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Comparative-Study-on-the-Public-Long-Term-Care-Insurance

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Comparative-Study-on-the-Public-Long-Term-Care-Insurance

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									            Long-Term Care Policy in South Korea and Japan
                     : From a Gender Perspective




This paper will be presented at the RC19 annual conference at Florence University, 6-8
September 2007.




                                      Si Yeon Won
                  (BK21 Governance Programme, Sung Kyun Kwan University)
              Long-Term Care Policy in South Korea and Japan
                       : From a Gender Perspective


                                                                              Si Yeon Won


                                            Abstract


       Ageing has been one of the most important social issues in South Korea and Japan.
       This paper seeks to examine the two countries’ Long-Term Care (LTC) policy from
       a gender perspective, which focuses on different impact of LTC policy to both
       genders. In particular, this paper adopts the perspectives for care-givers and care-
       receivers in order to analyze the gendered nature of LTC policy. In the care-
       receiver’s side, women are expected to be the main beneficiaries of LTC, because
       the portion of women in the elderly is much bigger than that of men. However,
       women are more likely to fall outside LTC insurance, partly because social
       insurance system itself has been based on economic contribution of the insured
       and partly because the gendered labor market structure has marginalized women’s
       status in employment. As women’s economic conditions have been restricted by
       their care-giving roles within families and irregular economic careers which can
       affect their old-age pension, women’s access to the public LTC service are likely to
       be limited. In the care-giver’s side, women’s care has not been appreciated fully
       whether it is paid or not because of the gendered nature of care. Until recently
       women’s responsibility of care-giving within households has been taken for
       granted; nevertheless, different conditions which both gender has faced have not
       been considered as significantly in Korea and Japan. Therefore, the investigation
       on the different gender impact of LTC is meaningful to South Korea and Japan.
       Key Words: Long-Term Care (LTC), South Korea, Japan, Gender



Introduction

Not until the early 1990s, did the mainstream welfare state research start to consider gendered
characteristics of the welfare state. Care responsibility has been regarded as in the private sphere,
and it has been taken for granted as women’s role within families. The maintenance of a
traditional family is one of the longstanding principles of care provision.



                                                                                                   2
         However, care is now a widely seen in the domain of the welfare state, as social risks
from ageing, low fertility, increase of women’s economic participation, and changes in labor
market structure have weakened the “male breadwinner model” of family (Lewis, 2001). Care is
very much provided in the “mixed economy” (Daly and Lewis 2000). It is, however, difficult to
decide how to share the burden of care among the family, the state, the market and the voluntary
sector; in other words how to shape the “care diamond” is the issue we need to take on.
         While the recent policy trend emphasizes de-familialisation and commodification of
care, care can neither be fully de-familialized nor fully commodified because care is embedded
in personal relationships of love and obligation (Giullari and Lewis, 2005). As Leira (1993)
argued, care can be paid or unpaid for, public or private, subject to cash payments or service
provision, and contractual or non-contractual. Nevertheless, the value of care has been
underestimated by the reason that care has been feminized in the society.
         This paper will analyze care, especially long-term care (LTC hereafter) for the elderly.
There have been a large body of feminist work regarding gender equality and care, but much of
the research deals with childcare issues (Hammer and Österle 2003) while the perspective of
care-givers has been applied. But care has always two sides, the care-giving and care-receiving.
This paper will adopt both perspectives of care-givers and receivers and examine long-term care
policies in Korea and Japan. Such approach will enable us to see gender relations regarding
social inequality and poverty not only in terms of care-givers but also care-receivers with
respect to LTC.
         While undertaking research on ageing and care, there is a tendency to see old people as
a cluster of people without giving due attention to their gender. The age of 60 or 65 has been the
only demarcation line to classify old people. Although some data give us useful information
about the elderly by gender, research on the elderly with a gender specific perspective is far and
few between.
         While examining care giving and care receiving, it is necessary to be gender specific to
get a precise nature of care. Gender perspective investigates whether gender affect people’s
opportunities, social roles and interactions differently. Gender perspective helps to capture the
different situations, priorities and needs of women and men in their daily lives and also to
examine the different impacts of policies and programmes on both genders.
         Many feminist scholars have produced analytical frameworks for welfare state and care
(Daly and Rake 2003). According to Sainsbury (1999), the frameworks can be divided into two
alternative approaches. One approach incorporates gender into the existing welfare state regime
concept. For example, Orloff (1993) refashions Esping-Andersen’s dimensions of variation,
rights and de-commodification. She then reclassifies three regime-types incorporating family
relations, gender stratification, access to paid work, and the capacity to form and maintain an



                                                                                                3
autonomous household. The other approach highlights gender in isolation from mainstream
theoretical framework. Lewis and Ostner (1991) have taken the male breadwinner model as a
point of departure1. It is an alternative categorization of welfare state regimes based on the
gender division of labor. Whichever approach is more feasible, both approaches are critical of
the mainstream theories on welfare states for their neglect of gender. Theoretical contribution of
feminist studies to the welfare state theory is that they brought the care back in and re-
conceptualized it as a mixed economy.
          Although I believe that the welfare regime approach could help us to understand the
big picture of the welfare state, and that feminist regime theories have given us insights about a
gender perspective, the notion of regimes is not always appropriate to undertake small but
detailed individual cases. Particularly when we focus on two counties, which are considered as
in a same group of regime, it is necessary to think over more specific factors rather than a
regime. Institutions and the political actors within them can be crucial factors.
          In this paper, we will first examine the political context of LTC in Japan and Korea in
order to find out how politics has shaped LTC policy. Secondly, we will examine the LTC policy
from both perspectives of care-giving and receiving, which will enable us to see its gendered
nature.



Policy Context of Long-Term Care


1> Japan


Since the early 1960s, Japanese government has introduced a series of welfare plans and
programmes for the elderly. Especially in 1973, so-called “the first year of welfare,” there was a
big change in welfare system and the health service system for the elderly. Government had
provided public care service for the elderly with low income by general tax, which was similar
to current LTC. And people over 70 could enjoy free medical service. The medical expenses
were funded by national health insurance.
          In 1989 the Japanese government introduced the Gold Plan (the Ten-Year Strategy to
Promote Health Care and Welfare for the Elderly) and subsequently New Gold Plan in 1994 in
order to reform the existing care system for the elderly.
          At the beginning, the Gold Plan was designed as a universal tax-based system,
although it was different from the Scandinavian model in focusing on the elderly only. Gold
Plan was approved by the Cabinet and subsequently included in the election promises. Tax-
based model was favored by nearly all organizations, most academic experts, and a substantial



                                                                                                4
number of officials at the Ministry of Health, Labor and Welfare which has been charge of Gold
Plan in central government (Campbell and Ikegami, 2003).
         Nevertheless, Japan changed its system into social insurance model (Gold Plan 21).
Such change was brought about in consideration of the mobilization of revenue. Social
insurance model is less constrained by the national budget than tax-based model. And insurance
premiums can help government have a stable source of revenues (Tsutsui and Muramatsu, 2005).
Most of all, it was believed that new social insurance contribution would be acceptable, because
LTC policy had explicit objectives, such as socialization of care. It would also increase the role
of local government in social policy. The LTC of the Gold Plan 21 was also expected to save
cost of the medical care for the elderly. The LTC would also give the care-receivers choices for
their care (Campbell and Ikegami, 2003).
         The LTC policy also had implicit but critical goals, such as reduction of “social
admissions,” unifying existing institutions, and encouraging community-based care rather than
institutional care to save health expenditure for the elderly, because the size of deficit in national
health insurance had been in high increase since 1992.
         It was 1993 that the government brought about LTC in the domain of public debate.
Bureaucrats in the Ministry of Health, Labor and Welfare had talked about the possibility of
fifth social insurance (Okamoto 2000; Takechi 2003; Cho 2005). It could be a best choice
without giving up the Japanese traditional policy trend.
         The government decided to leave much room for high quality services which had been
provided by privately. The LTC plan was introduced to the insurance companies earlier than to
the public in order to discuss the details of LTC. The coexistence of public LTC institutions and
private LTC service meant that the coverage of public LTC insurance would be restricted in
order not to damage the private insurance companies and the care burden of family members
would still remain (Cho 1997).
         The LTC in the format of social insurance would be financed by a flat-rate
contributions and consumption tax, which would then be regressive in terms of impact on
income distribution. That’s why the Japanese LTC was criticized as pro-market policy. It was
considered as an abandonment of public responsibility for elderly care and no more than a
replacement of social expenditure by private expenses (Shibata 1995; Cho 1997) rather than the
expansion of social security system and socialization of care.
         Before we move to next section it is worth noting that there is no cash allowance in
 Japanese public LTC. It is said that feminist movements have made a strong objection to the
 idea of cash allowances (Eto, 2001). They argued that cash allowances like German LTC
 would not change exiting care-giving patterns, because cash allowances could not relieve the
 excessive burden placed on the family care-givers, mostly women. They believed that cash



                                                                                                    5
 allowance has a tendency to justify and fix family members’ care-giving as a norm, although
 family members can choose as consumers many alternatives with cash.


2> Korea


Social policy in Korea has been driven and utilized by the state in order to facilitate
industrialization (Kwon 2005). Four social insurances such as Industrial Accident Insurance,
National Health Insurance, National Pension Program, and Employment Insurance Program are
the main contour of the Korean welfare state.
         With respect to the elderly, the Welfare Law for the Elderly was established in 1981.
Based on the Law, Korean government has carried out a range of programmes for the elderly.
Welfare facilities could be registered at and monitored by the MOHW. New provisions for old-
age pension for the poor elderly bracket were added in the 1997 revision. When the elderly
population reached 7 percent of the total population in 2000, the Korean government began to
take ageing issues seriously.
         Being aware that Japanese LTC insurance programme would be introduced shortly, the
Korean government started paying attention to LTC policy as a new social policy agenda. After
the economic crisis in 1997 was by and large sorted out, government set the task force to review
a range of possibilities. It is noteworthy that the Korean government has paid attention to LTC
as a part of “the productive welfare” initiative just after the sign of economic recovery.
         In 2001 at the National Liberation Day Celebrations, the President Kim Dae Jung
announced that the government would introduce public LTC plan. After the president’s talk,
government made a Ten Year Master Plan to expand the health and welfare facilities for the
elderly in 2002.
         The idea of introducing LTC was certainly influenced by Japanese LTC, but there were
other considerations for which the Korean government decided to introduce LTC. Above all, the
LTC policy was considered as job-creation industry. According to the public hearing on LTC
policy in 2001 hosted by KIHASA, the government sponsored research institute for health and
social welfare, the first object for LTC would be job creation on a large scale for the female
unemployed of low income bracket. The report presented at the hearing profusely argued that
the LTC would have very potential power for job creation. Once again, new social policy has
been designed as an instrument for economic development rather than the intrinsic goal of social
protection in Korea (Kwon 2005).
         In addition, financial consideration was another important reason, because the medical
expenses for the elderly, who were approximately 7% of total population, reached up to more
than 20% in 2000. Although there have not been social admissions in Korea as in Japan, it is



                                                                                              6
expected that the LTC system can reduce the deficit in health insurance for health expenditure
for the elderly.
          At last, the LTC plan was included in the presidential election manifesto of the
governing candidate at the end of 2002. After the governing candidate won the election, LTC
was again included in “the 100 tasks of Roh Moo-hyun Administration” in 2003. The political
debates for the new social agenda have focused on demographic data and social risks such as
ageing and low fertility in order to get public support.
          The Ministry of Health and Welfare (MOHW) established the public LTC Initiative
Committee composed of bureaucrats, academic, policy experts, professionals, interest group and
civil society members. The appearance of the LTC Initiative Committee looked desirable at first
glance because of its government-society network. How was the role of NGOs in policy making
process? Regarding LTC policy, civil society actors played as supporters for government-led
LTC policy. Particularly the associations for the elderly and women’s associations strongly
backed the LTC policy up, because they believed they would be the main beneficiaries of LTC
policy.
          Unlike Japan, cash allowance was not the main issue of women’s associations. It
seemed that the top policy priority would be placed on regulation of social care. At the several
public hearings, main policy issues were about training programmes for care-givers, assessment
process as a substitution of prior means-tested. In contrast, the quality of service provisions and
the satisfaction of care-receivers, let alone gender equality and social rights were hardly
mentioned.
          Germany, Austria, Belgium, Luxemburg, Netherlands, and Japan have implemented
the LTC policy as a social insurance, while most of other countries provide LTC based on tax
revenue and principle of universalism. In that sense, it is necessary to question why Korean
government wanted to introduce LTC as a new social insurance.
          Korean LTC has been designed as social insurance-type and the state still remains as a
“regulator” rather than “provider” (Kwon 2001). It seems as if the state concerned only about
the introduction of new social insurance without any substantial change. The function of finance
and social service provision has been under the private sector or agency like The National
Health Insurance Corporation which was selected as insurer of Korean LTC.
          It is interesting to see that the associations for care workers started to criticize
government’s LTC plan just after the Laws on LTC had been enacted. They insisted that Korean
LTC should have care manager system like U.K and Japan, which government refused to accept.
Government has maintained that the National Health Insurance Corporation would monitor the
whole process of LTC services without any problem. The crucial point of the arguments seems
to be related with the issues of care-providers and care-regulators. There has been a sharp



                                                                                                 7
conflict of opinion on this point.



Demographic Background


          In respect to the introduction of LTC insurances, we can find very big discrepancy
between the political rhetoric and reality. Particularly the demographic data has been utilized as
a critical point of departure in explaining the necessity of LTC insurance. However, there is very
different fact that Korean LTC is not so urgent as the government argues. Therefore it is
necessary to examine demographic data carefully.
          According to the statistics, Japan is already a super aged society with 20.5% of total
population is old people, while Korea is an ageing society (9.4%). The percent of the elderly is a
demarcation line for the ageing society (7%), the aged society (14%), and the super aged society
(20%).
          Concerning LTC, the rate of the oldest elderly (Age 80+) among the elderly (Age 65+) is
important. If the rate is high, it means that long-term care service is quite necessary, because a
third of age group 80-84 and two thirds of age group 85+ need LTC according to Japanese
statistics (KIHASA, 2004). As ageing society reaches to aged society, the percentage of oldest
old group will be higher than before. In Japan, the percentage of female oldest old group is
nearly 30% in 2005, while that of Korea (17.5%) is much lower than Japan.
           Of course, the time span in <Table 1> shows how fast the demographic ageing is
taking place in Korea. Elderly care issue has been caught big attentions in Korea and Japan,
because the speed and the scale of ageing are faster and greater than other OECD countries
(Chen and Kwon, 2006). However, Korean ageing society is not as urgent as Japan. Regarding
an estimate (NSO, 2005), the rate of the elderly in South Korea will be 14% in 2018, while
Japan accepted LTC (Kaigo Hoken) in 2000 when the percentage of the elderly was 17.0%. The
figure says that Korean case has time, at least 10 years, to think over new social policy system.


<Table 1> the Speed of Demographic Ageing
                Year reaching the proportion of the elderly   Time span
                7%             14 %            20 %           7 to 14 %   14 to 20 %
 Korea          2000           2018            2026           18          8
 Japan          1970           1994            2006           24          12
 France         1864           1979            2019           115         40
 USA            1942           2014            2028           72          16
Source: National Statistical Office (2005)



                                                                                                    8
       Rather than the population itself and ageing, we can find more serious social risks in
gendered nature of society. Regarding households, in Korea, the size has been declining from
4.5 to 2.9 during last 25 years. At the same time, single member household has increased steeply
from 4.5% to 20%. In Japan, the size of household was already 2.99 in 1990 and 2.52 in 2006.
The percentage of one member household has increased steeply in both countries. Especially the
elderly-only households are more common than before. The rate of single-member elderly
households increased from 21.3% in 1995 to 24.7% in 2005 of the total single-member
households during last decade. Even in Japan, the rate is over than 30% in 2006. And among
elderly households, the female households are more than 80% of all in Korea and 75.6% in
Japan in 2000. The change in family structure is significant since the traditional family with
three generations living together has been regarded as the main site of social care.
       In addition, the average life span in both countries can show how ageing issue can be
related with gender. In 1981, life expectancy for men was 62.3, while that of women was 70.5 in
Korea. The figure has steadily increased into 75.1 and 81.9 in 2005. In 1980, the life expectancy
of Japanese women was 78.8 and Japanese men 73.4. The figure has been changed into 85.6 and
78.6 in 2006. On the other hand, the morbidity rate of elderly women is generally higher than
that of elderly men. Particularly elderly women suffer from chronic diseases more than elderly
men. It is fair to say that elderly women usually need medical treatment and health expenditure
more than male counterpart. The female elderly also account for three fourth of the total elderly
recipients of national basic livelihood security in 2002 (MOHW 2004). It means that the number
of women is 3 times as many as that of men in the lowest income bracket.
         In short, the female elderly are expected to be the main beneficiary of LTC in both
countries. The portion of women is much bigger than that of men in the elderly population.
Given women’s health condition is usually worse than men in old age, one may expect that the
female elderly would be main care-receivers of LTC insurance. Will such expectation be
realized in practice? If not, what prevents them from getting the benefit? In order to find
answers to those questions, this study will examine the details of LTC policy in both countries.



Public Long-Term Care Policy


    1> Japan


It was German social insurance system that gave Japan alternative model. Germany is the first
country in the world to design the LTC as a social insurance. German long-term care called



                                                                                                   9
“Pflegebersicherung” was realized in 1995. German case has been based on universal coverage
to every citizen. Training program for care-givers was significant challenge for the decision-
makers in multi-level government, while German government still put priority on the family as
a primary care-provider by giving cash to the family members.
         Japanese approach to long-term care was different from Germany. Japanese long-term
care covers those who are 40 years old and more. Age 65 and 40 are two demarcation lines.
Those whose age is 65 and older (category 1), they are allowed to receive insurance benefits,
whenever their conditions require LTC at a fixed sum (¥ 3,293). Another age group “between 40
to 64” (category 2) can get insurance benefits only if their conditions are caused by aging-
related illnesses. Therefore category 1 could get 96.6% benefits of the total LTC insurance in
2005 (Yoo and Moon, 2006). Although it looks unfair to the category 2, it makes sense because
Japanese LTC is focusing on the elderly and senile dementia.
         Each category has 2 types of care, support needed and care needed. And the care
needed type is divided into 5 levels by the insurance benefits. 10% co-payment is required to the
insured person. Total budget is composed of premium (45%) from the two categories, taxes
(45%) from national government, prefecture and municipality, and co-payment of the insured
(10%). The insurers are municipalities. Japanese needs-assessment/certification system is
composed of the computer-aided initial assessment (85 item questionnaire), the secondary
classification by the Care Needs Certification Board (a kind of expert committee) and the care
planning by the care managers.
         Community-based management system of Scandinavian countries and care managers
 developed in the United Kingdom were incorporated into Japanese LTC (Tsutsui and
 Muramatsu, 2005). Cash allowances as in Germany were not included in Japanese LTC, as
 stated above. Feminists in Japan strongly criticized cash allowances.
         Independent of cash service, home-based care and informal family care have been
more preferable choice than facilities care to care-receivers, although the Japanese government
started public LTC under the slogan “From Care by Family to Care by Society.” There are 12
provisions of home-based care services and 3 facility-based services as in <Table 2>.


  <Table 2> Two types of care provided by the Japanese LTC
                    Home care                                   Institutional care
   Home help service                              LTC welfare facilities
   Home-visit bathing service                     LTC health facilities
   Home-visit nursing                             Sanatorium type medical care facility
   Home-visit rehabilitation
   Day service (commuting for care)



                                                                                              10
   Day care (commuting rehabilitation service)
   Short stay
   Medical examination
   Group homes for the elderly with dementia
   Care at the fee-charging homes
   Rental services and purchase allowance
   Allowance for modifying house


         According to <Table 3> most of LTC recipients in Japan are women. As the age is
getting higher, the disproportion between both genders becomes bigger. One notable thing is
that there was disparity between the number of people who had got official approval from the
test for care and the number of actual LTC recipients. Where are they who need care but did not
use LTC? Who care them? What prevented them from getting benefit of LTC insurance?


<Table 3> Approved Applicants and Care-receivers in Japan (2004. 5)
                                                     (Unit: 1,000 persons, %)
        Age              Approved Applicants            LTC Recipients
                       Numbers       Percentage     Numbers       Percentage
  Men         65~69      107.3          3.09          80.3           2.31
              70~74      184.6          6.32         140.7           4.82
              75~79      252.4         11.85         193.3           9.08
              80~84      240.7         21.88         187.3          17.03
                85~      332.4         43.74         267.4          35.18
        Total          1,117.4         10.76         869.0           8.37
 Women        65~69      117.7          3.06          88.2           2.29
              70~74      266.6          7.66         203.1           5.84
              75~79      494.6         17.11         391.0          13.53
              80~84      694.0         33.69         570.7          27.70
                85~    1,162.4         60.23         998.1          51.72
        Total          2,735.3         19.25         2,251.1        15.84
Source: (KIHASA 2004, 89)


         Firstly, it is supposed that family members have provided care for them informally.
Particularly it is possible for the support-needed group and care level 1 group, because the
estimated total care minutes per day is less than 50. Secondly, we can guess that volunteers
including relatives have given care to the elderly. Lastly but the most seriously, it is assumed


                                                                                             11
that there must be sick elders who cannot afford to 10% co-payment for the LTC. Which group
has highest possibility for being left uncared?
         Interesting thing was found at the 2004 reforms in public pension. Housewives were
categorized as class 3 insured who don’t pay premiums but can get benefits from Survivor’s
Welfare Annuity Insurance. Thanks to the reform, housewives can share welfare annuity
insurance of their husbands equally when they are divorced considering their contributions to
family care and housework. But it is conditional. In order to be beneficiaries, housewives are
not allowed to earn money more than ¥ 1.3 million or to work three quarters of hours of average
employers (Komamura, 2005). To make matters worse, the working wives cannot get the same
benefit like housewives from the new policy, because the working wives usually pay premiums
and their role of housework and family care cannot be evaluated fully. It implies that new
pension policy can constraint housewives’ work-seeking. New policy encourages housewives to
stay at home or just to get part-time jobs. And this makes women pensioners fragile. It looks
like a vicious circle.
         Social insurance made the public income transfer social right rather than charity due to
its reciprocity. But the principle of social insurance marginalized women. According to old-age
pension, average insurance of female pensioners is far short of that of male pensioners. In 2003,
men receive ¥ 55,434 while women ¥ 44,504 at average level. Compared with men, women can
receive 80% of insurances. There is remarkable difference in Welfare Annuity Insurance
between both sexes. The average insurance of men is ¥ 205,000, while that of women is
¥ 111,000. Women can get slightly more than 54% of men’s (Komamura, 2005). It implies that
women with old age have the highest possibility for falling into poverty group.
         Japanese LTC insurance based on nationally standardized computerized assessment
system has to be revised every 5 years according to the stipulation of law. From the beginning,
Japanese LTC tried to extract the merits from the LTC pioneers (Germany, Scandinavian
countries, United Kingdom, and so on). However, Japanese social insurance system including
LTC insurance still has gendered problems. Housewives are forced to stay at home for getting
benefits from public insurance. In this context, women are obliged to be informal family care-
givers, although feminist criticized cash allowances so strongly by that reason. Even after the
care by society was introduced, because of contribution based social insurance system leaded by
government, there remain still unsolved problems.


2> South Korea


From the Japanese experience, we can estimate the effect of Korean LTC policy and find out its
gender-impact. In Korea, two pilot projects for LTC were carried out recently. The first one was



                                                                                              12
just for the lowest bracket for free service, which ended in 2006, and the second one was
expanded to everyone who applied for the project voluntarily with 20% co-payment. The second
one provided not only some services under the coverage of LTC insurance but also many other
services for which the beneficiaries should pay.


 <Table 4> Three Types of Care Provided by Korean LTC insurance
 Home care                      Facility care                   Cash allowance
 Home help service              LTC welfare facilities          Allowance to family member
 Home-visit bathing service     LTC health facilities           Allowance to care-receiver who
 Home-visit nursing             Sanatorium-type medical           stays in nursing facility
 Day or night service               care facility               Allowance to care-receiver who
 Short stay                                                       stays in medical care
 Rental service
Source: Act on Long-Term Care Insurance for the Elderly (2007. 4. 2)


         Three types of care will be provided as in <Table 4>. Like Japanese assessment system,
the insured who need LTC should be assessed by a computerized system (51 items
questionnaire) and Care Level Decision Committee. But care manager’s planning is not
included in the Korean care-need certification process. Korean government has not regarded
care manager system as significant. Unlike Japan, there will be 3 levels of care service in Korea.
         Particularly cash allowance will be included in Korean LTC insurance policy.
Government states that cash allowance can give customers the rights of choice. It shows that
Korean welfare state is still based on the “principle of subsidiarity” (Hammer and Österle 2003)
like Austria. It can reinforce the family obligations and family ideology of separate spheres, that
is, a strict gender division of family work with women being responsible for providing care
work on an unpaid basis, although the cash allowance can promote the right to pay for the care
services given to care users.
         While in Japan the percentage of beneficiaries of LTC was 17.4% in 2005, only 1.7%
of the elderly can be estimated to be beneficiaries in Korea. The National Health Insurance
Corporation is charge of finance like National Health Insurance, but the municipalities have
managed the facilities. This is a big difference between two countries. While every insured of
the national health insurance has to pay premium regardless of age, only a little percent of the
elderly can be estimated to get LTC service. Therefore the big discordance between the insured
and beneficiaries can make social conflicts in Korea.
         Besides the co-payment for home care and facility care is 15% and 20% of total cost
respectively. Comparing with the co-payment level of Japanese LTC (10%), Korean co-payment



                                                                                                13
level is higher. It is estimated that the home care service for LTC beneficiaries of level 1 (the
most serious state) will pay about \140,000 (USD 150) within the coverage.
         The problem is that coverage will be too limited to provide adequate social care service.
For example, two home-visit bathing, two day-services, four home-visit nursing, and eight times
of 2-hour home-help services per month are not enough to take care of bed-ridden elderly with
dementia. It really cannot relieve the burden of informal care-givers (probably female family
members) at this stage. Recipients are expected to pay additionally to buy private care services,
and informal care-givers should stay at home even during the LTC service in order to monitor
whether the care workers keep times and provide proper care services or not.
         It looks controversial that every health insured person should pay the mandatory LTC
insurance for such limited services only for the 1.7% of the elderly. If the member of recipient is
so small and they are likely to be poor, tax-based LTC for the poor may be more effective.
         Of course, public LTC has positive side with respect to the middle class elderly,
because the public service will be extended to them who have had no choice but to buy care
service at the market until now. It means that Korean public LTC is regarded as regressive like
Japanese system.
         Furthermore, central and local government will pay 20% of total cost of LTC as other
social insurance programme like the National Health Insurance in order to balance the self-
employed households. Japanese government is charge of 45% of all the cost, although Japanese
LTC was criticized as being designed to reduce the medical expenditure. Therefore the Korean
government will minimize its role into an eager advertiser for new social service rather than
service provider or regulator, because Korean LTC insurance does not focus on social right of
care-receiver but on health insurance deficit.
         Before the social investment will be finalized, precise investigation to the new
institution and its side effects is necessary. It can be right time to think over and revise LTC plan
in Korea. Who can be falling out of Korean LTC? Does social insurance can affect every man
and woman equally in principle? Because social insurance system is usually based on the life-
long employment, women with irregular economic career can be precarious outsiders of social
security system not only in the old-age pension but also in the LTC for the elderly. Although the
Basic Old Age Pension will be introduced in 6 months, the pension will be expected to be far
short of the total cost of public LTC.
         In addition, we have to examine not only the lives of the elderly at present but also the
likelihood of the relatively younger generation can receive public pensions in future in order to
get living costs in their old age. KIHASA (2004) shows the difference between men and women
in the benefits from public pensions. Only 38% of women aged 20-59 will be beneficiary of
National Pension, while the percentage of male public pensioners will be more than 80% when



                                                                                                  14
they reaches to 60. It can tell us that women over 60 in future will not likely to enjoy good
quality of public LTC, because they may not afford high co-payment.
          Many factors can explain the difference. Firstly, women’s labor participation itself is
much lower than men. The rate of women’s economic participation passed 50% by the year of
2005, while the rate of men’s has been far beyond 70% since late 1980s.
          Secondly, the status in employment can be a significant factor. According to the data of
the Korean National Statistical Office (KNSO), large amount of women are unpaid workers.
Especially 42.6% of the female unpaid workers labor for family business, while only 3.7% of
male unpaid workers do in 2005. It means that women have rendered services to the economic
conditions of their households without any rewards almost 8 times as many as men have done
among the unpaid workers.
          In addition, the percentage of female regular employees is still low, although the figure
has increased from 19.2 in 2000 to 25.6 in 2005. Especially female temporary and daily, i.e.
irregular workers are much more than 60% among the paid female workers. The percentage of
female irregular employees is much higher than men. The problem is that the women’s status in
employment prevents women from being the primary beneficiaries of social insurances.
          Regarding benefits from National Pension Program, National Health Insurance and
Employment Insurance, irregular employees are placed at a disadvantageous position. Despite
some improvement, <Table 5> shows substantial difference between regular and irregular
employees. Workfare pension system could make women fragile.


<Table 5> Percentage of the Insured Persons by Employment Status
                                     2002. 8         2003. 8     2004. 8         2005. 8
    National         Regular          62.9               70.8      72.5            75.7
    Pension         Irregular         25.7               30.5      37.5            36.6
     Health          Regular          65.6               72.5      73.8            75.9
   Insurance        Irregular         28.8               32.6      40.1            37.7
 Employment          Regular          56.2               59.7      61.5            63.8
   Insurance        Irregular         26.2               29.2      36.1            34.5
Source: National Statistical Office, Additional Survey


          Thirdly, care can also be notable factor, because women’s labour market participation
is influenced by marriage and care. Figure 1 shows that economic activities of women by age
have changed because of late marriages, but the curve remains in M shape. Currently the age
group of primary care-givers for childcare is 30-34. And after the age group of 40-44, the
second peak, the economic participation rate is decreasing again in graph of 2004. It is very


                                                                                                15
likely to be related to elderly care. Because almost of all the families carry out childcare, the
falling seems steeply. While, because relatively small families have provided elderly care and
elderly care depends on the health conditions of the elderly, the figure is decreasing gradually.
         This implies that women quit their jobs with childbirth, which will, in turn, be
disadvantage in the labour market when they seek work again. Besides, they usually reenter to
the labor market after childcare at lower level working conditions compared with their first jobs.
As women grow older, the percentage of irregular employees is getting higher. Even more than
three quarters of female aged 60+ is irregular employee.




Figure 1. Women’s Economic Participation by Age in 1990 and 2004.


         In short, family care has been related with women’s economic career very negatively.
Discontinuity in working because of family care usually makes women slide into temporary or
daily workers. The KNSO data shows that 46.4% of married women are irregular workers,
while 35% of never-married women are irregular ones in 2005. It is contrary to those of men’s.
Women’s labour market participation itself cannot guarantee gender equality in general.
         Particularly, the most serious bracket is single, i.e. widows and divorced women.
Female singles can be the most fragile class, because 56.5% of them in 2005 are irregular
employees. It implies those age groups 60+ who are irregular single employees have no
alternative.
         Regarding the economic participation rate of the elderly aged 65+ in 2005, the rate of
the female elderly is 22.4% while that of the male elderly is 41.2% (KNSO 2006). It means that
women should depend on other income sources more than men. That’s why the female elders
receive living costs from children, government or society more than the male elders.
         According to the KNSO data, it is supposed that large portion of men can live for



                                                                                                    16
themselves, while women cannot. Even in the category “themselves or spouse,” big part of
women must be dependent on spouse’s income rather than themselves. Another data about
average pocket money per month can prove this supposition. 55.7% of female elders spend less
than $100 per month, while 27.4% of male elders do (KIHASA, 2005).
         In addition, there is big difference in monthly wage level between both genders. As the
Ministry of Labor survey report shows, comparing with average of total monthly wage, the
female elderly wage is only 57.3%. If we compare the elderly wages by gender, female can earn
just two thirds of men’s.
         In this condition, it is natural to expect that both sexes can be affected differently as
care-receivers by the LTC policy. The problem, again, is that all the services will not be
included in care service. Consumer can choose service with additional payment. It implies that
high-quality service cannot be given to the poverty group, and very large part of which is
woman.



Gender and Care-givers


This paper has focused mainly on gender in care-receiver’s side. There is another side of care,
the care-giving. Although the dual-earner model has become a norm, almost all the burden of
family care still remains to women.
         According to KIHASA (2005) survey report, 80% of main care-givers are women.
Even the women whose age is 65+ provide care. It is supposed that most of the female elderly
care their spouses. In practice, 27.4% of the elderly were provided care by their spouses
(MOGEF, 2003). KIHASA survey shows that the age spectrum of main care-givers is very
broad. The age distribution is relatively even. For example, age group 30-50 was 37.2%, 50-64
was 28.4%, and 65+ was 32.7%. The fact that women have provided informal elderly care to
their old parents, grandparents, spouses and relatives since the age of 30+ shows women’s life-
long care-giving role. If we consider child or grandchild care as well as elderly care, women’s
role as care-givers can be more obvious.
         As <Table 6> indicated, care-giving can be divided into two such as formal and
informal. Like informal or private care, most of formal care-givers are women. The problem is
that gendered division of paid care work can prevent the value of care-giving from being fully
evaluated. Women-only jobs can be marginalized in the labour market. As Korean government
has considered care workers as new job-creating industry, it is targeting women with low
income or no job. In order to reevaluate care work, professional training program for care-givers
should be provided.



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<Table 6> Role of Women as Care-givers
                                  Unpaid Work            Unpaid + Paid         Paid Work
                                   Housewives          Working women +        Care workers
    Informal or Private care                          Home-visit workers       (24 hours)
     (home-based service)           Volunteers         Working women +        Care workers
                                                         Care workers          (24 hours)
     Formal or Social care         Housewives          Working women +        Care workers
     (home-based service)                             Home-visit workers       (24 hours)
     Formal or Social care          Volunteers         Working women +        Care workers
        (facility service)                            Daycare or short stay    (24 hours)
Source: (KIHASA 2004, 107) and some modification added.


         Until recently formal training programs for paid care-givers have not been standardized
and unified in Korea. No detailed plans for vocational training have been introduced. Although
LTC policy has been considered as one of the job-creation strategies, Korean government has
paid little attention to institutional program for care-givers.
         From the beginning, the care workers have been regarded as for volunteers or low
income and part-time workers in Japan. The LTC policy for recruiting care workers has been
targeting housewives with relatively older children who do not need physical care from their
parents (Jung 2005). In particular, considering the institutional restriction on the job-seeking
activities of the housewives in Japan as mentioned above, policy makers have seemed to utilize
women’s labors as irregular labor forces. It implies that as women become care workers more
and more, the labor market for social care becomes more divided by gender. Since relatively
low income and hard work have increased the separation rate in care-providing workers,
Japanese LTC faces serious shortage of expertise care workers (MOHW 2005). Under this
situation, the international emigration issues for care-providing from other countries, especially
Philippines have been a big policy consideration.
           Regarding Korea, particularly after the economic crisis, female-headed households
with low income became the most vulnerable groups. This policy consideration encouraged that
Korean government has planned to create jobs by introducing LTC insurance. The government
has relatively positive expectations about recruiting social workers most of whom are women,
because 70% of care workers with national care-certificate could not find proper jobs until now.
However, the number of those who attend training program for care workers cannot guarantee
sufficient supply to meet social demand, if the trained persons quit their jobs easily because of
low evaluation for their works. Since Korean government has designed LTC insurance as job-
creation strategy for vulnerable female laborers and the care work has not been considered as


                                                                                               18
specialized field, it is very likely to underestimate their care work. It looks like a vicious circle.
Therefore, in Korea it may bring the shortage of care workers like Japan before long.



Concluding Remarks


This paper has examined the political context and institutional arrangements of LTC policy in
Japan and Korea. Although Japanese LTC policy created objective and computerized assessment
system successfully, the policy impact has been different according to genders. Reform to solve
gender bias between men and women would give rise to another equity problem among working
women and housewives. This made us know how complicated the gender-impact analysis would
be.
         This paper shows that public LTC policy will influence men and women differently in
Korea as well as Japan. While living longer but illness-prone, the female elderly are expected to
be the main beneficiary of LTC insurance, but because of the likeliness of the female elderly
being poor, LTC may not meet effectively their care need.
         Increase in women’s labour participation could not guarantee women’s economic
empowerment, because of their fragile status in employment. Particularly female single-member
elderly household with low salary will be the most likely bracket that is expected to fall outside
of the LTC insurance. 20% co-payment stipulation can prevent the vulnerable from accessing to
the benefits of public LTC.
         As care-givers, women will remain responsible for social care despite the introduction
of LTC insurance. As this paper argued, the limited range of care-services and cash-allowance
will hold women responsible for care-giving.
         The East Asian family-centered culture influenced by Confucianism has considered
informal family care provided by women as a norm. Change in family structures and low
fertility are women’s indirect response given inadequacy of social care provision in East Asia.
         Therefore, it is right time to think of merits and demerits of LTC insurance for Korea.
Because we can learn experience from pioneer’s trials and errors, Korean government should be
more sensitive to new social policy regarding gender-sensitivity.




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Biographical note


Si Yeon Won is Senior Research Fellow of BK21 Governance Programme, Sung Kyun Kwan
University, Seoul, South Korea. Her current research interest is on long-term care and childcare
policy in Japan and Korea. She served as Research Fellow of Women and Public Policy
Program at John F. Kennedy School of Government, Harvard University in 2004. She holds a
doctorate in Political Science.


Acknowledgements




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This paper was initially prepared for the International Workshop “Governing Global Social
Policy and East Asia” co-hosted by the BK21 Governance Programme and Global Social Policy,
25-26 January 2007. It was also presented at the annual meeting “International Politics in
Regionalization Era” organized by The Korean Association of International Studies, 7-8 June
2007. I would like to thank Miyoung An, Manuel Riesco, Sook-jong Lee, Ilcheong Yi, Miae
Jung, Jinhyun Kim for their comments, which have been useful for the revision of the paper.
Special thank is due to Huck-ju Kwon, who has always given me academic insights “lean, thin
and dry!”




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