How Da Ya Think He Does It?

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- The Who, Tommy (1969)

Open sore in the Cabinet, Minister of Law Tanaka Keishu (Link), was seen last night being driven in official car back to his condominium inside the Diet Members' Residences, a brigade of photographers and reporters in hot pursuit.

According to the Ministry, Tanaka will be attending today's regularly scheduled Cabinet meeting, after his missing the Friday Cabinet meeting due to pains in the chest and exhaustion...and missing his double summons to the House of Councillors Oversight Committee the day before. Tanaka will then hold a press conference, presumably announcing his resignation for...oh whatever it will be.

Not a bad little daily schedule for a vewy, vewy sick old man.

Would you not have wanted to have been in the physician's examining room yesterday?

"You're EKG is normal. Your blood pressure is high but looking at your chart, within the range of your usual levels. Blood sugar is normal. Considering we found nothing out of the ordinary on Friday, I am pronouncing you to be in reasonable health, given your age and lifestyle. We need your bed for someone coming out of the ICU so I am recommending you for immediate discharge. Oh, and one more thing...you are an incredibly ugly little toad...and that's on the outside."

Later - Days too late for the action to have anything but a perfunctory meaning, Tanaka has handed in his letter of resignation. (Link -J)

Now the questions are "Why was he selected to be Minister of Law?" and "How did he manage to avoid exposure all these years, only to be outed after he became a minister?"

That latter question begs real questions of the purposes and goals of The Fourth Estate in this blessed land.

Pawn Sacrifice - Reprise

Brave Sir Robin ran away
Bravely, ran away...away...
When danger reared its ugly head
He bravely turned his tail and fled
Yes, brave Sir Robin turned about
And gallantly he chickened out
Bravely taking to his feet
He beat a very brave retreat...

- Neil Innes, "The Ballad of Sir Robin" (1975)

Yesterday Minister of Law Tanaka Keishu failed to show up at not one but two summons to answer questions before the House of Councillors Oversight Committee (Link), leading to the committee's chairman to demand his resignation as Minister. According to the Asahi Shimbun, Tanaka was seen this morning leaving the Diet Members' Residences at 9 a.m., climbing into the back of an official car, talking all the while on a mobile telephone.

After this, all hell broke loose. The Ministry announced that Tanaka would be missing the bi-weekly Cabinet meeting. It then announced the cancellation of all Tanaka's Friday activities.

The news then came down from the Ministry that Tanaka had awoken this morning with pains in his chest and elevated blood pressure. As a consequence he ordered his official car to change direction and take him to a hospital. (Link -J)

Sigh...

How long have I lived in this blessed land?

How could fall into the binary Resign/Fire gravity well, forgetting the notorious Third Option -- the Cowardly Auto-Hospitalization?

Perhaps because it has been such a long time since anyone in the top ranks of politics has taken this route to avoid an inconvenient situation. Even the Liberal Democratic Party, which had for decades provided enough gutless miscreants running for the clinic doors for a "Guess Who's Hospitalized Now?" quiz show, gave up the maneuvre as being just too cheesy. Ozawa Ichiro of course has had his paper surgical mask fetish, donning The Mask whenever the heat got turned up in any of his scandals (Link). However Ozawa's mask is not on the same scale as the full Monty (Python) of running for the ER.

Perhaps I was blindsided by Tanaka's not being on verge of being arrested for anything. For so many of the most successful of this blessed land's political funds fundraisers, the cool white sheets of a hospital ward were preferable to accommodations the prosecutors were likely to provide.

In my previous post on Tanaka, I put forth the proposition that he posssibly lacked the decency to resign.

Clearly I underestimated his capacity for anachronistic douchebaggery.

So Mr. Sam Cooke, if you could, just one more time.

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.

* * *

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.

In Rude Political Health

In what is a probably astute gesture of restraint, the leadership of the Democratic Party of Japan has reportedly backed away from the plan for a vote of censure in the House of Councillors.

A DPJ candidate's defeat of the Liberal Democratic Party candidate in the Yamaguchi #2 by-election and the prime minister's disastrous public polling numbers have robbed a bill of censure against the PM, a member of the other house of parliament, of much of its former luster. The DPJ has proven itself relevant: it does not need an act of political theater to convince the public of its sincerity and importance. On balance, a censure motion now poses more of a risk to the DPJ's standing than the DPJ can perhaps stomach. Proceeding to a vote on a legally dubious bill could boomerang, leading to the public to call into question the DPJ's credibility.

As if to balance its new restraint in regards the censure with excess elsewhere, the DPJ has announced a plan to proceed with a bill terminating the new over-75 elder care system.

The move is smart in seikyoku (political street fighting) terms. The elderly vote in far greater numbers, both in aggregate and proportionally, than the young. In terms of regional power, retirees are a larger fraction of the voting public in the low population rural prefectures, where the move of a few thousand votes from one column to the other could switch a district from LDP to DPJ control. Elderly-dominated districts are also over-represented in the Diet due to the incomplete equalization of the declining rural districts with stable or growing urban-suburban ones. Appealing to the old cannot only win you more votes within a district, it can win you more districts period, due the dominance of elderly voting a larger number of districts. Add to this structural justification for pandering to the retirees a tone-deaf ruling coalition incapable of even breathing without offending—and you have what must be a seductive opportunity to position the DPJ for a seizure of power.

Such positioning is Ozawaism at its worst. It is Tanakaism reversed: the irresponsible promising to undo all unpopular LDP policies—even the difficult and necessary ones—in order to win the next election. It is irresponsible and dishonest—justifiable only to revolutionaries to whom the end of winning political control justifies the means. That Kan Naoto—a former minister of health and welfare—should be the DPJ's spokesman for this facetious termination bill is disturbing. He of all the leaders of the DPJ should know that health insurance system is doomed to a financial unraveling unless fundamental reforms of elder care are undertaken.

In seisaku (political policies) terms, the recently instigated elder care system seems a fair solution to the looming elder care crisis. With the young a decreasing fraction of the total population, relying upon on the underconsumption of healthcare by the young as the subsidizer of the healthcare of the very old puts one on a collision course with reality—no matter what one may think of the social justice aspects of the intergenerational transfers...

(I am an apostate. I hold as self-evident that the young today have high paying jobs in an advanced industrial society thanks to the savings, self-sacrifice and hard work of preceding generations. Whining about being taxed to death in order to coddle rapacious old folks grants to the individual an unearned aura of autonomy across time.)

The decision to deduct (tenbiki) a regular extra insurance fee from the pensions of persons over 75 years of age in return for lowering the patient's visit costs to 10% of the total cost does penalize very healthy seniors. Then again, all insurance systems penalize the healthy.

Having a regular fee deducted from one's pension and a low per visit cost avoids a major problem with the elderly: self-rationing of healthcare. One wants the healthcare system to discourage frivolous visits to the doctor—one of the reasons (aside from the obvious fiscal ones) that the authorities over the last decade have increased the percentage an individual pays out of pocket from the original 10% to 20% and 30%. However, one would want the very old to seek treatment for minor ailments before they deteriorate into major and expensive-to-treat illnesses. One would want the system to stimulate the individual retiree into rationalizing a visit to the doctor as a way of recouping for himself or herself at least some fraction of the money the government has forcibly taken from his or her pension.

The regular pension deduction and lower per-visit cost also addresses one of the real problems of the cost curve of healthcare over time—that the last six months of a person's life are the most expensive. As organs and internal systems fail, doctors and hospitals deploy all kinds of life-prolonging medications and devices...

(One unfortunately misinterpreted gesture has been the government program encouraging physicians to give their patients questionnaires asking them to specify about what kind of life-prolonging treatments they would not want deployed in case of incapacitation. Some critics [Veracity Alert - The following is according to Shūkan Gendai - quote at your peril] of the system have depicted the gathering of this information as a preliminary step to charging higher monthly fees to those individuals expecting more aggressive and expensive life-prolonging strategies. They have pointed to the assigning of a point system to certain kinds of treatment as evidence--as if a person amassing a certain number of points after saying "yes" to a particular number of life-prolonging treatments would be then charged an "X" amount in fees. The actual goal of the point system is almost certainly to help hospitals decide on how much to spend on certain technologies and treatments, and avoid overinvestment into life-prolonging technologies the patients do not want employed.)

To expect an individual to have liquid savings able to cover 20% or 30% of the cost of these end-of-life treatments, especially as life-prolonging technologies advance in their ability to increase lifespan, is simply not reasonable. Better to have each person pre-paying over the course of her or his retirement into a general fund, creating a special drawing right for the individual for the time when her or his vital systems begin to shut down, leaving the individual at that time liable for only 10% of the cost out-of-pocket.

Now, if the above is indeed a proper description of the new elder care system, it would take a special kind of genius to be so unnerved as to never, ever attempt to explain it. Perhaps the LDP and the New Komeitō deserve to be sent to perdition for having both delayed the introduction of this system and left it to the bureaucracy to justify.

However, the cowardice of the ruling coalition is no excuse for the DPJ's turning its back on reform. The public is not stupid: it will ask what the DPJ's plan is for the long-term financially stability of the healthcare system. Being in an advantageous position on the electoral map is a fine and wonderful thing—and elections are about winning. However, as a party that will win at best a plurality of seats in the House of Representatives, requiring the cobbling together of a coalition in order to form government, the DPJ should be at least considering the possibility that a reputation for conscientiousness could make the signing up of allies a slightly easier task.

Kan Naoto speaking out in favor of reverting to the previous system puts pressure on the DPJ's House of Councillors membership to speed up the consideration of the termination bill. Submitted to the House of Councillors in February, the bill has yet to see the inside of a committee chamber. A suspicious mind could even posit that the DPJ councillors have been stalling on their allies—all of whom are enthusiastic supporters of a rescinding of the new system.

Perhaps being in charge of one of the houses of the Diet has made DPJ's House of Councillors members the party's "responsible wing" —which would be a neat reversal of the traditional image of the House of Councillors membership as the breakfast cereal (i.e., the flakes and nuts) of every political party.