NIRA OPINION PAPER
No. 61 | March 2022

NIRA OPINION PAPER
No.61 | March 2022

Public Acceptance of an Increase in the Burdenof Medical Expenses for the Elderly- Considering the Issues based on the Results of a Deliberative Survey (2)Yuri Okina

Executive Vice President, Nippon Institute for Research Advancement(NIRA) / Chairperson, Japan Research Institute (JRI)

In a 2021 revision of Japanese law, it was decided to increase the rate of out-ofpocket medical expenses for the elderly (defined as aged 75 years and above). But whatis the actual public perception of this amendment?
The Nippon Institute for Research Advancement (NIRA) investigated the
trajectory of public opinion on economic and social themes through surveys involving“consideration” and “deliberation.” Among these themes, survey subjects displayedconsiderable interest in the issue of social security, and the majority agreed with the ideaof increasing the out-of-pocket burden borne by the elderly aged 75 and above. It appears
that many members of the public are prone to see issues related to social security asaffecting them directly, and these are issues that they are anxious about, both at present
and into the future. However, it should be noted that the points with which respondents
agreed or disagreed differed depending on the respondents’ individual circumstances. In
order to formulate medical policy that will be acceptable to the public, it will be extremely
important to take minority opinions into consideration while determining methods ofproceeding that can be considered valid by members of all generations.
The clues that we can garner here are the commonalities that are able to bediscerned in people's perceptions. These are concerns regarding the sustainability of the
medical system, awareness of efficiency in terms of the reduction of waste as it relates
to the cost of medical care, and, most notably, dissatisfaction with division of the burdenof health care costs by age. The idea of an “affordable burden,” which should beconsidered based on the ability to bear the burden rather than age, is gaining
considerable support. In the future, we will have to think about “distribution of burden,”
and an agenda should be created towards the formation of a consensus among the public.

Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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No. 61 | March 2022
NIRA conducted a project that combined two questionnaire surveys (we will term thisthe “consideration” component below) and an online interview (the “deliberation” component),
which sought to stimulate discussion on a variety of important issues*. In this paper, we willsummarize what we learned about the specific interests and opinions of the public regarding
the topic of increasing the rate of out-of-pocket medical expenses for the elderly, which was thefirst issue considered in this project.
*For this project, we selected four themes related to Japanese society and the Japanese economy,

engaged an Internet survey company to conduct a survey, and held an online roundtablediscussion. The Internet survey was conducted in two parts, with the first surveying basic
information (personal attributes, etc.) and opinions regarding public policy. The second survey,
conducted in order to determine how thinking regarding issues changes, asked the samequestions as the first, but was conducted after subjects read articles regarding the specific issues
focused on written by experts who hold differing opinions (the opinions were offered by Katsunori
Kondo, Takashi Oshio, and Kazuhiko Nishizawa). We termed this a survey involving“consideration.” We also conducted an online interview via Zoom with 12 of the respondents tothe first survey present. During this interview, subjects read the same expert opinions as in theprevious survey and listened to each other's opinions, allowing us to observe changes in opinion.
We termed this a “deliberative survey.” For details of the survey method and results, see
Taniguchi, M., (2022) “What Constitutes a Policy Vision That the Public Can Accept? –Considering the Issues Based on the Results of a Deliberative Survey (1),” (NIRA Opinion Paper
No. 60), and Kawamoto, M., (2022). Please refer to NIRA Working Paper No. 2, “A Deliberative
Survey regarding Medical Care for the Elderly aged 75 and Above: Consideration and
Deliberation (in Japanese).”In Social Security-Related Issues Are a Subject of Great Concern to the Public,
With a Majority in Favor of Raising Out-Of-Pocket Expenses
To begin, in the first questionnaire survey, when asked which issues the government
should prioritize, 26.8% of respondents answered “Pensions / Medical care / Long-term care.”
These were therefore considered to be the policies to which the highest priority should beaccorded. The survey made it clear that for many members of the public, social security-related
issues are issues that they readily see as directly affecting them, and they feel anxious about
these issues, both at present and into the future (Figure 1).

Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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No. 61 | March 2022

Figure 1 Responses regarding ”Policies that should be treated as having the highest priority”(Note) n=4,238(Source) Formulated by the author based on NIRA (2021), “Third Survey of Core Citizens”

In addition, we took opinions regarding the decision to raise the rate of out-of-pocket
medical expenses for the elderly aged 75 and above in the 2021 revision of Japanese law. As arule, elderly citizens aged 75 and above with an annual income of 2 million yen or more have
conventionally borne the burden of 10% of their medical expenses. Opinion was surveyed
regarding increasing this figure to 20% from October 2022. 66% of respondents agreed with thisincrease, indicating agreement among a majority of the public (Figure 2). Even in the
deliberative survey conducted as an online interview, most survey respondents supported theincrease. However, with respect to respondents who had withheld their opinion in the firstsurvey, in the second survey (conducted after a period of one and a half months from the firstsurvey), as a result of obtaining a variety of new information and refining their thinking, thenumber of these respondents who answered “Basically disagree” increased, and the number
responding “Disagree” significantly exceeded 20% (Figure 2 above). The impression received
from this was that topics such as medical care for elderly people aged 75 and above and thestatus of public finances are not issues that are so simple as to allow members of the public toattain an easy understanding based on discussion alone; rather, agreement and disagreement
are divided depending on factors including the circumstances of the individual. Furthermore,when analyzing agreement and disagreement among each age group, it was observed that many

Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 61 | March 2022
elderly respondents, whose burden will increase in the near future, regarded the issue as one
that affects them directly, and as a result opposed the increase, while the majority of young andmiddle-aged respondents were in favor of it (Figure 3).
Figure 2 Ratios of agreement and disagreement regarding “Increasing out-of-pocket
burden for medical care”(Note) Changes in responses among participants in the deliberative survey (n = 239)
(Source) Kawamoto, M. (2022), “A Deliberative Survey regarding Medical Care for the Elderly aged 75 and Above:
Consideration and Deliberation,” NIRA Working Paper No.2 (In Japanese)

Figure 3

Ratios of agreement and disagreement regarding increasing the out-of-pocket
burden for medical care (Age + Annual household income)(Source) Same as Figure 2

Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 61 | March 2022
As this indicates, there are more people who essentially agree with the increase to a
20% out-of-pocket burden that will come into effect from October. However, opinions are varied,
and results suggest that it will be extremely important in discussions concerning the burden of
medical costs in an aging society to find commonalities that the public can agree on, and to takeminority opinions into consideration while determining methods that can be considered valid bymembers of all generations.
Next, we will consider the concerns of respondents opposed to the increase in out-ofpocket costs. The first concern, as revealed through “consideration” via the questionnaire survey,
is that the elderly face a heavy burden in relation to medical expenses, and any increase in thisburden may mean that they will hesitate to seek medical attention even if they become ill. The
essential point here is that it is difficult to live on an annual income of 2 million yen. These
concerns vary significantly depending on the circumstances faced by the specific individual.
“Deliberation” via online discussion revealed that people with particular difficulties, such as
those having a chronic illness or those bedridden and unable to perform various tasks, were
opposed to the increase. The consideration” section of the survey also showed that elderly people
on low incomes were resistant to the increase (Figure 3 above). However, it was also found, giventhat people aged 75 and above bear only a 10% burden, that the sense of a burden was actuallylow (Figure 4). Nevertheless, there were also respondents who did have the sense of a burden,
for example elderly people living on pensions who are also responsible for the care of middleaged, socially withdrawn “hikikomori (“shut-in”)” children (those affected by the so-called “8050problem,” which refers to parents in their 80s caring for offspring in their 50s), highlighting thefact that there are individual circumstances that cannot be understood through the lens ofincome alone.

Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 61 | March 2022
Figure 4 Responses regarding “Sense of burden in relation to medical expenses”(Distribution by age)

(Source) Formulated by the author based on Nippon Institute for Research Advancement (NIRA) (2021)“3rd Survey of Core Citizens”

At the same time, commonalities shared by the majority of respondents also emerged.
First, the most significant commonality was dissatisfaction with dividing the capacity to bear
the burden of medical costs by age. In an aging society, there is considerable support for theconcept of “affordable burden,” the idea that we should consider ability to shoulder a burden,
rather than simply the category of “age.” This can be seen as an important point of departure as
we are forced to consider a “distribution of burden” into the future (Figure 5).

Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 61 | March 2022

Figure 5 Responses regarding “Expert opinions employed as reference material”(Note) See above* regarding the opinions presented by experts in the relevant fields. The parameter is participantsin the deliberative survey, n = 239.

Commonalities Revealed by the Survey
We will now take up three points regarding commonalities in the perception of relevant
problems among the survey subjects, which became clear as a result of the questionnaire survey
in the “consideration” component and the “deliberative” online discussion. The following are thepoints that became clear through consideration and deliberation.

Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 61 | March 2022•

Perception regarding sustainability: Many respondents shared a sense of crisis to the effectthat it would not be possible to maintain the system of health care because the burden on
the working generations is too great.
<Deliberation> Public finances are under pressure and it will be difficult to maintain theuniversal health insurance system.
<Consideration> The burden on the working generations is heavy, and there is a limit
to a mechanism that places the burden solely on the working•

Perception regarding fairness: Many respondents supported the concept of “affordable
burden.”<Deliberation>An affordable burden should be realized by having high-income earners
take on a graduated burden.
<Consideration> Affordable burden would result in correction of disparities in health inaddition to social disparities; raising the burden on people who are unable to cope withthat burden in order to alleviate unfairness between generations would be opposed tothe concept of “affordable burden.”•

Perception regarding efficiency: Many respondents were critical of the waste of medical
expenses.
<Deliberation> Elderly people have a low out-of-pocket burden, and this means that theyseek medical consultations too often.
<Consideration> If efficiency was improved to ensure that support could be delivered
directly to those who need it, it would be possible to control the size of the government
even in an aging society1.

Agenda for Discussion Towards Consensus-Building
As indicated above, the opinion that there are concerns regarding the sustainability ofJapan’s system of medical care and that a system that applies an affordable burden rather thanapportioning burden based on age should be put in place was shared by many respondents; inaddition, many respondents were of the opinion that the waste that contributes to the cost of
medical treatment should be eliminated. We can see these three points as a step toward
consensus-building.
However, the opinion that an affordable burden should be emphasized was observed

Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 61 | March 2022
among both supporters and opponents of an increase in the burden of out-of-pocket medical costs
on elderly citizens aged 75 and above. Given the fact that concern that the system of medicalcare cannot be maintained under current conditions was shared, we can conclude that there ismajority agreement regarding increasing the burden of medical costs according to the ability tobear that burden. However, opinion is divided here as to what constitutes an appropriate“affordable burden.” It is also necessary to keep in mind that the term “affordable burden” may
be used as a convenient excuse to avoid such a burden. Currently, income is the only standard
for an appropriate allocation of affordable burden, but this factor alone is not always necessarily
convincing to the public.
In this regard, as has already been pointed out above, it seems that there is an issue as
to whether income is the only factor that should be taken into consideration when there arefactors that result in expenses that are absolutely necessary for daily life, such as the existenceof dependents or chronic physical conditions. Another significant point to be considered isfocusing not only on income, but also on assets such as financial assets and properties. For theelderly, income may be limited to pensions, etc., but it is the extent of assets that determines
affluence, for example whether the individual owns a home or has savings that can be drawn
upon. At present, Japan’s My Number system is rarely assigned to financial assets, making it
difficult to grasp the extent of the financial assets possessed by citizens. However, it would surely
be possible to establish a mechanism by means of which an affordable burden could bedetermined. This would involve the setting of a specific standard, and judging whether
individuals possess assets in excess of that standard. This will be an essential consideration in
determining an appropriate level of affordable burden.

Responding to the Voice of the People
As indicated above, discussion regarding increasing the rate of out-of-pocket medical
expenses for the elderly progressively revealed the opinions and interests of our respondents. It
will be important to listen to the opinions of members of the public who are quietly but genuinely
concerned about these issues (i.e., the “silent majority”), and to consider on that basis how to put
forward better policies over the long-term.
Considering the speed of the decline in Japan’s birthrate and the aging of its population,
raising the rate of out-of-pocket medical expenses for elderly citizens aged 75 and above from
October 2022 is a milestone in maintaining the sustainability of the social security system. It is
Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 61 | March 2022
essential that we not only review the rate of out-of-pocket expenses, but also engage infundamental reform of systems, for example the systems of medical care and medical insurance.
The sustainability of Japan’s medical and financial systems are extremely important
policy issues from the perspective of alleviating anxiety among the public. In order to respondto such anxiety, the government should offer a frank and detailed explanation regarding theseverity of the situation of the nation’s medical and financial systems, and explain the types ofreform that are necessary. This is the response to anxiety among the public that we need. Whensuch explanations are offered, it will be essential to grasp the status of awareness of the issues
among the public, and to carefully implement policies on this basis.

Note
1 For more detail, please refer to Taniguchi, M. (2022), “What constitutes a Policy Vision that the

Public can Accept? - Considering the Issues based on a Deliberative Survey (1)-,” NIRA Opinion Paper
No.60.

Yuri Okina
Dr. Okina is the Executive Vice-President of the Nippon Institute for
Research Advancement (NIRA), and the Chairperson of the Japan ResearchInstitute. She holds a doctorate in economics from Kyoto University. Dr.
Okina’s publications include Kinyuu kiki to puruudensu seisaku (“Financial
Crisis and Prudential Policy”) (Nikkei Publishing Co., Ltd., 2010; inJapanese). She is also a member of government committees including the
Financial System Council and the Industrial Structure Council.

Copyright Ⓒ 2022 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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