A vague negative feeling is wide-spreading for the future of the Long term care insurance (LTCI) in Japan. The long lasting economic slump has made employment of younger generation unstable, which becomes an important reason of negative feeling among them for the sustainability of social security system. On the other hand, the aged also confronts the increase of LTCI premium because of increase in LTCI services consumption. The aged people feel the amount and quality of services might be insufficient compared with their financial contribution. The Japanese LTCI is not formulated to cover all care needs that the frail elderly have, even though the Japanese LTCI scheme offers a wider range of services compared with that of other countries. Too much dependency on the LTCI scheme among the citizen, the providers and governments must re-consider. If we want to realize an active aged society, we have to construct an appropriate mix of self-help, mutual assistance and public assistance. This requires for all citizen to have some responsibility for their community as some frontier programs teach us. The dependency prevention program that was introduced by the 2006 LTCI reform, must be re-considered as a tool for community movement.

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In 2000, the Japanese government implemented the Long Term Care Insurance (LTCI) as a new scheme for the frail elderly in order to socialize the ADL care services for the dependent elderly. After 12 years of implementation, LTCI has become an important infrastructure to support the QOL of frail elderly. This situation has caused, naturally, a large increase in users and expenditures. LTCI expenditures have increased from 3,953.5 billion JPY in 2000 to 7,930.8 billion JPY in 2010. The average monthly premium has increased from 2,911 JPY to 4,972 JPY in 2012. This rapid increase of LTCI expenditures are one of the most important political issue for today’s Japanese society. In 2012, the Japanese government has 10 trillion of debt. As the expenditure of social security is the largest among national budget, the reform of social security system becomes an urgent political issue for the Japanese society. In order to maintain the universal coverage of LTCI scheme, policies are needed to reconcile projected demand for (and cost of) LTC, with financial sustainability. A toolkit of policies to strike this delicate balance between fairness and fiscal sustainability is now to be prepared. We have to overhaul our LTCI scheme from the following four viewpoints; reducing the demand for care, cost-sharing on LTC benefits, an appropriate mix of formal and informal service and reconfirmation of principle of LTCI scheme among the citizens.

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Japan has moved toward socialization of care for the frail elderly by introducing a public, mandatory Long Term Care Insurance on April 1, 2000. The program covers both home-based and institutional caregiving. The budget of the insurance is based on fifty percent from the general tax and another fifty percent from the premium of the insured. The eligibility process begins with the individual or his/her family applying to the insurer (usually municipal government). That is followed by the two-step assessment process that determines the limit of benefit. The first is on-site assessment using the 79 items of standardized questionnaire. The 74 items are analyzed by the official computer program to classify applicant into one of 7 levels of dependency or to reject eligibility. In this article, the authors explain this logic in detail.

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As Japan tries to balance the volume of long term care for the aged and its financing by promoting the preventive activities for slightly frail elderly, a simple case finding instrument is needed in order to implement really effective programs. For this purpose, the MHLW has introduced a 25 items questionnaire for case finding. However, this instrument is considered inappropriate because of its low sensitivity. In order to improve the situation, we have developed an 8 items’ simple questionnaire, so called Quick 8. According to the ROC analysis based on the data of 289 aged who received the secondary in-depth assessment, It seems the criteria “more than equal 4 (sensitivity=1.00 and specificity =0.714)” is appropriate as threshold. The effectiveness and validity of this new instrument must be examined by larger scale of field studies in future.

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