Universal health coverage in the context of population ageing: catastrophic health expenditure and unmet need for healthcare.

BACKGROUND: Universal health coverage means that all people can access essential health services without incurring financial hardship. Even in countries with good service coverage and financial protection, the progress towards universal health coverage may decelerate or be limited with respect to the growing older population. This study investigates the incidence/prevalence, determinants, and consequences of catastrophic health expenditure (CHE) and unmet need for healthcare and assesses the potential heterogeneity between younger (≤ 64 years) and older people (65 years≤). METHODS: Utilising an annual nationally representative survey of Japanese aged 20 years and over, we estimated the incidence of CHE and unmet need for healthcare using disaggregated estimates by household members' age (i.e. ≤64 years vs. 65 years≤) between 2004 and 2020. Using a fixed-effects model, we assessed the determinants of CHE and unmet need along with the consequences of CHE. We also assessed the heterogeneity by age. RESULTS: Households with older members were more likely to have their healthcare needs met but experienced CHE more so than households without older members. The financial consequences of CHE were heterogeneous by age, suggesting that households with older members responded to CHE by reducing food and social expenditures more so than households without older members reducing expenditure on education. Households without older members experienced an income decline in the year following the occurrence of CHE, while this was not found among households with older members. A U-shaped relationship was observed between age and the probability of experiencing unmet healthcare need. CONCLUSIONS: Households with older members are more likely to experience CHE with different financial consequences compared to those with younger members. Unmet need for healthcare is more common among younger and older members than among their middle-aged counterparts. Different types and levels of health and financial support need to be incorporated into national health systems and social protection policies to meet the unique needs of individuals and households.

Economic effects of healthy ageing: functional limitation, forgone wages, and medical and long-term care costs.

This study aims to estimate the potential economic benefits of healthy ageing by obtaining estimates of the economic losses generated by functional limitations among middle-aged and older people. Utilising two data sources retrieved from nationally representative samples of the Japanese people, we analysed the association between functional limitation and economic indicators, including labour market outcomes, savings, investment, consumption, and unpaid activities among individuals aged ≥ 60. Using the estimated parameters from our micro-econometric analyses and the official statistics by the Japanese government and a previous study, we calculated the financial costs that can be averted if healthy ageing is achieved as foregone wages and formal medical/long-term care costs incurred by functional limitations. Our micro-econometric analyses found that functional limitation was associated with a 3% point increase in retirement probability, with a stronger association among those aged 60-69. Moreover, functional limitation was linked with higher total health spending and less active involvement in domestic work. Foregone wages generated by functional limitation were estimated to be approximately USD 266.4 million, driven mainly by individuals in their 60s. Long-term care costs, rather than medical care costs, for older people aged ≥ 85 accounted for most of the additional costs, indicating that the estimated medical and long-term costs generated by functional limitations were approximately USD 72.7 billion. Health interventions can yield economic benefits by preventing exits from the labour market due to health issues and reducing medical and long-term care costs.

An overview of systems for providing integrated and comprehensive care for older people in Japan.

As longevity occurs, people encounter various risks associated with ageing, including economic uncertainty and health issues. Therefore, in addition to extending healthy life expectancy, it is crucial to create an environment where older people can live better even when their intrinsic capacity declines. Additionally, integrated and comprehensive care for older adults is needed to maintain their functional ability and well-being at higher levels. This review provides an overview of the systems and initiatives in Japan, a forerunner of population ageing that supports the quality of life of older people and summarises their remaining challenges. In Japan, with support for access to necessary care available from social welfare councils and community comprehensive support centres, various health and welfare services are provided to respond to the needs of people with different levels of intrinsic capacity, including medical care, preventive care, long-term care, adult guardianship systems, pensions, and social assistance. Nevertheless, there are challenges for the systems, including the gap between life and healthy life expectancy, moderate accumulation and decumulation of retirement assets, lack of human and financial resources for care, and user-unfriendliness and non-covered needs of the current system. Therefore, integrated and comprehensive care beyond health and long-term care is needed to maintain the well-being of older adults, even with their intrinsic capacity declining.

Living Alone and Depressive Symptoms Among Older Japanese: Do Urbanization and Time Period Matter?

OBJECTIVES: Previous research has suggested cross-national differences in the association between living alone and well-being among older adults. This study examined whether the association varied across social contexts within the country, Japan, in terms of varying degree of urbanization and differential time periods. METHODS: Data were obtained from a nine-wave nationwide longitudinal survey with a probability sample of Japanese adults aged 60 years and over. Respondents belonged to one of the three periods (around 1990, 2000, and 2015) according to the year they commenced participation. As many as 4,655 individuals from 575 municipalities provided 9,016 observation sets of two consecutive waves (t - 1 and t). Within a framework of the Hierarchical Generalized Linear Model, depressive symptoms at t were predicted based on changes in living arrangements from t - 1 to t and their cross-level interactions with gender, level of urbanization, and time period, controlling for various covariates at t - 1. RESULTS: In general, older adults living alone continuously as well as those who started living alone between the waves showed more depressive symptoms than those coresiding with someone continuously. However, this tendency was more prominent among rural residents than their urban counterparts, especially for men. Moreover, the effect of continuously living alone on depressive symptoms became smaller in Period 2015 than that in Period 1990, because of the increase in depressiveness in coresident older adults. DISCUSSION: Our findings indicate that living alone has a differential effect on older adults' well-being depending on the social context where residents' preferences for living arrangements and availability of formal services could vary.

The Retirement-Health Puzzle: A Sigh of Relief at Retirement?

OBJECTIVES: While the health effects of retirement have been well studied, existing findings remain inconclusive, and the mechanisms underlying the linkage between retirement and health are unclear. Thus, this study aimed to evaluate the effects of retirement on health and its potential mediators. METHODS: Using a national household survey conducted annually from 2004 to 2019 in Japan (the Japan Household Panel Survey), we evaluated the effects of retirement among Japanese men aged 50 or older on their health, in addition to other outcomes that could be attributed to health changes associated with retirement (i.e., health behaviors, psychological well-being, time use for unpaid activities, and leisure activities). As outcomes are not measured every year, we analyzed 5,794-10,682 person-year observations for 975-1,469 unique individuals. To address the potential endogeneity of retirement, we adopted an instrumental variable fixed-effects approach based on policy changes in eligibility ages for employee pensions. RESULTS: We found that retirement improved psychological well-being, exercise habits, and time spent on unpaid work. The psychological benefits of retirement were no longer observed for longer durations after retirement, whereas healthy habits and unpaid activities continued. Moreover, health-related improvements after retirement occurred mostly in the higher-income group. DISCUSSION: Enhancement in personal quality of life owing to increased leisure time and stress reduction from work in addition to lifestyle changes may be key to understanding the health benefits of retirement. Considering the mechanisms behind retirement-health relationships and potential heterogeneous effects is essential for healthy postretirement lives when increasing the retirement age.

Towards universal health coverage in the context of population ageing: a narrative review on the implications from the long-term care system in Japan.

The two important elements of universal health coverage-(1) enabling everyone to access the necessary health services and (2) providing financial protection from catastrophic health spending-are vital for not only healthcare but also long-term care in the context of population ageing. In this review, we provide an overview of the public long-term care system in Japan to help other countries that are experiencing (or are expected to experience) problems associated with population ageing. Japan's approach to long-term care may not be universally generalisable, given the differences in population/geographical sizes, socioeconomic development, population ageing, and cultures across countries. However, the challenges faced by older people may be common. Japan's long-term care system has several challenges, including financing, labour force shortages, support for people with dementia, an integrated continuum of healthcare and long-term care, and utilising services outside the purview of insurance coverage. We have provided the government's actions and potential directions to address these challenges.

State of emergency and human mobility during the COVID-19 pandemic in Japan.

Introduction: The Japanese government declared a state of emergency (SoE) to control the spread of the coronavirus disease (COVID-19). However, the requirements of these SoE were less stringent than those in other nations. It has not been assessed whether soft containment policies were sufficiently effective in the promotion of social distancing or the reduction of human contact. Methods: Mobility changes across different travel destinations, such as, (a) retail and recreation spaces; (b) supermarkets and pharmacies; (c) parks; (d) public transportation; (e) workplaces; and (f) residential areas, were analysed using the Google mobility index to assess social distancing behaviour in all Japanese prefectures between 15 February 2020 and 21 September 2021. The changes were evaluated through the utilisation of an interrupted time-series analysis after adjustment for seasonality and various prefecture-specific fixed-effects, and distinguishment of potential heterogeneity across multiple SoEs and the time that had passed after the declaration. Results: The mobility index for retail and recreation exhibited an immediate decline of 7.94 percent-points (95%CI: -8.77 to -7.12) after the declaration of the SoE, and a further decline after the initial period (beta: -1.27 95%CI: -1.43 to -1.11). However, it gradually increased by 0.03 percent-points (95%CI: 0.02-0.03). This trend was similar for mobility in other places. Among the four SoEs, the overall decline in human mobility outside the home was the least significant in the third and fourth SoE, which suggests that people were less compliant with social distancing measures during these periods. Conclusions: Although government responses to the pandemic may aid the controlling of human mobility outside the home, their effectiveness may decrease if these interventions are repeated and enforced for extended periods. A combination of these with other measures (i.e. risk-communication strategies) would enable even mild containment and closure policies to effectively curb the spread of the virus.

COVID-19 vaccine hesitancy and vaccine passports: a cross-sectional conjoint experiment in Japan.

OBJECTIVES: While the development of vaccines against the Novel Coronavirus (COVID-19) brought hope of establishing herd immunity and ending the global pandemic, vaccine hesitancy can hinder the progress towards herd immunity. In this study, by analysing the data collected when citizens undergo public health restrictions due to the pandemic, we assess the determinants of vaccine hesitancy, reasons for hesitation and potential effectiveness of vaccine passports used to relax public health restrictions on mitigating vaccine hesitancy. DESIGN: Cross-sectional study, longitudinal study and conjoint experimental design. SETTING: An online survey conducted in Japan in July 2021. PARTICIPANTS: A demographically representative sample of 5000 Japanese adults aged 20-74. PRIMARY OUTCOME MEASURES: COVID-19 vaccination intention RESULTS: We found that about 30% of respondents did not intend to get vaccinated or had not yet decided, with major reasons for vaccine hesitancy relating to concerns about the safety and side effects of the vaccine. In line with previous findings, younger age, lower socioeconomic status, and psychological and behavioural factors such as weaker COVID-19 fear were associated with vaccine hesitancy. Easing of public health restrictions such as travel, wearing face masks and dining out at night was associated with an increase in vaccine acceptance by 4%-10%. Moreover, we found that more than 90% of respondents who intended to get vaccinated actually received it while smaller proportions among those undecided and unwilling to get vaccinated did so. CONCLUSION: With a major concern about vaccine safety and side effects, interventions to mitigate against these may help to reduce vaccine hesitancy. Moreover, when citizens are imposed with restrictions, vaccine passports that increase their freedom may be helpful to increase vaccination rates.

Effect of diabetes and prediabetes on the development of disability and mortality among middle-aged Japanese adults: A 22-year follow up of NIPPON DATA90.

AIMS/INTRODUCTION: To examine the association between diabetes and prediabetes at baseline, and disability, mortality over a 22-year period among middle-aged Japanese adults. MATERIALS AND METHODS: Participants consisted of 1,788 adults aged 45-64 years at baseline from the cohort study National Integrated Project for Prospective Observation of Non-communicable Disease and its Trends in the Aged 1990 (NIPPON DATA90). Disability, defined as having a decline in activities of daily living (ADL), was assessed by a modified Katz questionnaire at four time points. Disability and death without disability for 22-year follow up were used as outcomes to test the association with a diagnosis of diabetes or prediabetes at baseline, using multinomial logistic regression. Adjusted odds ratios (ORs) were obtained from four models that contained appropriate adjustment factors, such as age, sex, smoking status, drinking status, body mass index and cardiovascular risk factors (hypertension, hypercholesterolemia, triglycerides, low serum high-density lipoprotein), at baseline. RESULTS: In the present study, 334 participants (18.7%) reported at least one disability, and 350 (19.6%) were reported dead without observation of disability during follow up. Adjusting sex and other risk factors, participants with diabetes and prediabetes had a higher risk for disability (OR 1.43, 95% confidence interval [CI] 1.07-1.91 and OR 1.66, 95% CI 1.10-2.50, respectively) and for mortality (OR 1.56, 95% CI 1.16-2.08 and OR 1.77, 95% CI 1.18-2.65, respectively) than individuals with normal glucose tolerance. CONCLUSIONS: In middle-aged Japanese adults, individuals with diabetes and prediabetes were more likely to be associated with disability and mortality. Our findings suggest that prediabetes and diabetes in middle-aged adults should be paid more attention, and requires more intervention to prevent disability and mortality in later life.

Retirement and Social Activities in Japan: Does Age Moderate the Association?

Although retirement age is increasing in aging societies, its impact on individuals and communities is unclear. This study examined how age moderates the linkage between transition into retirement and participation in productive and non-productive social activities after retirement, using a nationwide longitudinal survey with a probability sample of Japanese aged 60 and over (n = 3,493). Multinomial logistic regression analyses were performed to predict changes in volunteering and hobbies/learning during 3-5 years of follow-up and their participation level at the follow-up. The significant interactions between change in work status (remained working as reference, full/partial retirement, remained not-working) and age at baseline showed that fully retired persons were more likely to increase these activities than remained workers only when they retired by their early seventies. Thus it is important to encourage engagement in social activities before retirement and remove psychological and environmental barriers that hinder starting new activities at old age.

National Health Spending, Health-Care Resources, Service Utilization, and Health Outcomes.

Cross-national studies of the linkage of health-care spending with population health have found surprisingly limited evidence of benefits. In this study, we investigated associations between national health spending and key health resources (numbers of hospital beds, physicians, and nurses) and utilization of cost-effective health services (antenatal care, attendance of trained staff at childbirth, and measles vaccination), sometimes in ways that curtail the benefits of that expenditure. Using annual panel data from 1990-2014 covering 140 countries, we show that variation in health spending as a share of gross domestic product is not associated with decreased mortality rates. It is also very weakly associated with increased health-care resources and health service utilization (elasticity smaller than 0.08), with the association being close to 0 in low-income countries. In addition, countries with a higher share of out-of-pocket spending have a significantly lower level of health resources and service utilization. These findings, rather than the ineffectiveness of health care, could explain the lack of impact of health spending. In contrast, gross domestic product per capita is significantly associated with increased health resources, a higher rate of service utilization, and lower mortality rates, suggesting that income is an important determinant of public health.

Age, gender, and financial literacy in Japan.

OBJECTIVE: The aim of this study is to investigate the association between financial literacy and age as well as gender differences in financial literacy. METHODS: We analyse a sample of 25,000 individuals from 'The Financial Literacy Survey 2016' conducted by the Central Council for Financial Services Information (Bank of Japan). The analysis focuses on the relationship of age and financial literacy as well as that of age and self-rated financial knowledge. To consider factors accounting for gender differences in financial literacy, we use the Blinder-Oaxaca decomposition method. To further our understanding of financial literacy, we conduct additional analyses on financial behaviour and attitude. RESULTS: Although age is associated with increased financial literacy (Men, ß: 0.249, standard error [SE]: 0.030; Women, 0.354, SE: 0.026), the growth rate decreases among the older respondents (Men, ß: -0.002, SE: 0.000; Women, -0.003, SE: 0.000). However, the association between age and self-rated financial knowledge among men moves in the opposite direction (Age, ß: -0.021, SE: 0.009, Age2, ß: 0.000, SE: 0.000). Furthermore, female respondents are likely to be less financially literate than their male counterparts (ß: -0.586, SE: 0.095) due to gender differences in the distribution of the factors that affect financial literacy (specifically education), their responses to financial literacy, and the interactions of these effects. In contrast to knowledge-based financial literacy, financial behaviour and attitudes among women are more preferable to those among men, namely, more premeditated. CONCLUSION: Financial literacy increases until about one's early 60s, after which it declines, while confidence in financial literacy reflects the inverse trend, especially among men. Additionally, men are more financially literate than women; however, these differences could be mitigated through education. Meanwhile, financial behaviour and attitudes among men are less premeditated. Thus, policies are needed that can help older adults with their financial decision-making, enhance women's financial literacy, and improve men's financial behaviours and attitudes.

Daily steps and healthcare costs in Japanese communities.

Physical inactivity is a pandemic that requires intensive, usually costly efforts for risk reduction of related chronic diseases. Nevertheless, it is challenging to determine the effectiveness of physical activity in healthcare cost reduction based on existing literature. Therefore, this study aimed to investigate the impact of physical activity (daily steps) on healthcare costs utilising the data retrieved from a health promotion project (the e-wellness Project, held in three municipalities in Japan). Evaluating the effects of daily steps, measured by pedometers, on healthcare costs by a quasi-experimental approach among participants aged 40-75 years (about 4000 person-years of observation, between 2009 and 2013), we found that a one-step-increase in the annual average daily step reduced outpatient healthcare costs by 16.26 JPY (≒ 0.11 GBD) in the short run. Based on the assumption of a dynamic relationship between the health statuses in multiple years, the long-run effects of daily steps on healthcare costs were estimated at 28.24 JPY (≒ 0.20 GBD). We determined the health benefits of walking in a sample of middle-aged and older Japanese adults by our findings that an increase in step counts reduced healthcare costs.

Parental socioeconomic status and adolescent health in Japan.

There is no consensus on which parental socioeconomic indicators should be used to define adolescents' socioeconomic status (SES). Utilising the data for 3154 parent-adolescent pairs obtained from the sample of the Survey of Lifestyle Value of Parents and Children 2011 conducted by the Cabinet Office in Japan, the associations between adolescent's subjective economic status, parental SES (i.e. education, occupation, and household income), and child health-related outcomes (i.e. self-rated health, dietary and oral health behaviours) were analysed using multilevel mixed-effects ordered logistic regression to investigate heterogeneity in these relationships across SES indicators and health outcome measures. Results demonstrated that income was the strongest predictor of adolescent health outcomes, suggesting that adolescents in the middle- or high-income groups tended to report better health status compared to the low-income group, have a higher frequency of having breakfast, and more likely to regularly brush their teeth by 24% (OR 1.24, 95% CI [1.06-1.46]) to 66% (OR 1.66, 95% CI [1.30-2.12]). Parental education was also related to child health-related behaviours, with higher levels of habitual healthy behaviours being observed in the middle- and high-education groups than in the low-education group by 15% (OR 1.15, 95% CI [1.01-1.32]) to 63% (OR 1.63, 95% CI [1.31-2.03]). Future studies regarding health disparities among children/adolescents should carefully choose an SES indicator, taking multiple pathways between each SES indicator and health/health behaviours into consideration.

Age trajectories of disability development after 65: A comparison between Japan and Taiwan.

INTRODUCTION: Disability development using age as the axis was void in the literature. Identification of the age trajectory of disability development across populations enables preparation for aging-related policies when conducting cross-national comparisons. This study compared three indicators of the development of physical disability in populations of Taiwan and Japan. METHODS: Data comprised two nationally representative panel surveys (1) the Taiwan Longitudinal Study on Aging (N = 3,037) in 1996-2011 and (2) the National Survey of the Japanese Elderly in 1996-2012 (N = 1,974). Older adults (65+) were examined longitudinally. Activities of daily living (ADL), instrumental activities of daily living (IADL), and mobility disability development during aging were analyzed using multilevel models. RESULTS: After age standardization, Japan reported higher prevalence rate of ADL disability (14.95% vs. 9.65%) but lower IADL (19.30% vs. 30.36%) and mobility disability (36.07% vs. 49.82%) as compared with Taiwan. ADL limitation occur (ADL limitation>=1) at the age of 77.9 and 77.2 for populations in Japan and Taiwan, respectively. Populations reached three ADL limitations at the age of 86.7 and 85.0 in Japan and in Taiwan, respectively. IADL limitation occur (IADL limitation>=1) at the age of 79.1 and 74.5 for populations in Japan and Taiwan, respectively. Mobility limitation occur (Mobility limitation>=1) at the age of 70.7 and 65.3 for populations in Japan and Taiwan, respectively. CONCLUSIONS: Older adults generally do not report ADL limitation until 77 and do not face serious disability until 85 or 86 in Taiwan or Japan, respectively. Mobility limitation occurs at a various age in different countries.

Increase in suicide following an initial decline during the COVID-19 pandemic in Japan.

There is increasing concern that the coronavirus disease 2019 (COVID-19) pandemic could harm psychological health and exacerbate suicide risk. Here, based on month-level records of suicides covering the entire Japanese population in 1,848 administrative units, we assessed whether suicide mortality changed during the pandemic. Using difference-in-difference estimation, we found that monthly suicide rates declined by 14% during the first 5 months of the pandemic (February to June 2020). This could be due to a number of complex reasons, including the government's generous subsidies, reduced working hours and school closure. By contrast, monthly suicide rates increased by 16% during the second wave (July to October 2020), with a larger increase among females (37%) and children and adolescents (49%). Although adverse impacts of the COVID-19 pandemic may remain in the long term, its modifiers (such as government subsidies) may not be sustained. Thus, effective suicide prevention-particularly among vulnerable populations-should be an important public health consideration.

Decomposition of gender differences in cognitive functioning: National Survey of the Japanese elderly.

BACKGROUND: It is well known that females generally live longer than males, but women tend to suffer from more illnesses and limitations than men do, also for dementia. However, limited empirical evidence is available why this 'male-female health-survival paradox' is observed. This study aimed to investigate factors which account for gender differences in health, particularly cognitive functioning and decline among older adults. METHODS: Data were retrieved from the National Survey of the Japanese Elderly, which is a longitudinal survey of a nationwide representative sample of Japanese adults aged 60 or over. Gender differences in cognitive functioning and decline in three-year follow-ups were decomposed using Blinder-Oaxaca decomposition analysis, regarding demographic, socioeconomic, and health-related factors into the 'explained' component, by differences in individual attributes listed above, and the 'unexplained' component. RESULTS: Empirical analyses showed that women's lower cognitive functioning was partly explained by the endowment effect. Moreover, a shorter duration of formal education and a larger proportion with their longest occupation being domestic worker accounted for steeper cognitive decline and more prevalent mild cognitive impairment in women than in men. CONCLUSION: This empirical study suggested that gender differences in cognitive functioning and decline account for different individual attributes of social determinants among men and women. Particularly, men seem to be more engaged in activities which accumulate intellectual experiences through education and occupation, as suggested by the cognitive reserve hypothesis.

Social Isolation and Cognitive Functioning: A Quasi-Experimental Approach.

OBJECTIVES: This study aimed to assess the relationship between social isolation and cognitive functioning. METHOD: Data were retrieved from the National Survey of the Japanese Elderly, a nationally representative sample of Japanese adults, aged 60 years or older. We estimated a social isolation index to incorporate variables, such as social interactions, social engagement, and social support, with perceived social isolation, for a comprehensive measurement. The association of social isolation with cognitive functioning was assessed using a panel data fixed-effects model, controlling for age, socioeconomic status, health-related variables, and time-invariant heterogeneity. Moreover, we conducted analyses using the System Generalized Method of Moments (GMM) to address the dynamic relationship of cognitive functioning and potential endogeneity. RESULTS: For both men and women, the association between social isolation and cognitive functioning was significant, particularly among those aged 75 or older, as a 1% increase in social isolation was associated with decreased cognitive functioning (24% decrease for men and 20% decrease for women). However, this association was not confirmed by the System GMM, after addressing endogeneity. DISCUSSION: Our findings potentially suggest that the association between social relationship and cognitive functioning reported in previous studies was biased, due to endogeneity. Although we did not observe causal impacts, this does not necessarily mean that social isolation does not have a negative impact on health, as both positive and negative consequences of social relationships may exist. Further research is needed to reveal the causal relationship, as well as the detailed mechanisms of health effects of social relationships.