The Yomiuri ShimbunThis year, the nation faces a crucial juncture as it seeks to establish a sustainable social security system at a time when Japan’s society has a shrinking population and is becoming increasingly elderly.
Two major issues need be addressed. One is reform of the medical and nursing care system tailored to “the era of the 100-year life,” the other is changing the existing model that centers on paying benefits mainly to elderly people to one that supports all generations, including the working population.
Japan’s total population has been declining since it peaked in 2008. If the birthrate remains at its current level, the current population of 127 million people will fall to 88 million in 2065. The proportion of people who are elderly is forecast to increase from more than 27 percent now to almost 40 percent.
Last chance for reform
The proportion of the population who are elderly people aged 75 and older will surge in the years ahead in line with the aging of the baby-boomer generation. Their need for medical and nursing care will unavoidably soar. How will the government curb snowballing costs while ensuring these necessary services are provided? This is the largest issue to be handled with regard to stability of the social security system.
April this year will mark a very important stage, as this will be the start of the government’s next health care program in parallel with the simultaneous revision that occurs every six years of medical treatment fees and nursing care fees paid to medical and nursing care institutions. This can be described as the last chance to implement reforms before 2025, when all the baby boomers will be aged 75 or older.
Patterns of disease are changing as people become elderly. Due to the increase in lifestyle-related diseases and dementia, many elderly people have multiple chronic ailments. The nation needs reforms that will transform medical treatment from a system aiming to help patients completely recover through intensive treatment such as operations, to a system that supports patients with chronic diseases as they live their daily lives.
Fewer hospital beds will be for seriously ill patients requiring expensive treatment, and more beds will be designated for the recovery period that supports patients and prepares them for after they leave hospital. Home-based medical care services also will be improved. By cooperating closely with nursing care providers, the shift from medical care to nursing care will move ahead.
It will be important to build an efficient system that meets the needs of an elderly society, and to provide higher-quality services while also keeping a lid on the costs of providing them. The revisions to medical treatment and nursing care fees should be subtly adjusted to assist this process.
Prefectures across Japan are pushing ahead with work to give concrete shape to visions of regional medicine based on future demand for medical services. Will prefectural governments be able to reorganize the allocation of hospital beds after discussions with medical institutions? These governments will face a rigorous test of their competency.
What to do about “free access,” in which a patient freely chooses where they see a doctor, is also an issue. Free access is believed to be one cause of patients becoming concentrated at major hospitals and seeing doctors at multiple medical facilities. Coordinating through family doctors where patients should be treated is one realistic method to gently restrict such a practice.
In the nursing care field, a review of services for patients receiving a low level of care is required. At a time when financial resources and personnel are limited, focusing benefits on people who require heavy levels of care cannot be avoided.
In the future, it is desirable that “living support services,” in which care workers visit a person’s home to prepare meals and clean, become operations transferred to the control of city, town and village governments. Creating the conditions for these local authorities to accept such a responsibility should be done quickly. Encouraging greater activities by regional nonprofit organizations and volunteer groups also would lead to the revitalization of regional areas.
No wait-list children
Japan’s public expenditures for child care-related and other family-oriented services, as compared to its gross domestic product, is about half that in European nations. To rectify the present situation in which the lack of sufficient assistance in this respect has led to the low birthrate, there is a pressing need to shift to a type of spending that will serve all generations.
The problem is that the government has designated the provision of free infant education and child care services as a key policy. In its economic policy package devised at the end of last year, the government came out with such measures as making education and day care services for children aged 3 to 5 uniformly free. These moves seem to show that the government adhered to the Liberal Democratic Party’s campaign promises made for last autumn’s House of Representatives election.
The fees for services at day nurseries and other facilities have already been subjected to reductions or exemptions in accordance with the income of each parental guardian. Making such services uniformly free would even more greatly benefit high-income groups and therefore doing so does not deserve high priority.
Parents raising small children ardently hope there will be no children on waiting lists for admission to child care centers. If infant education and child care services are first made free, it would result in even greater inequality between households whose children have been admitted to day nurseries and those whose infants have yet to be admitted. Given this, the first and foremost priority must be improving the quality of services, such as creating and improving day nurseries and increasing the number of child care workers assigned to such facilities.
Creating an environment in which children can be raised without anxiety, including measures to ensure there are no children on waiting lists — doing so will require even more funding than was estimated under integrated reform of the social security and tax systems. To realize expenditures that would cover all generations, the government and the ruling parties must rebuild the integrated reform scheme, not shying away from discussing an increase in the burden on the recipients of services.
Work style reform
Amid the continued decline in the working population, it is indispensable to promote a work style that can also enable people to raise their children and nurse their family members, and to encourage a diverse range of people to join the labor force, including women and elderly persons. To sustain the social security systems, it is important to expand the scope of people who can support them.
The situation in which working long hours is common practice has continued to prevent women from playing an active role in society and to invite such tragedies as suicide due to overwork. An increase in nonregular employment, in which workers are low-paid and given few education and training opportunities, would exhaust social and economic vitality.
Last March, the government put together an action plan for work style reforms. The main pillar of the program is to impose upper-limit restrictions on overtime hours and to promote the principle of equal pay for equal work, which bars wage gaps based on employment status. The government will submit relevant bills to an ordinary Diet session. It is hoped that the legislation will be passed into law at an early date.
Work style reform is the centerpiece of the vowed efforts by the government to realize a society in which the dynamic engagement of all citizens is promoted. The public and private sectors need to join hands in promoting the reform drive.