Bonnie Ewald, former Program Coordinator with Health & Medicine’s Center for Long-term Care Reform and the Chicago Area Schweitzer Fellowship, left Health & Medicine in August 2015 and has been traveling around the U.S. and abroad since. In this guest post, she shares some public health-related insights from Japan. (For more on her travels, visit her blog at bgewald.tumblr.com.)

In my time at Health & Medicine, I was exposed to a range of issues related to population health, piquing my interest in continuing to work around developing effective systems to meet the healthcare and social needs of aging populations. We face many challenges in achieving this: people are living longer; Medicare only covers a fraction of the things they really need to have good quality of life as they age; we rely on the unpaid work of family members (more often than not, women) and the underpaid work of domestic care workers; and only a small fraction of older adults have private long-term care insurance to cover things like extended nursing home stays or in-home support to meet their daily needs. On top of that, a lifetime of social, economic, and environmental factors accumulate resulting in vastly different quality of life and support needs for those on opposite ends of the socioeconomic spectrum – so inequalities abound.

Countries all over the world – including Japan, Taiwan, and several in northern Europe – are facing similar challenges due to rapid population aging. In fall 2014, while attending the American Public Health Association (APHA) annual conference in New Orleans along with a few other staff from Health & Medicine, I met a researcher, Dr. Yoko Kawamura of Kumamoto University in southern Japan, studying the Japanese government’s policies with regard to aging and long-term care insurance, and how local communities are reacting. At the time, I was already planning a winter 2016 trip to Japan (where my brother and his family are stationed with the U.S. Air Force), so I was excited to connect with her. We stayed in touch, and now that I am actually in Japan, I was lucky to be able to meet with her for a few days! My visit fortuitously overlapped with two faculty members from the University of Georgia – Athens, who were visiting to explore the possibility of starting a short study abroad experience for their undergraduate public health students – so we were able to make visits to a few communities the students may spend time in. The info I share here is a mix of insights I learned from my conversations in these visits, and from some background reading from the Lancet, and I’d like to qualify it all by saying these issues are of course very complex and that my short immersion has likely simplified much of it.

Japan’s Aging Population
About 1 in 4 Japanese is 65 years old or older. Due to a lower-than-replacement birth rate (1.3), the proportion of 65+ year olds is estimated to rise to 1 in 3 by 2030. Japanese women have the longest life expectancy in the world at birth – 86.4 years (compared with 81.2 for women in the US). In our visit, we met with city leadership from a nearby town of 17,000 residents that is expecting a net population loss of 6,000 in the next 25 years. We also visited with the nurses from the public health department of a different municipality (36% 65+), as well as leaders from a farmers’ cooperative and community-building organization in a small village of 235 people (47% 65+). All of the communities we visited are considered rural, and on top of the general aging phenomena the country faces, are grappling with the rapid urbanization of their young people. (The short documentary Brain Drain gives a nice overview of the challenges the villages are facing.)

They all showed ingenuity and hope in being able to figure out a way forward, though. The farmers’ co-op, in anticipation of TPP reducing the market value of the high-end rice they produce, are taking on initiatives that will support the co-op farmers moving forward – growing and producing biofuels to run their farm equipment, hosting farming workshops for youth, adapting farming practices so people with aging-related ailments can still farm if they’d like, and providing eco-tourism opportunities including homestays and educational workshops. One of the municipalities is engaging older adults as community-health workers of sorts to provide social connection and basic health outreach. Kumamoto University itself is working to promote connections with these initiatives (a major reason we were meeting with them, in the first place!) – including a federally-funded initiative to provide interdisciplinary and community engagement for its medical and pharmaceutical research graduate students. It was so neat to meet with people working on all of these initiatives – initiatives similar to many in the U.S. that Health & Medicine supports.

Japan’s Health Care Landscape
To put this all in context, here’s some background on the healthcare system. Japan has had universal healthcare coverage since 1961, a combination of employer-provided and public option, with reimbursements for low-income and low-asset families. Their healthcare system achieves great results for comparatively little money (Japan is ranked as having the best health status in the world, yet spends 10.3% of GDP on healthcare, vs. the US’s 17.1%) even though it is a fee-for-service system and the delivery system is predominantly private hospitals and providers. This is in large part due to their nationally uniform fee schedule – none of the wide-ranging “chargemaster” rates negotiated behind back doors like we have in most US states.

One specific aspect about the Japanese healthcare system that impressed me was their robust maternal-child health initiatives. Each municipality’s public health department is actively involved in ensuring prenatal, post-natal, and child wellness care are all procured in a timely fashion. Japan actually has a nation-wide “Maternal and Child Health Handbook” that a pregnant mom receives upon registering her pregnancy at the public health department (which everybody does) and serves as a universal document that is to kept up-to-date from pregnancy until the child turns 18 – keeping track of things like rates of breastfeeding, height and weight, oral health, vaccinations. In our meeting with the public health nurses, a few Japanese people in the room proudly claimed that they still have their books today. While most births take place in hospitals, there is a shortage of OB-GYNs, and medically unnecessary C-section rates are low (0.4% vs 10.8% in U.S. – likely due to a few things, including a different culture of much less medicalization of birth and not having wide use of epidurals or other anesthesia, which can complicate the pushing stage of labor).

After the birth, moms are given lots of time to stay in the hospital, allowing for family visits and a visit from the public health nurse – after an uncomplicated birth, moms can stay in the hospital room for up to 5 days (many U.S. hospitals are 1 day). In terms of follow-up appointments, if parents miss the 6-week or 3 month check-up appointment and are unresponsive to telephone and mail outreach from the public health department, child protective services get involved (and the agencies seem to work efficiently and effectively together). When asked if there is an anti-vaccination movement at all in Japan, the nurses looked confusingly at us and shook their heads. In terms of services provided for adults of all ages, the public health departments often provide activities such as health fairs, exercise classes, and social support groups. Frequent hospitalizations do not seem to be a cause for concern.

Despite these many successes of the healthcare system, significant issues remain. The biggest red flag for me is the stigma around mental health issues. Apart from post-partum moms, nobody is routinely screened for depression or anxiety, and there is not wide availability of services such as psychotherapy (talk therapy), much less art therapy or other creative therapies that have been shown to be extremely effective in the U.S. – and there are less clear licensure standards for those that do offer counseling services. Stress and other potential symptoms are typically internalized to not shame one’s family. This is even more alarming given Japan’s high rates of cigarette smoking, alcoholism, and suicide attempts (all of which are the most common among working-age males).

I would be remiss to not mention the pervasive gender gap in economic and social roles in traditional Japanese culture, although this is changing as more and more women are working, especially young women. While the government is implementing measures to try to promote more paternity leave (as part of a range of initiatives to increase childbirth rates to try to address the aging conundrum), the latest survey showed that just 2.6% of new fathers take leave. Hormonal birth control pills were not legalized until 1999; they are still not widely used and are not covered by health insurance. However, early-term abortion seems to be more culturally accepted than in the U.S., possibly in part due to religious differences. There seems to be much room for improvement in terms of having a more open society for discussions of sexual and reproductive health across age spans.

The State of Long-Term Care in Japan
Now, back to aging, which is what started my interest in studying Japan’s public health system. After getting universal health coverage, one big issue presents itself: health coverage does not include social support services that help prevent the advancement of chronic conditions and maintain wellbeing and safety – services such as in-home support for daily activities, meal delivery services, or long-term nursing home care – known in the U.S. as “long-term services and supports” (LTSS) or “long-term care”. (Note that Medicare does not cover this either, leaving many people to rely on family caregivers or spend down their assets to qualify for Medicaid; a huge issue we face in the U.S.) In traditional Japanese society, daughters or daughters-in-law were expected to provide such care for aging parents; however, with more women in the workforce and a declining ratio of adult children to aging parents, Japan’s government anticipated the need to develop a system to provide LTSS, both community-based and institutional (in a nursing home).

So, in 2000, they launched a public system of mandatory long-term care insurance for those 65 and older, with varying benefit levels based on one’s physical need. (For those curious, it is funded by a combination of “premiums” from all individuals over 40 years old, general tax revenue, and a co-pay of 10% for those receiving services [capped or waived based on income]. Once one’s need level is identified [via an assessment by the local public health department], she can choose which services she’d like to “purchase” to meet her needs, and from which providers, up to the corresponding maximum benefit. Individuals can also elect to have a care manager who helps with service selection and coordination, for no out-of-pocket cost; such care managers receive a 44-hour training, none of which touches on counseling techniques – another sign that mental health is an afterthought in much of the Japanese care system.)

After working through some kinks and adjusting some of the financing, the long-term care insurance system is working overall and is largely well-liked. However, it still faces the challenge of having an increasing pool of people to cover and fewer people paying premiums; reducing eligibility and benefit levels is seen as politically unwise (such a move would not only reduce individuals’ benefits, but would likely increase costs paid out down the line by other agencies, such as by health coverage), so they may need to implement reforms to the calculus of premiums, tax revenue, and co-payments – and have changing expectations with regards to retirement age. Time will tell! But for now, the Japanese health system – and the challenges it faces—has many parallels to the U.S., something that all of us interested in population health, aging, and health policy can learn from.