Can the national health insurance be converted into a sustainable system, changing its nature of operating at a chronic loss? Efforts must be made to ensure that the latest reform helps rebuild the national health insurance, to which nearly 30 percent of the public subscribe.
Beginning in April, the financial management of the national health insurance -- a task that had been performed by city, ward, town and village governments -- was transferred to the control of Tokyo and prefectural governments. This reform signifies one of the most sweeping changes since the current system was inaugurated in 1961.
The national health insurance covers people who are not eligible to join such health insurance associations as those for corporate employees. There was a time when the system mainly covered farmers and self-employed people. At present, however, 80 percent of its subscribers are elderly people who have passed their retirement ages, people without jobs, and non-regular workers.
Its subscribers tend to be advanced in age, and this results in a large sum of medical expenses. Their income levels are low, and the amount of revenue raised through collected premiums does not increase. The population decrease in provincial areas is also making the system even more small-scale and unstable. For these structural reasons, many city, ward, town and village governments had effectively been operating the scheme in the red.
The system is the last bastion of efforts to provide people with health insurance-covered medical care in what can be described as "medical insurance for all members of the public." The transfer of its management to prefectural governments, as a means of stabilizing the scheme through an expansion in its size, is indispensable for maintaining the national health insurance.
Doing so will also help facilitate medical care arrangements suited to a super-aging society.
The prefectural governments are tasked with improving medical services based on the needs of their regions. Their assumption of responsibility for the system's financial management will motivate them to strive for the establishment of a more efficient and effective system. There are expectations that these endeavors will consequently curb the sharp increase in medical costs.
Even out premium disparities
The latest reform of the national health insurance's finances entails a shift from the previously used system in which each city, ward, town and village government operated the system on their own. This has been replaced with a system under which the prefectural governments allot a share of expenses to be covered by city, ward, town and village governments in their areas. They inform the local governments of the insurance premium rate commensurate with the amount of expenditures they cover. The city, ward, town and village governments determine the actual amounts of insurance premiums to be paid and collect these premiums.
A problem facing this reform is how to level the amounts of premiums for which there are large disparities among regions.
In the past, there were gaps even among local governments within a single prefecture that could exceed a three-fold disparity. This was due to differences in such matters as the age demographics of subscribers, their income level and the quality of the medical services received, as well as health promotion efforts.
Preferably, the level of medical care received and insurance premiums collected in one area should be made equal to that of others. However, only a small number of prefectural governments, such as Osaka, have announced a policy of collecting standardized premiums in their regions.
Hastily standardizing insurance premiums can produce harmful effects. There could be an increase in the burden shouldered by city, ward, town and village governments working to curtail their medical expenses through disease prevention and other efforts, affected by those whose medical costs add up to a large sum. A feeling of inequality could increase among such regions as mountainous areas where there is a shortage of sufficient medical services.
The prefectural governments should make quick efforts to facilitate an environment for leveling the amounts of insurance premiums, through such efforts as eliminating regional disparities in medical services and promoting measures to curtail medical costs in their entire region.
Many city, ward, town and village governments make up for deficits in their premium revenue, using money from their general accounts. To restore financial health to the national health insurance, it is necessary to ensure there is no need to make up for such shortfalls, and to clarify the revenue and expenses in this area.
(From The Yomiuri Shimbun, April 2, 2018)
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