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    Don’t send me no doctor

    Here we go. This is hardly the beginning–there’s been news like it at regular intervals for years–but the Ministry of Health, Labour, and Welfare (note the British u in that fourth word–this is a class-act, civilized country, you know) bean crunchers and number counters have estimated that total health expenditures in 2025 will be more than double what they are now: 69 trillion yen (about US $630 billion). That includes out-of-pocket payments by users but, naturally, mostly consists of Social Insurance premiums and taxes. The most quickly increasing sector is geriatric care, of course; it’s projected to be half the total by then.

    When people ask me what the health care system is really like over here, I never quite know what to say. Care for minor stuff is great; so is care for catastrophic illness. I’ve had friends who had heart bypasses and treatments for cancer that were, to judge from the results, first-rate. No, it isn’t the Nirvana a lot of collectivists in America think it is: care for things that are significant but not life-threatening is seriously hit-or-miss. You have to work hard to find a good dentist. It’s common to tell a GP that you’ve already tried aspirin for your fever and still walk out of his office with powdered acetaminophen. Treatments are often drawn out into short segments given over weeks or months. Part of this is because the traditional Asian view of how to restore health involves slowly and naturally prodding the life processes back into normal alignment.

    But part of it is also that more visits help maximize revenue from patients who don’t have many other options. Despite the long average life span here, the lack of transparency in operations (and deemphasis on personal responsibility and initiative) that create drag on the Japanese domestic economy are bad for the health care system, too. This article is out-of-date, but it compiles several of the cases that got the most publicity in the first few years I lived here. Since then, you get similar stories regularly: a sociopathic nurse in Sendai killed his patients by giving them heavy doses of muscle relaxant. Even though the frequency with which his patients worsened was such that his colleagues called him “Nosedive Mori,” and he was using unprescribed doses of muscle relaxant that were missing from inventory, he seems to have kept this up for years. And then there’s the “thank-you money” that people routinely give their surgeons in addition to the set fee.

    None of this is to be interpreted as meaning that people are lying or incorrect when they say that Japan has good health care. It’s just that you can’t point to Japan and say that having a national health care system improves things over private insurance by ensuring better control and an orientation toward service rather than profit. Everyone knows that as the population ages, caps on care will change; it will be unpleasantly interesting to see how the revised MHLW rules play out as they move through the medical system in real time and on real terms.

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