Make Japan’s universal medical care system sustainable!

Translated by Kenji

An article entitled "Appointment Availability after Increases in Medicaid Payments for Primary Care" was published in the February 5 issue of the New England Journal of Medicine. In this article, the authors investigated influences on medical appointment availability after increases of provider payments under Medicaid, which is a public medical insurance plan. These increases to medical providers and institutions were mandated under one part of "Obamacare" (Patient Protection and Affordable Care Act).

Before explaining this content, we need to understand the American medical care system. Since the United States is a country which puts a high value on autonomy, individuals bear the responsibility for obtaining his/her medical insurance by themselves. Even if people belong to the same private insurer, the medical treatment options which can be covered by the insurance vary depending on their group membership and premium options. Because health insurance is not a simple automatic check-off system from their salary like in Japan, it is a personal decision whether to have which type of medical insurance. However, from the point of view of guaranteeing a minimum level of medical care, the United States has implemented some publicly supported medical care systems, such as “Medicaid” and “Medicare”. The former mainly covers low-income people, and the latter covers elderly people.

However, prior to the implementation of Obama care, there were millions of people who did not have any medical insurance; some were unable or unwilling to make the payments for expensive premium costs and some believed medical insurance to be unnecessary. Many of these individuals were not eligible for Medicaid or Medicare, and one of six American people were in such a situation before the implementation of Obama care. In the future, the number of uninsured people is projected to decline, and it is predicted to drop to 5-6% in 2020 under Obama care. However, the Republican Party has been strongly against this bill from the outset, and massive chaos may occur depending on the outcome of the Presidential and congress election in 2016.

Thus, in the United States, conservative thinking which generally favors an ethos to “decide about oneself by oneself" strongly seeps into the medical care arena, which is nothing like the conditions in Japan, where generally speaking "Everyone can have equal access to any medical institution." In addition, medical providers often refuse to treat Medicaid patients because there are significant limitations in reimbursement levels covering examinations and medications even if they have public medical insurance. In Japan, such refusal by doctors or hospitals would trigger big reprisals.


 “Medicine is a benevolent art” is not the United States way, but “Money opens all doors”

After Obama care began, medical expense coverage under Medicaid increased. However, since each state runs its own Medicaid program, the increases in the coverage rates were different. For example, New Jersey, Illinois and Pennsylvania increased by approximately two folds and Texas by more than 60%. In contrast, Massachusetts, Georgia, Arkansas, Oregon, Iowa increased by about 40% and Montana by just a few percent. Although appointment availability in clinics in the former four states increased by 10-15%, availability increased by only around 5% in the states where payment increases were relatively low. Medicine is not a benevolent art in the United States. Rather, it is very highly influenced by money.

Although I have leveled many criticisms about the Japanese health care system in the past, I recognize the great advantage of Japan’s public system whenever I hear about the lack of equal access to medical care in the United States. Freedom is guaranteed for any Japanese person to access whatever hospitals or doctors they wish.

Because an inclusive payment system (a system where medical expenses are decided by classification of illness) is replacing a piecework system (a system where medical expenses are calculated by the multiplication of individual treatment acts) to control medical expenses, medical institutions may come to have a deficit — at least temporarily — but the system generally manages well.

Since Japan’s universal medical care system was established in 1961, we tend to take it for granted. However, these expenses are covered by premiums, a general tax, and self-pay (either by individuals or companies). Slightly less than 50% of the nation’s annual medical costs of approximately 40 trillion yen are covered by premiums. A little over 10% is covered by self-pay and the tax share is approximately 40%.

Whereas medical expenses have increased by more than 20% from 2000 to 2010, salary increases have been far less than this. Furthermore, the proportion of older adults has been increasing very rapidly because the large number of babies born in the decade immediately following WWII — baby boomers, called the “Dankai” generation in Japanese — are reaching old age. Under such conditions, further increases in medical expenditures are unavoidable. It is a given that maintenance of a high quality health care system will become more and more difficult.

Pennies don’t fall from heaven. What should we do to maintain Japan’s world-class public health care system? All citizens should be urged to face this problem.

The development of new drugs, medical equipment, and devices has accelerated and will be further accelerated, and of course they will also be more expensive. In order to sustain the world's highest level of health care with new drugs and equipment, we have to make up our minds that costs will inevitably rise. Mass media should take up these issues of how to maintain and meet expected levels of medical expenditures overall, the public medical care system as a social good, as well as giving some consideration to raising the consumption tax as one way to help both goals simultaneously.