Are Japan’s medical and welfare services parts of the ‘service industry’?
Around the time the Nursing Insurance Policy was introduced, the announcement was made that social welfare services would now be provided by private contractors and that for-profit corporations would be licensed to dispense the public welfare services that until then were the domain of government-run social welfare service corporations.
Setting aside for the moment the question of how the situation has changed since the introduction of private corporations into the realm of medical care, the services available to ordinary citizens have diversified and improved in quality dramatically.
On the other hand, services for persons burdened with physical and mental disabilities as well as economic hardship have worsened. The reader is asked to recall an incident several years ago of a fire at an unregistered, private residential service for the elderly in the northern Kanto Region which left several of its inmates dead. The incident garnered public attention on homes for the elderly specializing in taking in social welfare recipients. No doubt there are facilities which provide as many services as they can at the lowest possible price in the name of helping society, but there are also many, like the one in the incident alluded to above, which have collected welfare recipients in housing facilities with appalling living conditions that hardly bear scrutiny.
Writing about incidents like this is likely to provoke government bureaucrats to argue that policies are in place to pay for nursing home costs for low-income earners. However, at the hospital specializing in care for patients with dementia where I served as the director until March, whenever I requested arrangements to be made to house patients following their discharge, almost every social welfare office without exception recommended a private residential home of this sort. Between the official position that there is a policy to help these patients and the actual availability of facilities fit for habitation, there exists an almost insurmountable wall. While there are numerous advantages to privatizing nursing services, and the policy does not deserve unqualified criticism, delegating welfare services promising assistance to low-income individuals with no family to market forces is a dangerous proposition indeed.
Debates about the service industry in relation to medical care became common around the time deregulation and market forces were sweeping our nation. Even in the medical domain, it was argued, deregulating the public sector and leaving the provision of services to market forces would lead to higher quality services by virtue of competition.
There are not a few parties who believe that in uncertain economic times, ample opportunities for business exist in turning medical care into an industry. Apart from questions of efficiency and the proper place of industry, should we define the medical services provided by our nation as a kind of service industry?
I, for one, disagree. A service sector business provides services in exchange for money. Thus, individuals who are able to pay large sums of money are entitled to receive more services while those who are unable to pay need not be served. But this cannot be right where medical organizations are concerned.
When I took on the mantle of director at Matsuzawa Hospital, I swore an oath to obey the constitution of Japan. Article 25 of our constitution guarantees the right to live as the precondition for all basic human rights, in other words, the most important and fundamental right accorded to citizens. As an embodiment of this principle, our universal health insurance policy respects the life and equality of citizens irrespective of their economic standing, origins or social standing. It requires all citizens who are eligible for insurance to pay premiums, making up any deficit with taxes against the time when medical care becomes a necessity.
Insurance carriers might be health insurance associations or local municipal governments, but whatever the case, these organizations are of a public nature. In the event of an injury or illness, insurance payments are made to the insured party by the carrier, but these ‘payments’ take the form not of cash payments but medical treatments, such as examinations, tests, treatments, and medication.
In other words, the medical institution dispenses these treatments as a proxy for the insurer and is later compensated by the latter. The citizenry bear a portion of the cost, in a way analogous to the auto insurance deductible. Thus, the medical organization does not ‘deal’ directly with the patient. Accordingly, a significant moral problem arises when this relationship takes the form of a transaction between a private service provider and the consumer. For example, let’s suppose that the consumer wishes to have a cold remedy, pain killer, stomach medicine or antibiotics as part of his travel kit in preparation for an extended trip abroad.
The private service provider would only be too happy to oblige the paying customer. In this way, a person who is not ill can obtain the items he wants for his trip at a price 70% lower than he would pay at a drugstore. The physician is rewarded with a prescription fee, and because an in-house prescription would net a healthy profit generated by the difference in the wholesale and retail costs of medications, both parties would happily profit from this relationship. Or would they? Since 70% of the cost of the medications and the insurer’s payment to the physician for the medical treatment would come out of tax payers’ money, the transaction would be tantamount to the patient and the physician cheating the citizen. Medical insurance is meant to insure people against the cost of treatments incurred in the event of sickness or injury, not something that provides payment for the cost of medications merely for the peace of mind of persons who are not even ill. It would, in effect, be a classic case of fraud. For this reason, our national medical services are not a service industry and must never be.
Reference to ‘our valued patients’ have probably coupled medical treatment with the notion that it is a type of service business. Addressing patients in this way may have had value as means of putting haughty physicians in their place, but it can cause considerable harm if patients are encouraged to believe that, as consumers in a commercial transaction, they have the right to expect medical institutions to provide them with any medical service they wish. Physicians should be cognizant of their duty to provide adequate medical care within the constraints of the budget they have been provided in order to uphold the right to life, which, as we have said, is guaranteed by our constitution as a fundamental human right. And the patient, for his part, must be content with receiving the medical treatments permitted by budgetary constraints, not least to help sustain our universal health insurance system, which is unparalleled by any other in the world. The word, ‘service’ originally denoted an act freely rendered without expectation of reward by an individual to God, country, the group to which he belonged or to some other object of value. I have already spoken about how Japan’s medical services are not a ‘service business.’ Rather, our nation’s medical services should be considered to be a ‘service’ in the original sense. We render our ‘services’ to realize the high ideal of the Japanese constitution which forbids placing a price on human life. My wish is that Matsuzawa Hospital remain an institution that is able to provide the requisite medical treatments to those in need of them in the most efficient manner possible.