Resolution to Achieve a Society Guaranteeing “Access to Medical Care” as a Human Right
Approximately 1.95 million households have fallen behind on their national health insurance premium payments, accounting for approximately 11% of all beneficiary households. According to private surveys, a consistent number of individuals have been losing their lives due to economic factors such as inability to pay insurance premiums or out-of-pocket expenses, which hinders their access to medical care. During the COVID-19 pandemic, the shortage of hospital beds and healthcare workers, as well as the compromised functioning of public health centers responsible for hospital admissions, resulted in undesired “at-home care” and “dispatch difficulty cases” where patients were unable to receive immediate emergency care. These conditions have precipitated a “medical system collapse,” leading to the loss of many lives of those without access to the essential medical attention they required.
Looking at the history of healthcare system reforms in Japan, healthcare cost containment became the focal point of the policy due to administrative and fiscal reforms initiated in the 1980s. Measures were implemented to restrain demand through an increase in the burden of medical expenses on citizens and to restrict supply by downsizing the medical care provision system. Then, in the 1990s, neoliberal reforms gained momentum and the containment measures accelerated further under the guise of “self-reliance” and “efficiency”.
Regarding the burden of medical expenses, in addition to the regressive insurance premium burden that imposed a significant hardship on low-income individuals, out-of-pocket payments were increased from a fixed amount to 30% for those covered by Employees’ Insurance. For the elderly, it increased from zero to 10-20% (30% for income earners similar to active workers). This represents a substantial burden even when viewed on a global scale.
In the medical care provision system, both private and public hospitals have experienced bed reductions and limitations on the number of doctors. This arose due to successive amendments of the Medical Care Act, restrictions on the number of medical school admissions, and the institutionalization of the “the regional medical care vision” which occurred through the Law Amending Related Acts for Securing Comprehensive Medical and Long-Term Care in the Community (2014). Bed capacity decreased by over 250,000 beds between 1999 and 2019, through mergers and closures of public hospitals. The number of doctors dropped to 2.5 per 1,000 people, ranking 33rd among the 38 OECD member countries, and the number of nurses was also insufficient, with only one-fifth to one-tenth of the average for nurses per bed seen in Western countries, leading to a chronic shortage of medical professionals. Furthermore, similar to the situation with medical expenses, there have also been reductions in the budgets for public health, which encompass measures for infectious diseases. The number of public health centers has also significantly decreased from 847 in 1994 to 468 in 2023, accompanied by a reduction in personnel.
Individuals’ access to medical care is being impeded as a result of the growing burden on individuals and limitations within the medical care provision system. Moreover, in a society characterized by increasing poverty and a widening wealth gap, individuals who are marginalized from labor, education, housing, family and other communities face even greater challenges in accessing medical care due to economic, regional and geographical factors.
While the COVID-19 pandemic has brought attention to these issues surrounding the medical system, containment measures such as bed reductions still persist.
Medical care, however, is a matter of critical importance to human lives and health. It demands highly specialized skills, and predicting the specific types of care required, as well as the timing and circumstances in which it may be needed, can be challenging. On the other hand, medical care is essential to ensure that individuals maintain their dignity throughout their entire lives. Therefore, individuals should not be denied access to medical care for reasons unrelated to their medical needs, such as their economic status, place of residence, disability, gender, sexual orientation or identity, age or nationality. Everyone should have the right to access medical care at any time and from anywhere, as access to safe and high-quality medical care is guaranteed equally to all as a fundamental human right (Articles 13, 14 and 25 of the Constitution of Japan; Article 12 of the International Covenant on Economic, Social, and Cultural Rights (ICESCR)).
Furthermore, national and local governments have the responsibility to maintain and expand the health care insurance system, the medical care provision system and the public health system to effectively guarantee access to medical care as a human right. The COVID-19 pandemic served as a reminder of the fact that medical care is a public good essential for maintaining a society. Now that questions are being raised about the future of medical care in the post-COVID world, the Japan Federation of Bar Associations calls on national and local governments to shift away from policies centered on containing medical costs and instead implement new measures to guarantee the right of access to medical care.
1. Establishing Universal Health Care Insurance for All to Ensure Access to Necessary Medical Care
The following measures should be implemented to ensure that no one is hindered from accessing medical care due to economic and other circumstances:
- (1) In recognition of the critical situation where many lives have been lost due to a lack of access to necessary medical care, promptly expanding the coverage of beneficiaries who can receive medical care without incurring out-of-pocket expenses.
- (2) In order to address the issue of households failing to pay insurance premium payments, broadening the eligibility for reductions and exemptions from national health insurance premiums; and implementing measures on a solely income-based approach, including substantial premium reductions for low-income households and an increase in the Employees’ Insurance premium rate for high-income households currently benefiting from premium reductions.
- (3) Providing health insurance cards to individuals with overdue premium payments, and offering individuals the option to retain their current health insurance cards if they prefer, in recognition of the fact that many citizens are uncomfortable with the integration of health insurance cards and My Number Cards.
2. Upgrading the Medical Care Provision System
The following measures should be implemented to ensure access to necessary medical care for everyone, regardless of their place of residence:
- (1) Reviewing the regional medical care vision, halting bed reductions by national and local governments that do not take into account the circumstances of each region, considering the feedback of citizens and patients in the formulation of medical care plans, removing the list of public hospitals slated for restructuring, and recognizing the vital role of public hospitals, especially in underpopulated areas, and, at a minimum, maintaining them to protect citizens’ lives.
- (2) Addressing the shortage and uneven distribution of doctors and nurses, particularly in underpopulated areas, and implementing measures to enhance their working conditions.
3. Upgrading the Public Health System
Based on the observations that: (i) it cannot be denied that the reduction of public health centers may have contributed to delays in responding to COVID-19; (ii) it is necessary to ensure access to medical care by integrating with community health initiatives, such as public health nurses reaching out to those who cannot access medical care; and (iii) the role of public health system is crucial in bridging healthcare disparities, the public health system should be enhanced through the establishment of new public health centers, expanding and improving the functions of existing centers, and increasing the number of public health nurses, all as part of a public responsibility.
4. Recognizing the Significance of Medical Care and Public Health as Fundamental Elements of Local Communities
Medical care and public health exert a substantial influence on economic growth and the generation of employment opportunities within local communities. They also contribute to the tax revenue of local governments and play a crucial role in fostering positive economic cycles within communities. Conversely, the closure of hospitals and public health centers can lead to the impoverishment of local communities and may initiate a destructive cycle that hinders access to medical care. Hence, policy decisions should focus on the impact on local economies and rely on evidence-based assessments.
5. Social Systemic Factors and Public Initiatives
Social systemic factors not originating from individuals (pointed out as “the social determinants of health (SDH)” by the WHO), such as poverty and social disparities and inequities, constitute the majority of the causes of healthcare disparities, and some of these factors may significantly impede access to medical care. The following measures should be implemented to address this issue:
- (1) Advocating for WHO-led initiatives targeting healthcare disparities and ensuring prompt access to medical care for those currently facing obstacles due to various social determinants.
- (2) Conducting public surveys on healthcare needs and the factors contributing to the lack of fulfillment of these needs, including the actual number of uninsured individuals and the true state of limitations regarding medical consultations.
In an effort to address SDH issues, it is considered essential for healthcare workers to collaborate with various professionals on-site to implement “social prescriptions” and to undertake efforts to eliminate social systemic factors. Lawyers and bar associations have been working with a range of local professionals, including healthcare professionals, to assist both individuals facing poverty and foreign residents through activities such as consultations. In recognition of the importance of protecting individual rights through the collaboration of medical care and legal assistance, the JFBA will further enhance its cooperation with healthcare personnel. This includes participating in initiatives led by healthcare professionals to address SDH issues, such as on-site collaboration in outreach activities and regular consultations with medical associations. The JFBA will strive to guarantee access to medical care as a human right.
October 6, 2023
Japan Federation of Bar Associations
