国民健康保険 都道府県移管は必要な方策だ

The Yomiuri Shimbun August 5, 2013
National health insurance program should be managed by prefectures
国民健康保険　都道府県移管は必要な方策だ（8月4日付・読売社説）

The financial condition of the national health insurance program, which was originally started as medical insurance for the self-employed, has taken a serious turn for the worse. The program must be rehabilitated as soon as possible.
　自営業者らの医療保険制度として発足した国民健康保険（国保）の財政悪化は深刻である。立て直しが急務だ。

The National Council on Social Security Reform will propose in an upcoming report that the national health insurance program, currently managed by cities, towns and villages, should be run by prefectures.
　政府の社会保障制度改革国民会議は近くまとめる報告書で、国保の運営主体を市町村から都道府県に移すことを求める。

The biggest aim of the proposal is to enhance the financial foundation of the program. We think having prefectural governments, which are larger than city, town and village governments, manage the program is a necessary means to maintaining the program.
　財政基盤の強化が最大の眼目だ。運営の広域化は国保を維持する上で必要な方策と言えよう。

There are about 35 million subscribers to the national health insurance program. With a decrease of farming families and private shops, about 70 percent of the subscribers are now nonregular workers and the unemployed.
　国保加入者は約３５００万人に上る。農家や商店の減少に伴い、全体の約７割を非正規労働者や無職の人が占めている。

Because more and more low-income earners are joining the program, revenues from insurance premiums remain low. In fact, less than 30 percent of the more than 11 trillion yen in national health insurance payouts a year is covered by premiums.
　低所得の加入者の増加で、保険料収入は低水準にとどまっている。１１兆円余の医療給付費のうち、保険料で賄えているのは３割に満たないのが現状だ。

To cover revenue shortages, the program must depend on financial assistance from employees’ insurance programs such as those operated by corporate health insurance unions and on public money from the national and prefectural governments. Nonetheless, this does not cover the deficits. To compensate for the deficits, 350 billion yen is allocated to the insurance program every year from the general accounts of municipal governments. The structure of the insurance program apparently ensures it will lose money.
　財源不足を補うため、健康保険組合など被用者保険からの支援金や国、都道府県の公費に頼っているが、それでも赤字を解消できない。穴埋めに市町村の一般会計から年３５００億円も繰り入れている。構造的な赤字体質である。

Besides, small municipalities that operate the program easily find themselves in the red with high medical costs from advanced treatments. Depopulation worsens this situation.
　高度医療で高額な医療費がかかれば、人口が少ない市町村の国保会計はすぐさま赤字に転落してしまうという事情もある。過疎化がこの傾向に拍車をかけている。

Adjust insurance premiums

Another problem is that premiums have become a heavy burden on subscribers.
　加入者の保険料負担が重いことも問題である。

As a percentage of income, subscribers to national health insurance pay twice as much in premiums as do subscribers to health insurance programs run by corporate health insurance unions and mutual aid societies for public servants. And even among cities, towns and villages within the same prefecture, the difference between the most and least expensive national health insurance premiums is up to 2.8 times.
　１人当たりの所得に占める保険料の割合は、健保組合や公務員の共済組合の約２倍だ。同一都道府県内でも、市町村ごとの保険料には最大２・８倍の格差がある。

If management of the national health insurance program is transferred from cities, towns and villages to prefectures, its financial foundation would be improved by economy of scale.
　国保の運営を市町村から都道府県に移せば、規模の拡大によって財政は強化される。

And the difference in premiums among subscribers would become smaller if prefectural governments recalculated premiums necessary to sustain the national health insurance within their jurisdictions.
　都道府県単位で保険料を算出し直すことで、加入者の保険料格差は縮小するだろう。

Of course, a reduction in medical spending is important to rehabilitate the finances of the national health insurance program.
　無論、国保財政を健全化するには、医療費の削減が重要だ。

If they run the programs, prefectural governments will be able to gather a great deal of information about medical treatment within their jurisdictions. Analysis of such information would enable them to monitor wasteful spending such as expenses for unnecessary medical tests and excessive administration of drugs.
　都道府県が運営主体になれば、管内の多くの診療情報が集約される。その情報を分析することで、過剰な検査や投薬といった無駄を把握できるようになる。

This would eventually help prefectures exercise leadership in the operation of medical institutions after scrutinizing the contents of treatment.
　都道府県が、医療機関の治療内容を点検した上で指導力を発揮することにもつながるだろう。

However, there are still many problems in transferring management of the national health insurance program to prefectures.
　都道府県に移管するにしても、様々な課題がある。

For example, the National Governors’ Association demands the central government increase its financial assistance to them before they will agree to manage the program. But where is that money going to come from?
　全国知事会は、都道府県への移管を受け入れる前提として、政府に財政支援の強化を求めている。財源をどう確保するか。

According to the proposal, cities, towns and villages will likely keep collecting premiums for the national health insurance program. However, it is doubtful that municipalities no longer running the national health insurance program will collect premiums in a responsible manner.
　保険料徴収については引き続き市町村が担う見込みだ。国保を運営しなくなる市町村が、責任を持って徴収業務を行うだろうか。

It will be necessary to create a system to prevent the rate of national health insurance premium payments from declining further.
　納付率を低下させない仕組み作りが必要となろう。

(From The Yomiuri Shimbun, Aug. 4, 2013)
（2013年8月4日01時22分 読売新聞）