Building Life-Support Networks in Local Communities by Spreading the “Free or Low Charge Medical Care Scheme”: Efforts by Hokkaido Workers Medical Care Association

Do you know what the “Free or Low Charge Medical Care Scheme” is? This scheme provides those who are unable to bear medical fees due to poverty with medical treatment for free of charge or at low cost.
However, this system is available only at a limited number of government-approved hospitals, clinics or healthcare facilities for the elderly. There are several prefectures with no such facilities. In its General Assembly in March 2008, Min-Iren (Japanese Federation of Democratic Medical Institutions) adopted a policy to encourage its affiliates to become licensed institutions.
Local communities all over Japan abound in people in need of this system. Our editorial staffs visited 2 hospitals of Hokkaido Workers Medical Care Association (Kin-Ikyo), which promote medical services to the people in need after obtaining license of this system.

Even Company Workers are “Uninsured”
In August 2008, a woman in her 60s contracting rectal cancer was carried on her husband’s car to Kin-Ikyo’s Chuo Hospital. Although her husband was a worker at a construction company, he was not insured. She was hospitalized immediately and the Free or Low Charge Medical Care Scheme was applied to her.
“Due to the recession in the industry, many construction firms cannot afford to provide health insurance to their workers”, said Mr. Tanaka Yuji, Chief of the Medical Welfare Section of the Chuo Hospital. “In such a case, workers have no choice but to be enrolled in the National Health Insurance. But he was uninsured, because he could not pay the health insurance premium out of his monthly salary of about 200,000 yen. Though his wife fell to rectal cancer and needed to take anticancer drug treatment, he could not afford it, as it would cost 30,000 to 40,000 per month. People tend to think that they should be able to lead a normal life with 200,000 yen a month, but I have witnessed many people who become impoverished in the wake of unexpected medical expenses, such as for an anticancer drug treatment.”
In September 2008, a man in his 60s, who had earlier suspended his diabetes treatment, came to Okadama Clinic of Kin-Ikyo and asked the hospital to “examine within the price range of 4,000 yen”. He held a short-term health insurance card. It was revealed that while he fell behind in his payment of the national health insurance premium, his insurance card was invalidated. When his condition worsened, he took 5,000 yen, what little money he had, to the municipal office. He paid 1,000 yen as part of his payment in arrears and received a short-term insurance certificate, and brought the remaining 4,000 yen to the hospital. He was transferred to Chuo Hospital in the same group of Okadama Clinic, where the Free Medical Care System was applied to him.
The man used to be a temporary agency worker and worked as a night watchman. He lived with his two sons in their 20s, but they were also temporary workers, earning only 100,000 yen per month each.
Mr. Tanaka said, “I have thought about making him a separate householder and assisting him to apply for welfare benefits. But that would make it impossible for his sons to live. If they have to bear their rent or utility charges, they cannot afford to live.” Mr. Tanaka expressed bitterness at this typical case of inextricable poverty.

Poverty Seeps into Children Appearing Deceptively Happy
Tomakomai Hospital of Kin-Ikyo conducted visits to local schools in 2008. At 7 primary, junior and senior high schools, the hospital staff explained the Free Medical Care System and encouraged them to refer students in need to Kin-Ikyo. The teachers and staffs at these schools appreciated this information, saying, “We never knew about such a good system.” The visits were welcomed not only by school nurses but also by principals and vice-principals, and the talks with them shed light on the widespread hardships and poverty among the people in the community.
“In one junior high school, a student was found to have urinary sugar in the annual health checkup, requiring reexamination. But the student’s parent had disability in walking and could not take the child to the hospital. When the school nurse finally persuaded the parent to send the child to the hospital, the condition was nearly past cure, and the child was immediately hospitalized”, said Mr. Muraguchi Ikko, General Manager of Tomakomai Hospital.
Mr. Sugano Yoshimasa, Secretary of the Association of Friends of Kin-Ikyo Tomakomai and President of the Liaison Council of Associations of Friends of Hokkaido Kin-Ikyo stated, “I was surprised to know that in one school, more than 40% of the students’ families live on welfare or receive school expense subsidies”. There are also a number of parents “who come home very late from work and have supper with their children only after 11 p.m. every day.” Others cannot take their children with high fever to hospital because they cannot pay medical fees. Mr. Muraguchi said, “During our visits, teachers commonly observed that most children were seemingly happy, but poverty was actually widespread among them.”

Rapid Increase in Applications for Free or Low Charge Medical Care Scheme
It was in the General Assembly in May 2008 that Hokkaido Kin-Ikyo decided to disseminate and actively make use of the Free or Low Charge Medical Care Scheme in local communities, and produced posters, leaflets and stickers for broader public information. During October to January, the special months for reinforced cooperative and organizational activities, the hospital staffs and members of Friends Associations visited a total of 12,500 families, inviting them to take health checkups and explaining about the Free Medical Care system. The members of Chuo Hospital and Sapporo-East Friends association canvassed around 3,500 families, and collected answers for questionnaires from 551 people. 16% of them said they had a past experience of “restraining themselves from seeing the doctor”, and nearly 50% of them felt “cost of medical care is too high.”
Ms. Mikami Junko, Chuo Hospital’s chief of local medical care section said, “One sick mother kept herself from going to hospital, giving priority to paying the medical bill for her child with asthma.” During the special months, hospital staffs also visited the patients who had discontinued treatment at the hospitals. In one of such visits, a nurse found a former patient with renal failure immobilized at home and she immediately transferred the patient to the hospital. “That patient could not afford a taxi fare to the hospital, and kept himself at home even after he lost his motor function”, Ms. Mikami said.
Such activities brought changes to hospital staffs, too. At Tomakomai Hospital, more doctors and nurses now report about their patients’ financial difficulties, which has led to the increase of cases among out-patients applicable to the free medical care scheme.
This also happened to Chuo Hospital. Especially among emergency visits, cases for consultation about and application of the scheme increased, and “the posture of the hospital staffs has been changing.”
“In the past, some of our staffs thought that the lifestyle of the patients themselves might be part of the problem of their financial difficulties. But now, they see their patients through different eyes, knowing that there are actually no jobs available and increasing medical cost is adding to their difficulties” Ms. Tanaka said.
In November 2008, Kin-Ikyo set out clearly the criteria for the application of the scheme. The households with 120% or less income of that of the standard household living on welfare can be entitled to free medical care, and those with 140% or less income can receive medical care at reduced cost. This triggered a rapid increase of applications for the scheme. At Chuo Hospital, the number of cases increased from less than 30 in 2008 to already over 70 as of February this year. At Tomakomai Hospital, there were none last year, while already 30 cases have been approved this year. The total number of these cases in Kin-Ikyo group has surpassed 240.
The Kin-Ikyo group produced leaflets describing model cases applicable for the scheme. “This has been a great help for us to identify which patients can be covered by the scheme. We want to make this scheme available to broader range of people”, Mr. Saito Hiromi, Vice President of Sapporo-Higashi Friends Association said with enthusiasm.

Press Reports Brought More Patients to Hospitals
The Free or Low Medical Care service launched by Kin-Ikyo hospitals has been taken up by a local TV and newspapers, which drew more patients to their hospitals for consultation and resulted in rescuing some of them using this the scheme. In February this year, a man holding a clipping of newspaper article in hand came to Chuo Hospital. He had been unemployed since December 2007. “During unemployment, he relied on his brothers for financial help”, said Ms. Honma Eriko, medical advisor of the hospital. He had been suffering from lumbago, possibly caused by a hernia of intervertebral disk.
Also around the end of January, a woman in her 30s came to Chuo Hospital, learning about the system from a TV program. She suspended the treatment of Graves’ disease, divorced several years ago and had to raise two children alone. Since her temporary agency’s job was terminated in December, she had no income this year. Even until December, she earned only 120,000 yen per month. Despite holding a national health insurance card, she could not afford the out-of-pocket medical expense.

Encouraging People to Visit Hospitals is not Enough
“Those who are truly in need have not yet reached our hospitals”, said Mr. Sugano, describing the special difficulties poor people have. He said it was really hard for them to speak out straightforwardly, “I have no money” or “I have financial difficulty”. “One of our Friends Association members handed a leaflet and sent a patient to the hospital. But the patient could not say anything at the hospital reception and simply returned home.”
Even after the application for the scheme was approved, some patients insist on paying the medical fee, not fully believing that their payment could be exempt.
Mr. Sugano of Tomakomai Friends Association said, “I remember one patient who said to me before leaving the hospital, ‘How much was the medical fee? I will pay by monthly installments.’ Although I explained to him many times earlier that his medical fee was exempt, he would not believe me. Therefore, just extending our ‘human rights antenna’ high and ‘inviting patients to hospitals’ is not enough. We must identify and actually accompany those who are really in need of this service to hospitals.”

Campaign to Realize People’s Right to Life Called for
Ichijo-Dori Hospital of Dohoku Kin-Ikyo started the Free or Low Charge Medical Care service in November 2008. A letter from a reader was carried on a local newspaper, saying, “The decision by the hospital was proactive, going ahead of what the government should do. It was impressive.”
The efforts by Min-Iren affiliates to get approvals from local governments to start the scheme at their hospitals/clinics are spreading nation-wide. In 2008, Honma Hospital (Yamagata) launched the free medical service for in-patients. The application of Amagasaki Medical Coop Hospital (Hyogo) was approved, and in March this year, the free medical service was launched at the group hospitals and clinics. Tokyo Metropolitan Government has long held a position that the new application would not be accepted for adoption of this scheme, but Ota Hospital repeatedly approached and urged the Tokyo government for approval. Finally in February this year, the application was accepted and approved.
Regarding this scheme, the Ministry of Labour, Health and Welfare still maintains the stance expressed in its official notice of 2001, saying, “The necessity of this scheme, in light of changed social circumstances, has been waning.” However, this is completely opposite from the actual social situation today. Poverty is spreading, exacerbated by ongoing massive dismissal of temporary and even regular workers. Although recently the Ministry softened its attitude and said that handling of the applications is at the disposal of prefectural and city offices, the responses of these local authorities differ greatly. Some say, “Applications, if any, will be accepted”, while others say, “Applications will not be accepted” or they “do not have enough knowledge about the scheme.” Mr. Murota Hiroshi, Assistant General Secretary of Min-Iren said, “The application for adopting this scheme is part of the struggle to realize people’s right to life, as laid down in Article 25 of the Constitution of Japan.” Min-Iren is now making effort to spread the campaign to apply for adopting the scheme among hospitals beyond Min-Iren.

Now is the Time to Assert Our Significance of Existence
According to Mr. Muraguchi of Tomakomai Hospital, “Most people living alone on national pension should be eligible to this scheme.” He said, “This scheme will not give much burden on hospitals. Although initial medical fee of these patients might be shouldered by the hospital, about half of such patients are led to be covered by social welfare benefits, and their medical fee would be exempt.”
“The present medical system is really in chaos. Although we have health insurance as a system, people cannot get medial treatment at hospitals”, said Mr. Shoji Kunio, President of Sapporo-Higashi Friends Association. He stated with firm conviction, “If Min-Iren or our Friends Associations do not work for expanding the free medical care system, who else would? We must assert our existence more powerfully. You know, the danglers on the flying trapeze can perform without anxiety because they have a safety net underneath. Our Friends Associations want to play such a role in the society.”