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Experts propose medical, social security program revamp as more foreigners work in Japan

TOKYO -- As more foreign workers are expected to live in Japan with the introduction of new residency statuses in April, attention is being focused how to adapt a social security system -- including medical and pension programs -- initially designed with Japanese users in mind. The Mainichi Shimbun sought the opinions of three experts on necessary revisions:

    Yoneyuki Kobayashi, head of the AMDA International Medical Information Center. (Mainichi/Go Kumagai)

    --- Interpretation, consultation services for foreigners should be enhanced: Kobayashi

    A medical system that discriminates against foreigners is not acceptable as a matter of human rights. But treating foreigners favorably may spark and expand xenophobic sentiments. Major problems can occur unless we make sure that there is no discrimination against foreigners or counter-discrimination against Japanese.

    We can draw lessons from our experience of accepting more than 10,000 refugees from Indochina since 1975. When I was working at a municipal hospital in the city of Yamato in Kanagawa Prefecture, where reception facilities for the refugees were located, we heard many complaints that other hospitals had turned down refugees because they could not speak Japanese.

    There were issues rooted in difference of culture or habits. The refugees considered cold meals bad for pregnant women, and serving bowls of vegetable salad triggered a big commotion. They came to Japan with only shirts on their backs, so I intended to provide minimum and efficient treatment. There were other troubles beyond medical treatment. I wonder if Japan has done a comprehensive review of this experience.

    I opened a clinic in Yamato, south of Tokyo, in 1990 to treat local residents regardless of their nationalities, and set up an information center the next year. I have tried to hit an optimum balance in providing medical care, asking myself if what I'm doing is discriminatory to foreign or Japanese patients. Base on this experience, I think we need to provide interpreters, and introduce consultation counters for foreign residents. Offering telephone interpretation services would be more convenient because they would be able to respond to emergency cases quickly and across a wide area.

    Consultation counters would provide information about hospitals that accept emergency patients, or explain the medical payment system. Our information center receives inquiries stemming from a lack of knowledge on how the system works.

    Medical institutions cannot function properly if such questions are directed at them, and consultation counters can control the inquiry traffic and defend hospitals and clinics. Costs for interpretation and consultation can be covered by revenues from the departure tax (charged on foreigners and Japanese nationals leaving Japan).

    The government is considering accepting foreign patients at designated hospitals with multilingual capacities. If other medical institutions end up refusing to see foreigners, they would have to travel long distances to reach those designated institutions. Like Japanese patients, foreign patients should be able to be treated at any medical institution. Doctors treat their patients sincerely, regardless of their nationality.

    Meanwhile, newcomers to Japan are required to pay the minimum national health insurance premium because it is difficult to determine their income in the previous year, which is the basis for determining the figure. If foreign patients paying the minimum premium use the high-cost medical expense benefit program with a cap on monthly medical fees and receive expensive treatments, discrimination and hatred against foreigners may rise. This program was introduced when Japan did not have many foreign residents, and it needs to be revised.

    (Japanese original interview of Yoneyuki Kobayashi, head of the AMDA International Medical Information Center, by Go Kumagai, Medical Welfare News Department)

    Professor Shinichi Oka of Meiji Gakuin University, specialist in European and international social security systems. (Photo courtesy of Professor Oka)

    --- Equality, consideration should determine responses: Oka

    Japan's social security system has to overcome many challenges, and the international social security law in Europe, where free movement of people is allowed, should be considered in reviewing the Japanese system. European countries coordinate national social security programs based on the following principles: Equal treatment of foreigners and local citizens; coverage by social security programs of countries where recipients work; determination of benefits claims based on all previous contributions; the right to international remittance of benefits; and the right to continuous social security coverage.

    The foundation of social security is equality for local citizens and foreigners. However, foreigners, who live under different conditions, may suffer disadvantages. There are cases in which foreigners are not covered or receive reduced benefits because their stay is shorter than required for payments. On top of the principle of equality, special considerations for foreigners are needed.

    Japan's pension programs allow foreigners leaving the country to receive a lump-sum payment from their past contributions, but the amount is substantially lower than the total money paid. The national pension program pays back only 15 to 50 percent of total contributions. Foreigners, who are forced to join the programs, face a disadvantage. In addition, they can only file for the payment within two years of losing coverage, which violates the principle of continuous coverage.

    Foreign workers in Japan aged 40 or older are also forced to pay nursing care insurance premiums. At age 65 or older, many of them are already back in home countries and are unable to claim their nursing benefits in Japan. In addition, Japan's public assistance programs cover only Japanese nationals in principle. There are certain foreign recipients based on humanitarian considerations, but they cannot file appeals should they have problems with coverage.

    Recently, we see news reports of foreigners misusing the social security system. Misuse should be stopped regardless of the nationality of those committing the act, but appropriate measures should also be applied regardless of recipients' nationalities.

    A person from a country without social security and one from someplace with better social security coverage than Japan are both foreigners. It is not legitimate to punish all foreigners because of wrongdoing by a few.

    Japan has been signing bilateral social security agreements one after another to avoid double payments of contributions, but the agreements differ from country to country, and different standards apply to people from different nations. This will cause complications in the future, and management under a standard like the one used in Europe is desirable.

    Under the economic partnership agreements and as part of trade policy, nurses and nursing care workers are beginning to come to Japan, and the latest changes to the immigration law will expand the range of such foreign workers. Conditions need to be improved quickly to accept foreigners as people carrying out social welfare activities.

    Acceptance of foreigners is the focus of the day, but many Japanese workers are active throughout the world, and positions of countries sending their people need to be considered. A common goal for the international community today is the establishment of a social security program that can stabilize the lives of people who move beyond borders. Japan's social security system, which is premised on application only inside the country, should respond to internationalization now.

    (By professor Shinichi Oka of Meiji Gakuin University, specialist in European and international social security systems)

    Norio Ohmagari, deputy director of the General Hospital of the National Center for Global Health and Medicine. (Mainichi/Kaori Gomi)

    --- Burden on medical professionals should be eased: Ohmagari

    At the General Hospital of the National Center for Global Health and Medicine in Tokyo's Shinjuku Ward where I serve as deputy director, 16 percent of new outpatients and 5 percent of new inpatients in the fall of 2018 were foreigners. I assume these ratios are fairly high for a Japanese medical institution. The hospital opened the International Health Care Center in 2015, which received accreditation by the Ministry of Health, Labor and Welfare as a medical institution accepting international patients.

    As of December 2018, medical institutions so accredited numbered 52 across the nation. Requirements for accreditation focus mainly on facility conditions, such as the introduction of multilingual in-house directories, but they are not enough to offer an environment for treating foreign patients. Medical institutions must connect patients, medical staffers and outside bodies such as insurance companies. Organizational efforts such as introducing a specialized in-house section are vital.

    One of the challenges faced by medical institutions accepting many foreign patients is handling of administrative work. A variety of payment methods such as cashless payments and use of foreign insurance companies need to be prepared. Hospitals face the risk of nonpayment should they not introduce credit card payments, which are in wide use overseas.

    At our hospital, we have full-time interpreters for languages such as Chinese. As for interpreters of other languages, we depend on our personal connections or prepare a list of available people and contact them in time of need.

    Medical interpreters need to have high communication skills for understanding special terms and explaining symptoms and test results, or discussing treatment methods with patients in serious condition. Securing highly skilled interpreters is not easy, and medical institutions are competing to hire good ones. It is desirable to set up and expand a pool of able interpreters that can be utilized by multiple medical institutions. Telephone or online interpretation services should be used in areas where interpreters are in extremely short supply.

    For doctors, translating medical reports can be an extra burden. Measures to make their jobs easier, such as preparing medical report templates in foreign languages are required. The number of administrative workers supporting doctors is not enough, and people with language skills will be highly valued further in the future.

    Medical staff treating foreign patients will be required to change their thinking because medical cultures overseas are different from that in Japan. Here, it is ordinary to tell patients with cancer about their ailments and discus a treatment policy. In some other Asian countries, people are not used to the concept of being told that they have cancer, but you cannot proceed with treatment without informing the patients. Some foreign cultures have a stronger sense of self-determination, and patients from those countries want to decide on which tests and treatments they receive based on what costs are acceptable to them.

    Communicating with foreign patients can take double to triple the time needed for Japanese patients. This means that the number of patients a doctor can see during a set period goes down. We have to discuss how to handle this increased time cost, including the pricing of each treatment.

    (Japanese original interview of Norio Ohmagari, deputy director of the General Hospital of the National Center for Global Health and Medicine, by Kaori Gomi, Medical Welfare News Department)

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