation of compulsory insurance payments without receiving benefits; 3) insurance fee payments from age 20; 4) deletion of the provision stating "necessity of care caused by the aging process" and expansion of benefits to all people with disabilities including younger people; 5) the establishment of a Care Insurance Managing Council consisting of an equal number of male and female representatives of the insured in order to protect the human rights of the insured. This council was also intended to be provided with an "ombudsman" function so that it would have the power of "investigation, recommendation, and public disclosure" (KSSISI 15.09.1996: 7-8).
__The KSSISI group received a great deal of attention during the two years since its establishment. They appeared in the news media whenever they held symposiums, seminars, and general assemblies. Its role as a citizen's public policy-making body was, for the first time in Japan, very well accepted by government policy-makers, candidates for the Diet at the time of the 1996 general election, and the people in general.
__One of the most remarkable features during this public policy process was the publication of a series of newsletters which carried valuable information on survey results, data, and proposals. From issue 1 to 7 (including an extra issue immediately after the passing of the bill in the Health and Welfare Committee of the House of Councillors on December 2, 1997), the group gave a very positive input and even exerted strong pressure to consider amendments in the final process of law-making (KSSISI 02.12.1997: 2-3).⁷

5. Concluding Remarks: Disappointments and Hopes for the Future

I have discussed the remarkable process of public debate on the long-term care issue and its implications from a bioethical point of view. This debate was in many respects the first of its kind in Japan, yet not many Japanese recognized its grave importance for particular bioethical concerns, such as care for those in need, in the public policy-making process. Democratic efforts were made through nationwide public hearings held in certain prefecture, such as Okayama, Fukushima, Hokkaidô, and Niigata, organized by the Welfare Committee of the House of Representatives, and in the prefectures of Yamanashi, Kôchi, Ôita, and Aichi, organized by the Health and Welfare Committee of the House of Councillors.
__However, the most encouraging approach of public participation that enjoyed the strong support of both the people and the media was the formation of special citizen's interest groups on the care issue. One of the most influential groups was the KSSISI that organized more than 18 meetings, seminars, symposiums, public gatherings, and press interviews, including publication activities supported by members and the general public. As of February 10, 1998, the KSSISI claimed a membership of 2,320 of which around 60% were women, 37% men, and 3% associations. The whole process of making the Kaigo hoken-hô gave new hope for many people as the KSSISI's proposal for amendment was seriously taken into account:
__On May 22, 1997, the general meeting of the House of Representatives of the Diet passed the Long-term Care Insurance Law that included the following amendment: "Local municipalities should be given the necessary administrative discretion in order to get a feed-back from the insured whenever they make a plan or intend to change services provided by the care insurance policy" (KSSISI 01.06.1997: 1-3).⁸ The concrete content and meeting of "administrative discretion" was suggested as "1) the establishment of a planning policy committee, consisting of people with learning and experience and experts from the fields of health, medicine, welfare, and insurance; 2) a public hearing or briefing including the insured should be held" (Kôseishô Kaigo Hoken Seido Jisshi Suishin Honbu 1998: 35). This amendment shows the actual influence of KSSISI's movement, and one cannot deny its role in the public policy process for the new care insurance system.
__With regard to the fundamental concept of people who are entitled to receive care, however, the group was unable to influence the legislators. The Kaigo hoken-hô clearly stipulates that people will be only eligible according to the care-category they are classified in, and on the condition that they are suffering from certain symptoms of disability or a condition caused by the "aging process", this particularly in the case of people between 40 and 64 years of age. It is important to note that the original draft of the law did not have such a sentence mentioning kôrei ni tomonatte shô-zuru [caused by the aging process] but only kaigo o hitsuyô to suru hito [those who need care]. In spite of the opposition to keep the latter wording in the law, it was passed using the former phrase. The KSSISI and the majority of the public consider the phrase absurd and are concerned about the serious implications this would have for those who need care because they suffer from a symptom or a disease that is not related to the aging process.
__Nevertheless, through activities including concrete proposals for amendments of the law, the Japanese public experienced direct participation in the democratic political process. Because of the importance the issue of care for increasing numbers of people in need has, many people felt that it was their own issue. It relates to their life in the community and to images of mutual caring, the family, welfare, and medical services. This new trend in Japan will also have positive implications for realizing the "Health for All in the Year 2000" global agenda initiated by the World Health Organization (WHO) of the United Nations (Kimura 1997).
__In order to determine the necessary level of care for people in need, international comparisons should be made and concerted efforts initiated to solve these issues, which are usually considered domestic problems. On not a few occasions we have learned that a breakthrough in unsolved and difficult problems can only be made by investigating and looking at the issues from different socio-cultural and bioethical perspectives.
__Naturally, the trend toward socializing care for the disabled as full members of their community in each region of the world should not discourage any form of traditional values that emphasize care in the family and community. Rather, we enter a new era of care and support with additional mechanisms that were influenced by international bioethical guidelines brought in during the course of a public policy-making process.
__However, it should not be forgotten that there is a need for continuous cooperation beyond national, generational, and gender gaps. We need to safeguard the clear image of respecting the autonomous decision of those people who need care. Participation, commitment, and voices of the people who are in a situation of disablement or of providing care are crucial when making bioethical public policies for building communities in which humane care is fully realized (Kimura 1995).

Footnotes

References

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Asahi Shinbun (17.12.1997): Inochi nagaki jidai ni: kaigosha o miru seken no me [In the Age of Long Lives: People's Way of Looking at Care-givers], p. 34.
HISAZUKA, Jun'ichi (1997): Iwayuru kaigo hoken to iu mono no sonzai kôzô [The Basic Structure of the So-called Care Insurance]. In: Jichi Sôken 23, pp. 1-20.
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