Health-care reform before higher costs

医療制度改革をめぐる対立

Mr. Koizumi and his aides say the increase at the start of fiscal 2003 is necessary to establish a "sustainable" national health insurance system. They emphasize the need for an "equitable" sharing of medical costs, saying that people should be more "cost-conscious" about the services they receive. The sorry state of health insurance cannot be overly emphasized. But it isn't clear as yet what kinds of reform the Koizumi administration wants to put in place.

A combination of factors are contributing to the crisis in the nation's deficit-ridden health insurance system. Medical costs for elderly patients are soaring amid the falling birthrate and the rapidly increasing average age of the population, while premium revenues are leveling off as a result of continuing economic stagnation. Virtually every insurer is now either in the red or having difficulty making ends meet. Building a financially viable system is therefore an urgent necessity.

Public support is essential to develop a "sustainable" system, particularly if the public's share of medical costs is to increase. The latest agreement, however, hardly takes into account the plight of recession-hit employees. To be sure, the prime minister projected his image as a fighting reformer, but he failed to credibly explain why the burden must be raised next year and how the quality of health care would be improved as a result.

The Health, Labor and Welfare Ministry argued that the new cost-sharing plan could be postponed if premiums for the government-run health insurance program for small-business workers were slightly increased. The prime minister reportedly replied that his opponents in the LDP were trying to put off reform and that the public should accept more of the pain it entails. One wonders whether he has a political ax to grind in his push for an early increase in the burden: making a pre-emptive strike at the antireform forces in his party.

The prime minister has said time and again that all three sides involved in health-care reform — patients, insurers and medical institutions — should share the pain. The message, however, is directed at the insured. The timing of an increase in premiums, along with an increase in medical payments, is in question, but its inevitability is widely recognized. Still, people are understandably loath to bear a higher burden at a time when economic prospects are clouded. It would indeed be cruel for the government to ask them to be "cost-conscious" when it is doing a poor job of promoting growth.

If Mr. Koizumi is in a hurry to shift more of the cost to the people, his critics in the LDP are slow in making their own reform efforts. They argue, in effect, that the system should be overhauled before the burden is increased. But it is unclear how they want to change the system, much less how they want to see the cost shared over the longer haul. What is clear, unfortunately, is that both the government and the ruling parties are again trying to put off real reform.

In the past, insurance premiums or patients' payments have been increased almost regularly in the name of health-care reform, but little systemic change has been made. It is time to break this habit of procrastination. Perhaps the public will be willing to accept an increased burden if a credible road map for reform is presented.

The agreement between the government and the ruling parties, which came on Monday, provides clues to changes likely to be made in the future. It says basic policies should be laid out in fiscal 2003 with a view to integrating or reorganizing the existing insurance programs, creating a new health-care system for the elderly, and updating the payment system for medical examinations and treatments. Similar changes have been promised before, but so far no meaningful progress has been made.

The nation must face up to the stark demographic reality: Japanese society is aging at an unprecedentedly rapid pace. According to the National Institute of Social Security and Population Problems, the population will begin to shrink in five years, and by 2050 more than one in three people will have reached the age of 65. This will create formidable social security problems that cannot be effectively addressed without enlightened political leadership and enhanced public understanding.

The Japan Times: Feb. 15, 2002
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     健康保険制度が危機に陥った要因はいくつかある。出生率の低下と人口の高齢化により、高齢者医療のコストが上昇し、景気停滞で保険料収入が横ばいになった。健保組合は財政が逼迫している。維持可能な制度の早急な確立が必要だが、そのためには国民の支持が欠かせない。しかし今回の合意は、不況下のサラリーマンの苦境を考慮に入れていない。闘う改革推進者としてのイメージを打ち出してきた首相だが、自己負担割合の引上げの理由と、その結果期待される医療の質の向上について納得できる説明をしていない。

     厚生労働省は、中小企業対象の政府管掌健康保険の保険料の小幅引上げで、被保険者の負担増を延期できると主張する。首相は、党内の抵抗勢力が改革の先送りを図っていると述べ、国民に改革の痛みを受け入れるよう求めたという。早期の引上げ断行で、反改革勢力に対する先制攻撃を狙っているのだろうか。

     首相は患者、健保組合、医療機関の三者が医療制度改革の痛みを分かち合うべきだというが、この発言は被保険者に向けられている。保険料引上げが不可避だという認識は浸透しているが、経済の見通しが暗い中での負担増はつらい。政府の景気回復策が進まないなかで国民にコスト意識を持てと言うのは酷だろう。

     小泉首相が国民の負担増を急いでいる一方、自民党の反小泉派は改革を支持していない。彼らは負担増の前に医療制度の抜本改革が必要だと主張するが、制度変更の内容や、長期的なコスト分担については立場を明らかにしていない。明らかなのは、政府、与党が改革を先送りにしようとしていることだ。過去にも医療制度改革の名のもとで保険料、医療費の負担は増えてきたが、制度自体はほとんど変わっていない。先送りの悪弊を今こそ打ち破るべきだ。改革の具体的な道筋が示されれば、国民も負担増を受け入れるだろう。

     今回の合意に基づき、医療保険の一元化、新たな高齢者医療制度の創設など、抜本改革の基本方針が2003年度に策定されることになる。以前にも同様の改革が公約に盛り込まれたが、意義ある進展はなかった。

The Japan Times Weekly
Feb. 23, 2002
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