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Global Health Econ Sustain Effects of community-based activities on LTC needs

of health instead of high-risk individuals (Saito et al., health as poor compared to other elderly or middle-aged

2019). There is a need for interventions promoting social individuals who did not pay regular visits to physicians
activity among older adults living alone to prevent social (Kumagai et al., 2023).
isolation (Kumagai, 2018); according to the 2020 national We used the LTCI premium categories in Japan as

census, among those aged 65 years and older, one in every the representative variable of SES in our study. We drew
seven men and one in every five women live alone in Japan. relevant data from the survey of LTCI needs from A
A community intervention for frailty prevention in Gunma
Prefecture (Shinkai et al., 2016) and a social participation city in Fukuoka prefecture, Japan. The survey is part of
intervention in Aichi Prefecture (Saito et al., 2019) both the city’s participation in the Longevity Improvement
contributed to reducing the need for LTC. Furthermore, & Fair Evidence (LIFE) study, which provides data from
participation in hobbies reduces the risk of developing government-administered LTCI enrollees and public

dementia in older adults (Takeda et al., 2009). assistance recipients to researchers(Fukuda et al., 2023). In
this study, we consider the endogeneity problem between
Although Sekizawa et al. (2022) showed that men older adult’s SAPH and their SES. We propose that the
who engaged in hobbies and cultural activities had no SAPH of older adults living alone can be explained by
significant association with new diagnoses of mild lifestyle- their current SES, which is in turn affected by past health
related diseases, no prior observational studies have found behaviors and/or medical history.
which community-based activities can reduce the need for
LTC among older adults. This study, which focuses solely 2. Data and methods
on older adults, fills the gap between interventional and
observational studies. 2.1. Data source
Self-assessed poor health (SAPH) is an important We analyzed the data of A city as the representative insurer
health indicator; however, little is known about the effects of Japanese LTCI with a standard LTCI premium. The
of SAPH on older adults’ need for LTC. We investigated average standard LTCI premium during the current term
the inter-relationships between SAPH of older adults (FY2021 – 2023, 1571 insurers) is 6041 yen/month for
living alone, their socioeconomic status (SES), and their older adults, which is 2.5% higher than the previous 3 years
need for LTC. (Table 1). However, 36% of insurers and 569 municipalities
did not change their standard LTCI premium in 2021.
The previous studies have examined the association About 31% of LTCI insurers have premiums between 5501
between subjective health and SES. Family or household and 6000 yen, including A city.
income is one of the main components of SES, which
represents an individual’s absolute level of resources. Lower Municipalities generally use 5 – 10 LTCI income
income levels have been associated with greater risk of categories, based on older adults’ income or that of
cardiovascular disease (CVD). A substantial proportion of household members, to calculate LTCI premiums. A city
disparities in health between SES levels can be attributed to has 11 LTCI income categories according to respondents’
differences in health behaviors (Kucharska-Newton et al., household taxation, that is, non-taxed (level 1 – 3) and

2011; Mosquera et al., 2016; Adler & Rehkopf, 2008; Cutler taxed (level 4 – 11). The former includes welfare recipients
& Lleras-Muney, 2010; Mackenbach et al., 2019; Pampel (50% discounted premium in 2020), respondents, and
et al., 2010; Petrovic et al., 2018; Stringhini et al., 2011). all family members who are excluded from taxation
Studies have shown that SAPH in older adults is associated (25% or 30% discounted premium in 2020). To ensure a
with low SES, chronic illness, and past health production certain minimum standard of living in terms of health, the
behavior(Etilé & Milcent, 2006; Hardman et al., 2020). For necessary assistance to welfare recipients whose household

example, mortality risk was only elevated among men in income falls below the national standard is provided by

the lowest taxation category of LTCI(Fujino et al., 2013). the public livelihood assistance system. Taxed households
Moreover, the absolute gender disparity in SAPH is include those where the respondent is excluded from
explained by differences in SES (Takahashi et al., 2020). taxation, but family members are subject to taxation (level

Women with SAPH tended to not respond to questions 4 – 5) and households where the respondent is subject to
about their family caregiving, whereas men did not show taxation (level 6 – 11). Higher LTCI income categories
this tendency (Kumagai, 2022). It was found that older include older adults whose taxable income during the

adults, who were still employed, had subjective better past year was higher. Respondents who belong to the
health than those who were unemployed (Watanabe et highest LTCI income category are obligated to pay double

al., 2022). Some retired individuals who continued to the standard LTCI premium in A city: a total of 12,000
visit physicians were less likely to evaluate their subjective Japanese yen/month.

Volume 1 Issue 1 (2023) 2 https://doi.org/10.36922/ghes.0891