Department of Health Economics and Epidemiology Research, The University of Tokyo School of Public Health, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
Soc Sci Med. 2012 Oct;75(8):1372-8. doi: 10.1016/j.socscimed.2012.06.006. Epub 2012 Jul 3.
Universal coverage of healthcare aims at securing access to appropriate healthcare for all at an affordable cost. Since 1961, Japan's national health insurance has provided an equal package of benefits including outpatient, inpatient, dental, and pharmaceutical services. Reduced copayment and other welfare programs are available to the elderly. However, social health insurance may not be a panacea to achieve healthcare for all, especially when facing household impoverishment due to economic stagnation. Using time-series cross-sectional data of a nationally representative survey of Japan, we assessed the degree of inequity in healthcare access in terms of the "equal treatment for equal needs" concept, to identify the impact of changing economic conditions on people's healthcare access. Concentration indices of actual healthcare use (C(M)) and standardized health status as a marker of healthcare needs (C(N)) were obtained. We decomposed C(M) to identify factors contributing to inequalities in healthcare use. Results showed that horizontal inequities in healthcare access in favor of the rich gradually increased over the period with a widening health gap among the poor. The inequality in favor of the rich was specifically observed among people aged 20-64 years, whereas high horizontal equity was achieved among those aged >65 years. Decomposition of C(M) also demonstrated that income and health status were major contributors to widening inequality, which implies that changes in household economic conditions and copayment policy during the study period were responsible for the diminished horizontal equity. Our results suggest that the achievement of horizontal equity through universal coverage should be regarded as an ongoing project that requires continuous redesign of contribution and benefit in the nation's healthcare system.
全民医保旨在以可负担的成本确保所有人都能获得适当的医疗服务。自 1961 年以来，日本的全民健康保险提供了包括门诊、住院、牙科和药品服务在内的平等福利套餐。老年人可以享受降低的共付额和其他福利计划。然而，社会健康保险可能不是实现全民医疗保健的万能药，尤其是在面临因经济停滞导致家庭贫困的情况下。我们使用日本全国代表性调查的时间序列横截面数据，根据“平等对待平等需求”的理念，评估了医疗保健获取方面的不平等程度，以确定经济条件变化对人们医疗保健获取的影响。我们获得了实际医疗保健使用的集中指数（C(M)）和标准化健康状况作为医疗保健需求的标志物（C(N)）。我们对 C(M)进行了分解，以确定导致医疗保健使用不平等的因素。结果表明，在整个时期内，有利于富人的医疗保健获取水平不平等逐渐增加，贫困人群的健康差距也在扩大。这种有利于富人的不平等现象在 20-64 岁人群中尤为明显，而在 65 岁以上人群中则实现了较高的水平公平。C(M)的分解也表明，收入和健康状况是扩大不平等的主要因素，这意味着在研究期间家庭经济状况和共付额政策的变化导致了水平公平性的减弱。我们的研究结果表明，通过全民医保实现水平公平应被视为一个持续的项目，需要不断重新设计国家医疗保健系统中的缴费和福利。
