Friday, May 16, 2008

The new elder care insurance system and the disappearing art of dying at home

Over the next few weeks, the ruling coalition and the Democratic Party of Japan-led opposition will have to make some tough decisions about the newly-installed eldercare insurance system.

The ruling coalition will have to look at the numbers and decide whether or not the system can really afford the proposed fiddle with the payments of low income elderly. In the proposed revision to the law, low income couples would see the monthly withdrawals from their pensions shrink from 30% of the standard cost for their prefecture to 10% of the standard cost.

The proposed revision seems to defeat one of the basic goals of the program: encouraging the very poor to go to see a doctor early on because they have already paid a significant lump sum upfront. The proposed revision would of course also decrease the aggregate contributions to going into the insurance system -- meaning that the revenues supporting the the program will have to be drawn from elsewhere.

For its part, the promise-happy DPJ-led opposition will have to decide whether it is serious about the submission of a bill to House of Councillors bill reversing the imposition of the new eldercare system. The opposition camp has made pledges and noises about passing a such a bill by the end of the month....then again, the opposition also swore that if the the road construction bill were overridden, it would pass a motion of censure in the upper house of the Diet against the Prime Minister.

One can hope that both sides in this political fight will leave the program alone. While unpopular, the new program has the ambitious and admirable goal of providing for the healthcare system that exists--not those of some fantasy trade-off-free universal low cost system for an imaginary group of cuddly and genki oldsters.

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A few weeks back I looked at the publicity campaign for a book by Sakurai Yoshiko. In the ad, the right wing's Madonna calls on the Japanese people to rediscover their identities in their traditions, one of which she identifies as "seeing the dying off while seated at their bedside" (kazoku no saigo wa mitoru).

Too bad Sakurai's moral lashings are reprehensible nonsense--people are not staying away from being by the bedside of their dying relatives out of selfishness or disinterest--for she does hive near an ultimately unsustainable trend in the country's handling of death.

Public opinion polls conducted by the Ministry of Health, Labour and Welfare find that about 60% of citizens would prefer to die in their own homes in their own beds. However, figures from the Ministry show that while fifty years ago 80% of all deaths took place at home, in 2007 only 12% of all deaths occured at the deceased's residence.

The Tokyo Shimbun published this dramatic graph of the new reality of death and dying:

Image courtesy : Tokyo Shimbun

The number of deaths at home has plummeted (white line) while the number of deaths in hospitals and other medical facilities has soared (black line). The percentages of each have almost completely reversed over the course of the last 50 years. Since Japanese have low rates of deaths from accident and disease and nearly all suicides happen outside of hospitals, this number--8 out of 10 deaths in a hospital--can only represent the accelerating warehousing of the feeble elderly in medical facilities.

The immense additional cost to the national health insurance system resulting from this complete reversal in the treatment of death is one of the major reasons for the new elder care system's introduction. It is simply not reasonable to expect that the previous system of low payments and a moderate deductible can finance the final hospitalization of 850,000 pensioners per year.

Beyond the monetary cost of keeping all these near moribund persons in a hospital, the opportunity cost--the loss of hospital bed space to a persons with little chance of long-term survival or improved quality of life--is large and growing. It should not be at all surprising that there is a crisis in "patients in need of emergency care being turned away from hospitals multiple times because of a lack of beds and proper facilities". In 2006, 83.5% of all hospitals beds were occupied at any one time. For assisted care facilities (kaigo ryōyō byōshō) the occupancy rate was 94.1%.

Unless there is a dramatic shift in behaviors--meaning at least a doubling of the rate of those dying at home over the next decace--the dying elderly will simply overwhelm the physical plant of the healthcare system. As the passing of the baby boomers drives the number of deaths per year from its current 1.1 million to at least 1.7 million, where will those near death going to be drawing their final breaths?

Perhaps I am just doomed to suffer the disquiet arising from the ravages of intelligence, but underfunding the health care of the very old in order to score cheap political points seems a hell of an answer.


Janne Morén said...

Two of the most common causes of death in the industrialized world - cardiovascular disease and cancer - usually doesn't kill you instantly. If you get a heart attack or a hemorrhage, you'll be whisked away to a hospital with the quite reasonable expectation that you have a chance of surviving the ordeal given prompt enough care. I certainly do hope nobody suggests we stop picking up people so they can get a certain death at home rather than a chance at life in an emergency ward.

And once in hospital care, whether cardiovascular disease, cancer or some other late-stage disease, you often can't move dying people home; "unplugging" them from the care infrastructure would quickly kill them, meaning you'd need a legal revision to allow what amounts to active euthanasia on the part of the physician. And even then I suspect not all that many patients are interested in a faster, more painful death in the interest of tradition.

Jun Okumura said...

A tour-de-force! Factual and passionate! You've even managed to slip in a Hack-a-Sakurai aside, in a move worthy of Bill Laimbeer! Seriously.