Current Situation of the Long-Term Nursing Care Insurance System

–Problems Calling for Solution 10 Years After its Introduction–

By KINOSHITA Naoko

　Ten years have passed since the nursing insurance system was introduced.　Recently we are witnessing a number of murder and joint suicide cases involving family members giving nursing care.　Has the aim of the system, “Society should be responsible for nursing care” been met?　Will the review of the system now undertaken by the Ministry of Health, Labor and Welfare to be implemented in 2012 dispel our fear?　This report has been compiled to inform our readers of the current situation of the system, on the occasion of November 11, the “Day for Good Nursing Care.”

Cases involving nursing care in neighborhood
　Mr. Kawata (pseudonym), a member of Min-Iren’s Friends Association works as a driver for nursing care patients.　This summer, he learned about a murder case in a family, which he used to work for.　The bed-ridden mother in her 80s was killed by her son (50s), who had been caring her at home.
　Mr. Kawata was surprised, as he had received a call from the family only an hour before the killing took place.　They reserved his taxi service to go to a care center in the community.　The son, who made the call, told him that his mother would go for a short-term stay from the next day.　His voice sounded nothing unusual.
　“It must have been an impulsive conduct”, said Mr. Kawata.　During the several years he has known them, the son once said to Mr. Kawata, “I want to take a good care of my mother, as I gave her a very tough time when I was young.”
　They lived in a public housing flat alone.　The son had to quit his work in order to nurse his mother, who had fallen ill.　It was about 10 years since he started caring her at home.　He used to take notes about the points on nursing care and people around them were impressed by his hard work.　He was also kind to other elderly persons in the neighborhood, helping them to take their garbage out for collection.　Some neighbors are now petitioning to the court to have his sentence reduced.

Husband kills his wife with dementia
　There are a number of similar cases reported from other communities.　In a public housing flat near the house of Mr. Kuriyama (pseudonym), a reader of this magazine, an 81-year-old husband killed his 82-year-old wife.　Without applying for the nursing care insurance service, he was caring his wife with dementia at home.　It was revealed that shortly before the killing, the husband himself had his illness diagnosed, which would require hospitalization and surgery.　Mr. Kuriyama said, “He must have thought that if his condition got worse, it would be all over with her, too.”　
　About half a year after the incident, the husband got a suspended sentence.　He was set free and visited the house of one of the leaders of his neighborhood association.　The leader and his wife had known the man through the activities of the neighborhood association, and they tried to visit him while he remained in custody.　However, his visit was so abrupt and they could not have any conversation at all.　Soon, the man left the apartment and nothing more has been heard of him, which has made his neighbors feel regret.
　Though there is no official statistics on the incidents involving nursing care, one press report says, “Until October 2009 since the nursing insurance system was launched, there were at least 400 cases in which killings occurred among the families or relatives in connection with nursing care of the elderly, or the elderly who were cared were killed in joint-suicides: 59% of them were murders (including murders at the consent of the victims — 6%, and murders at the request of the victims — 3%); 11% were bodily injuries resulting in deaths; 4% were negligence as guardians resulting in deaths; 24% were joint suicides.　Since 2006, every year, more than 50 such cases have been reported.”　41% of the accused (perpetrators) received suspended sentences. (Report by Tokyo Shimbun)

Caring families are “driven into a corner” by the system
　The incident described in the beginning of this article was found out when the son telephoned the care agency and said, “I have done it.”　A person at the agency said, “The current nursing care insurance system is pathetically insufficient to meet the needs of those who require nursing care and those who provide care to patients.　I believe the caregiver was driven up the wall.”　
　The mother had a gastric fistula fixed into her stomach and the level of need for nursing care was severe.　While this family chose nursing care at home, those patients who need medical supervision with gastric fistula or sputum aspiration are often denied acceptance at care facilities.　This is because these facilities have to maintain their operation with minimum number of staff, as the reward for nursing care is very low.　The son, after leaving his job for nursing his mother, could not afford to pay for extra service out of the coverage of the nursing-care insurance.
　The son had been evidently exhausted from caring his mother for several months before the incident.　Learning of his difficulty, the care agency also reported to the regional nursing-care support center and the municipal office in charge of welfare, asking for assistance to the family.
　On the day before he killed his mother, the son telephoned the agency in tears and said, “Mother is very ill.”　The staff, who immediately visited their house, heard him say, “I can no longer take care of her.”　A facility for the mother’s short-term stay was searched for and arranged by the agency, so that the son in quagmire could get some rest.　But the incident occurred the night before she was due to set off for the short-term stay.
　When the agency reported the case to the municipal office, the person in charge responded, saying, “If only a housekeeping helper had been available to them… (this should not have happened).”　He referred to the problem of unavailability of housekeeping help service, such as cooking and cleaning, when family members live together with the patient.　
　The manager of the nursing care agency expressed her regret, saying, “We could not save them, though they had issued SOS signals.　There should be kind of services, which give more consideration to the people giving care for their families.　If you look into only caregivers or care agencies for the cause of such an incident, you will misjudge the nature of the problem.　The government should not ignore the outcry from actual scenes of the nursing care.”　She also said to the author, “When we hear the news about such killings or joint suicide cases involving the nursing care, we often say, ‘It’s not someone else’s problem’ or ‘I won’t be surprised even if it happens near myself.’　Don’t you think such a state of affairs itself is fearful?”　

The nursing care insurance is not only “unavailable” but “designed to be unavailable”
　The Japan Federation of Democratic Medical Institutions (Min-Iren) has warned of the shortcomings of the long-term nursing care insurance system and called for solutions from the standpoints of both users and care workers.　Mr. Hayashi Yasunori, Assistant General Secretary of Min-Iren, evaluates the nursing care insurance system 10 years after its introduction, saying, “This insurance system is not only unavailable to users but designed to be unavailable.”
　Revision has been made to the system three times since it was launched.　Every time the revision was made, the burden on the taxpayers grew, the scope of services available was restricted, and the reward for nursing care received by care agencies was reduced. (See “10 Years History of Long-Term Nursing Care Insurance”)
　Being far from its original vision, “Nursing care should be supported by the society as a whole”, the system is on the brink of collapse.　The killing of the nursed elderly by the caregiving families may be the worst expression of the crumbling system.
　In the background of the priority given only on the “sustainability of the system”, while the plight of users and caregivers was left neglected, we can find the policy imposed by the Koizumi Government to cut the social security expenditure by 220 billion yen every year starting in 2002. (Actual cut in 2002 was 30 billion yen.)

“Nursing Care is our legitimate ‘right” — Hayashi Yasunori

What will become of the review on the nursing insurance system?
　In light of the next revision of the nursing insurance system in 2012, the Ministry of Health has held sessions of its advisory panel made up of experts and care agencies.　The recommendation from the panel is expected to be issued in November this year.　If everything goes on schedule, based on the panel’s recommendation, the government will submit a bill for the revision to the Diet in 2011, and after it is approved by the Diet, the revision will be implemented from April 2012.
　The main topics for examination by the panel are “building of a sustainable structure” and “Achieving the optimum service system.”　Can the panel come up with proposals for the betterment of the system, taking into account the current situation on the brink of collapse?
　Assistant Secretary Hayashi of Min-Iren says, “Unfortunately, the point of view of the panel has not changed since 2005.　The priority is given on the finance, not on how to support the caregivers and nursing family members.　So the restriction on providing benefits and the increase of burdens on users are discussed before anything.”
　In January this year, an official of the Ministry of Health gave a lecture in which he set out the future vision of the nursing care insurance system, saying, “The premium for the nursing care insurance should be charged from those in their 20s and 30s”; “The out-of-pocket medical cost paid by users should be raised from 10% to 20% of the total”; “Those categorized to be with lesser need for nursing care should be excluded from the coverage of the nursing care insurance”; “Support for household work should be uninsured” and so on.　The public inquiry survey on the nursing care insurance system conducted by the Ministry blatantly revealed the intention of the government.　To answer the question, “How should the cost for the nursing care service be met?” there were only two options to choose: “The insurance premium should be raised for maintaining and improving the nursing care service” and “Content of the nursing care service should be cut down to maintain the current cost of insurance premium.”　How could you choose either of them?
　Also, a concept of “community-based comprehensive care” has been proposed as an ideal future for the nursing care service.　The proposal includes such attractive plans as “visiting service available for 24 hours”, “an overnight-stay service” or “strengthened coordination between medical care and nursing care,” etc.　
　While admitting that a certain degree of elderly people’s desire has been reflected in this proposal, Mr. Hayashi points out the problem in the government’s planning, saying, “There has been no verification made on the realities during the last 10 years of the long-term nursing care insurance.　The “ideal” upheld in this new conceptual plan is to stress the mutual help among neighbors in the community and self-responsibility of individuals, while reducing the financial burden shared by the State.　There is concern that people of low income will be even more excluded from the nursing care than now.”

Kan Government regards nursing care as “industry”
　The “New Strategy for Growth” of the Kan Government identifies “nursing care” as an “industry” for creating market and employment.　In the current review of the nursing care system, the view of the business community is incorporated broadly as never been before.　The “Vision for Industrial Structure” issued by the Ministry of Economy, Trade and Industry around the same time went so far as to declare the “departure from the dependence on public insurance system.”　
　The review on the medical service fee, as well as on the nursing care service, is also planned during 2012.　The government sees this as a perfect opportunity to switch the entire system of providing medical and nursing care into a “low-budget” system, in view of the expected increase in the elderly population in the coming 10 to 20 years.　
　Facing the current challenges, Mr. Hayashi of Min-Iren says, “Nursing care is the right of the people as guaranteed in Article 25 of the Constitution of Japan.　This autumn period is crucial for us in mobilizing the movement to press for fundamental improvement of the nursing care insurance system.　We must work to inform the public of the serious problems involved in the government’s “review.”　And we are determined to create a big “Wave of nursing care movement”, in which we verify the 10 years of the nursing care insurance system and raise our voices out of the ground reality, through our coordinated campaign involving the users and members of our cooperative organizations.”

Reference: 10 Years of the Nursing Care Insurance System

2000:　April: Long-Term Nursing Care Insurance system was launched; Chaos and confusion were caused among users, care agencies and municipality offices due to insufficient preparation before the start of the system.
  ◇2001: Koizumi Government inaugurated.
  ◇2002: Decision was made to cut social security expenditure by 220 billion yen annually.

2003:　First review on the nursing care insurance system:　Reward for nursing care was cut by 2.3%; Government subsidy on establishing of new facilities was either reduced or abolished.　The policy of “optimization of provision of services” started, including the restriction of living support to the patients living with family members
  ◇2005: Revised Nursing Care Insurance Law was enacted, giving top priority on the “sustainability of the system.”

2006:　Second review on the nursing care insurance system:　The Revised Nursing Care Insurance Law was put into effect.　Reward for nursing care was cut by 2.4%.　In the name of “preventive service provision”, nursing care was withdrawn from the less disabled patients.　Since October 2006, restriction was imposed on the use of welfare equipment by the patients categorized as Nursing Care Level 1 or lighter.
　※Comsn’s scandal revealed.
　◇2008: Min-Iren conducted a survey on 1,000 cases of nursing care, which revealed the following problems.　
　Difficult economic conditions of the elderly: They cannot bear the cost for nursing care, therefore cannot avail themselves of nursing care services.　
　Impact on the restriction of service provision: There was a higher tendency of foregoing or suspending the use of services, causing difficulties in the life of users and family members.　
　Nowhere to go: People had to wait for many years before they were admitted to care facilities.　Those who need medical care were often denied the use of facilities or admission into institutions.

2009:　Third review of the system.　Reward for nursing care was raised for the first time, but with only 3% increase, it did not help raise the entire level.　Due to the revision on the system of certification on the need for nursing care, many patients were rejudged as having less need for nursing care.　Subsidy to improve the treatment of nursing care workers started.
　◇Government announced that 420,000 people were on the waiting list for admission in special elderly nursing homes; Democratic Party formed the government after the general election.
　◇2010: “Missing” elderly citizens emerged as a social issue.
　◇Discussion on the review of the system started toward 2012

Increase in the number of patients on the waiting list for special elderly nursing homes

1999: 100,000
2003: 240,000
2004: 340,000
2006: 385,000
2009: 420,000

Source: Survey by the JCP Diet member group (1999 and 2003)
　　　　　　 Statistics by the Ministry of Health (2004, 2006 and 2009)