A bill for integrated welfare
(From The Japan Times May 23 issue)

障害者自立支援法案は慎重審議を

    At present, support services are available under four different laws, which cover people with physical, intellectual or mental disabilities, as well as juvenile delinquents. Under a unified system, facilities and services would be provided according to the degree of disability.

    That would open the way for the "mutual use" of welfare institutions, with patients at one facility using another that could have been intended for a different group of patients. In addition, they would be able to receive services either at or near their homes.

    More specifically, if one wanted to receive nursing services at home under the bill, he or she would first file an application with the local office in charge, regardless of the type of disability. The office would examine the application, then submit it to the review board, which would determine the degree of disability. The same procedure is required to commence nursing care for the elderly.

    However, a decision on the degree of disability would not automatically mean that services would be provided. This is an important difference from the nursing-care insurance system, under which care-giving begins once the degree of care required is determined. A final decision would be made after related factors were considered, such as physical conditions at home, family relationships and the willingness to work.

    Another advantage, for the government, is that the cost-sharing formula would ease fund shortages. For patients, the chances of returning to work would improve through hands-on functional training.

    On the other hand, the 10 percent charge for welfare services would be a big concern to those who receive those services, as well as to organizations who run welfare facilities. To this flat-rate fee would be added utility expenses, or "hotel costs," and food expenses. According to the Ministry of Health, Labor and Welfare, "standard" hotel costs and food expenses would be up to ¥10,000 and ¥48,000 a month, respectively. The ministry says that actual amounts would depend on contracts between individual patients and institutions.

    Those payments would deal a double blow, financially, to patients and their families. For many, basic disability pensions are the only source of income. Although the ministry plans to set ceilings on payments according to household incomes, a fundamental question remains: Is it appropriate to impose a flat-rate fee burden on the recipients of disability-welfare services?

    Currently, payments vary with the incomes of those obliged to support disabled people. Under the new system, payments would be based on the incomes of patients' families — a change that the ministry says is needed to maintain symmetry with medical and nursing-care insurance systems. As a result, payments from patients who have spouses, parents and siblings might increase.

    All this indicates strongly that the real aim of the support bill is to integrate measures for the disabled with the nursing-care insurance system. In the background looms a dire shortage of public funding for expanding disability-welfare services. While the proposed cost-sharing would help reduce the deficit, some of the funding for nursing-care services could be diverted for disability welfare.

    The Upper House is debating a bill to amend the nursing-care insurance system, but no integration plan is incorporated in the measure, due to opposition by the governing parties. The health and welfare ministry may be counting on passage of the disability support bill as a way toward integration, but the very purpose of that legislation — supporting the efforts of the disabled toward self-reliance — will be compromised unless the anxiety felt by patients and their families is removed.

The Japan Times Weekly
May 28, 2005
(C) All rights reserved

      現在の福祉サービスは、障害の種別によって異なる法律のもと実施されている。法案の目的は、制度の一元化により種別を越えて共通の福祉サービスを提供することだが、同案は多くの問題をはらんでいる。

      例えば、法案では利用者はサービス料金を所得に応じてではなく定率1割負担することになっているが、障害者と家族の意向を十分考慮して最終決定すべきだ。施設利用者の食費、光熱費の負担などについても同様に審議されるべきだ。

      一元化された制度では、施設、サービスは障害程度区分に応じて利用できることになり、各種施設の「相互利用」が可能になる。

      新法の下で在宅サービスを受けるには、障害の種類に関係なく、市町村に申請し、審査会が障害程度区分を決め、身体状況、家族関係、労働意欲などを勘案してサービス開始が最終決定される。

      福祉サービス料金の利用者負担は1割だが、施設居住者に対しては光熱費（ホテルコスト）、食費が加算される。厚生労働省によれば、標準のホテルコスト、食費はそれぞれ月額1万円、4万8000円までとなるが、実際額は利用者と施設の契約で決められる。

      法案の真の目的は、障害者福祉制度と介護保険制度の一元化にあるようだ。問題の背景には、障害者福祉サービスの財政難がある。費用分担で赤字を減らすとともに、介護保険の財源を障害者福祉サービスに振り分けることができる。

      参院は、 介護保険法改正法案を審議しているが、与党の反対で、障害者福祉制度との一元化は法案に含まれていない。

      厚労省は、一元化への道として障害者自立支援法の成立を期待しているだろうが、障害者と家族の不安を払拭しなければ、同法案の目的は危うい。