The adoption of the Japanese LTCI Act in 1997 was preceded by a decade of extensive public discourse on how to deal with the (rising) need for care among the elderly population. In addition to changing socio-economic structures, extended hospitalisations of elderly patients created “negative policy feedback” (Maags 2020, 9) through rising expenditure in the healthcare system (see e.g. Campbell 2000). In 1989 and 1994, the government presented strategies aimed at expanding the existing means-tested, state-run LTC scheme. As these did not provide sustainable solutions (Campbell 2000), policy-makers continued to search for alternatives throughout the mid-1990s. As Japan had experience with both state-based welfare schemes and social insurance programmes, both kinds of schemes were institutionally anchored and seen as potential paths for the new LTC system (Campbell 2000; Campbell and Ikegami 2009).
The literature highlights the role of several relevant domestic actors in the policy design of the novel LTC scheme: administrative officials, especially within the Ministry of Health and Welfare (MHW), political actors like parties and governments, and several interest/advocacy groups (e.g. Campbell 2000; Peng 2005; Campbell et al. 2009; Maags 2020). While we cannot go into detail on their roles here, for our purposes it is important to examine whether and to which extent they were exposed to “foreign” ideas. Campbell and Ikegami (2009), Campbell et al. (2009) and Theobald and Kern (2011) report cross-national exchanges between Japanese officials and German, but also Scandinavian LTC experts. An interesting observation is provided by Campbell (2000, 92–93) who describes that there were two camps of MHW bureaucrats in the 1990s, one “deeply influenced by British and Scandinavian social policy”, the other connected with social health insurance. While this point stresses the importance of transnational ideas or ideologies, it does not necessarily link them to LTC. In any case, it seems that ideas from Germany (and elsewhere) were known and studied within the social policy administration.
Most articles refer to the general model of social LTCI as the object of transfer without greater detail on the transferred features. Some authors (Campbell et al. 2009; Campbell 2000; Theobald and Kern 2011) also mention that monetary LTC benefits were explicitly not adopted, although they are a key aspect of the German system. Campbell et al. (2009, 72) point out that the proponents of cash allowances in Japan used the German example to legitimise their proposal. However, the role of domestic political considerations and (feminist) advocacy in the decision against cash transfers is highlighted much more in the literature (e.g. Peng 2005; Campbell 2000). It therefore remains unclear how important the German benefit model was as a reference point—negatively or positively—in the Japanese policy design.
All in all, what do researchers conclude about policy learning in the case of Japan? Campbell and others stress in several publications (Campbell 2000; Campbell et al. 2009; Campbell and Ikegami 2009) that the German LTCI mainly provided legitimacy for establishing the social LTCI in Japan but did not notably influence or form the choice(s). Others, like Maags (2020) and Theobald and Kern (2011), attribute a greater role to policy learning/adaption, but without showing to what extent foreign policies concretely became relevant for Japanese decision-making. We can thus conclude that knowledge transfer from abroad occurred. However, when it comes to naming precise policy choices or transfer channels, extant research does not adequately corroborate data for the sufficient condition of policy learning to be met.
4.2 South Korea
In Korea, the Elderly LTCI Law was passed in 2007 and implemented the following year, making Korea a comparably early adopter with regard to the country’s welfare state, economic and demographic development (Campbell et al. 2009). The policy process for establishing a new LTC system started in 2000 and was mostly driven by the government’s progressive welfare agenda (Seok 2010; Campbell et al. 2009). The public was generally positive about the establishment of a more comprehensive LTC system; the proposed policy features did not evoke much debate nor advocacy activities (Seok 2010; Maags 2020; Rhee et al. 2015). Consequently, an independent social LTCI model was agreed upon quite easily and deemed suitable for several reasons, among others the existing institutional infrastructure and experience with social insurance programmes (Chon 2012).
In terms of the present interest in transnational policy learning, evidence of exchange in the form of study trips and analysis of foreign systems are mentioned by Campbell et al. (2009, 75) and Chon (2012, 220). However, they do not provide details on the content of the exchange. All we learn is that Korean “experts”, “politicians” and “policy-makers” studied approaches elsewhere. Additionally, Sunwoo (2012, 49) points out that the emerging Korean academic discussion about LTC in the 1990s coincided with the implementation/drafting of the schemes in Germany and Japan, implying a relevance of these policy examples as well.
In the reviewed studies on Korea, only Germany and Japan are cited as concrete foreign models (e.g. Maags 2020; Campbell et al. 2009; Sunwoo 2012), with a somewhat stronger significance ascribed to the latter (e.g. Chon 2012). Authors attribute this to the Korean interest in social insurance. Regarding specific policy features transferred, the idea of a five-year basic LTC plan for revising the system regularly was brought from Japan (Sunwoo 2012, 59), as well as the needs and eligibility assessment instrument (Campbell et al. 2009, 78; Chon 2012, 223). While these specific policy adoptions indicate policy transfer resulting from positive learning, a third instance—the implementation of a cost control mechanism in Korea—points to negative learning. As mentioned earlier, the benefit coverage of the LTC scheme was limited in order to control expenditure. Chon (2012, 222) points out that this financial prudence was inspired by “Germany’s and Japan’s experiences of increasing deficits within a few years of their implementation of LTCI systems”. While more evidence on how these examples specifically exerted an influence on the Korean policy design is certainly necessary, this could be an instance of learning from negatively perceived foreign experiences.
In the literature reviewed, most authors (Chon 2012; Maags 2020; Seok 2010; Sunwoo 2012) attribute influence to foreign models, but base this assessment on similarities of policy features without specifying the sufficient condition of how ideas from abroad might have found a place in Korean LTCI design. In contrast, Campbell et al. (2009) are, as in the case of Japan, sceptical about a greater significance of foreign models. Furthermore, the availability of internationally circulating ideas is mentioned as a source of inspiration for Korean policy-makers (Campbell et al. 2009, 78; Maags 2020), but, again, without much explication of concrete ideas and “travel routes”. Consequently, while research highlights Korean experts’ interest in German and Japanese policies, uncertainty about concrete transmitters and influences remains.