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Sunday, April 20, 2008
Notes on 'Later Term Elderly People Medical Treatment' joke
Stop me if you've heard this one. A bunch of elderly people are sitting in the waiting room of a doctor's office, catching up on neighborhood gossip and their own health woes. As Mrs. Sato goes on about her lumbago, Mr. Kobayashi interrupts. "Where's Suzuki-san?" he says. "He's usually here by now." Everyone looks around and confirms that Mr. Suzuki is indeed not there. "I guess he's sick today," says Mrs. Sato.
This is obviously the image of old people that the Ministry of Health, Labor and Welfare had when it devised the new health-insurance system for persons 75 years of age or older, a system launched so carelessly that the ministry has yet to come up with an English name for it. Local governments who administer it have had to improvise. Soka City in Saitama calls it by the unwieldy term Health Insurance System of Later Term Elderly People Medical Treatment, while Onojo City in Fukuoka simply uses Senior Medical Insurance.
The confusion is understandable since the ministry has even changed the Japanese name. Originally it was called Koki Koreisha Iryo, meaning "late-term senior medical service," a phrase that conjured up a depressing vision of old people in their last throes. It has since been changed to Choju Iryo Seido, which can be translated as "medical service for happy seniors who live long, fruitful lives," or something like that.
The old folks are not placated, and many have been moved to open rebellion. Last Monday, TV Asahi's "Hodo Station" reported on various petition drives to repeal the plan. Anchorman Ichiro Furutachi commented that "even the media didn't understand [this new system], so we should take some of the blame." It was too late for apologies, since the next day the payment system went into effect.
Though the senior health-insurance debacle doesn't compare to the pension fiasco, it was brought about by the same bureaucratic mentality ("We know what's best") and exacerbated by the same media attitude ("Since we don't understand it, let's not report it") that led to it. The government started pondering a new insurance plan in 2001 and passed it into law two years ago, but until it went into effect on April 1, the media ignored it.
Anyone 75 years of age or older now belongs to a separate health-insurance plan. Though seniors' insurance premiums are still determined by income, the burden of payment will now be spread "wide and thin," as the government puts it, among Japan's 13 million over-75s. The most notable change is that, from now on, premiums will be automatically deducted from the pensions of about 8 million seniors.
Some retirees will pay less than they did under the national health insurance while others will pay more. The most common complaint was voiced by an 82-year-old man who wrote to the Asahi Shimbun asking why he has to be lumped in with everyone else his age when he makes an effort to stay healthy, avoids doctor's visits, and waives his right to kaigo (nursing care), which he has to pay for anyway. The government has tried to point out that, on average, seniors won't be paying much more than they did in the past, which hardly makes sense since the whole purpose of the new system is to bring in more money. The media have said that premiums are sure to increase in the future since the payment system is renewed every two years and prefectural governments have yet to gauge the real impact of the new system on their finances.
Moreover, there are new exceptions and limitations that few people understand. Coverage didn't really start until three weeks ago when it was discovered that many seniors had thrown away their government notices because they either thought they were a direct mail scheme or couldn't read them for all the small print. When they learned about the automatic deductions starting April 15, they were surprised, and thus the backlash. Opposition parties have taken advantage of this anger and Prime Minister Yasuo Fukuda apologized for both the confusion and the naming of the plan. Thirty-one local governments have postponed payment deductions until October.
In the past week the media have finally started to explain the background. The nation's health-insurance program is hemorrhaging money, a situation that will only worsen as the population ages. What the government is worried about is the huge cohort of boomers turning 75 in 2025, when it's estimated that ¥30 trillion will be needed to pay for their health care. Right now health-insurance premiums bring in about ¥12 trillion a year.
The new system has been called paternalistic and cold, an image that was reinforced by one health ministry bureaucrat who told reporters it would make elderly people "understand the pain" caused by their disproportionate use of medical services. Sunday Mainichi equated the new insurance with the old practice of ubasuteyama, or dumping old people on mountain tops to die.
It's obvious that the health-care system is broken, but what the new plan mainly does is maintain the current setup by simply isolating the elderly and making them assume the burden of their own health care so as to make it easier for younger people to pay for theirs. Last week, health minister Yoichi Masuzoe called Japan's system the best in the world, "and we want to keep it that way."
"Best" is a subjective word here. The government's insistence that national health insurance be as self-supporting as possible makes it not much different from private insurance. You can pay your premiums on time for decades, but once you fail to do so for even a few months for whatever reason, you'll lose your insurance. The government may still not know what to call the new system for seniors, but first they should fix the name of the overall program. Kokuminkai Hoken means "universal insurance," but it isn't universal at all. Only those who pay get in.