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2019.2.1经济学人官译：日本老龄化

Ageing in Japan

Home help

The government is struggling to curb the rising cost of health care

日本老龄化

居(👜)家照护

日本政府竭力控制医疗支出上涨

IN A SUNNY room in a small apartment in the Tokyo satellite town of Kunitachi lies Yasuyuki Ibaraki, eyes closed and breathing laboured. Yukio Miyazaki, his doctor, who visits fortnightly from a local clinic, suspects that he does not have much time left: he has brain damage from a cerebral infarction, a tumour in his digestive system and is unable to swallow or talk. Reiko, his wife, feeds him through a tube to his stomach and clears phlegm from his throat. “He is from a close-knit family and is a quiet man, so I think it is better for him to be here rather than in a hospital,” she says, over green tea and grapes.

在东京卫星城国立市（Kunitachi）一间光照充足的小公寓里，茨木康行闭着眼躺在床上，费力地呼吸着。当地诊所的医生(💿)宫崎之男每两周上门探视他一次。他患有脑梗塞引发的脑损伤和消化系统肿瘤，无法吞咽或说话，医生怀疑他将不久于人世。他的妻(⚪)子玲子通过一根胃管给他喂(👼)食，并帮他清除喉咙里的痰。“他来自一个关系紧密的家庭，不爱说话，所以我认为他(🎚)最好还是待在家里，而不是住进医院。”她边(⏱)喝着绿茶、吃着葡萄边说道。

Life expectancy in Japan is the highest in the world, at 84. This is good news for its people, but means that an ever-higher share of the population is elderly. Fully 28% of Japanese are older than 65, compared with 15% of Americans and 21% of Germans. More old people, in turn, means higher health-care costs. Last year the government budgeted ¥15trn ($138bn, or 15% of its total expenditure) for health care and nursing, excluding the charges it levies for the public health-insurance scheme. With public debt at 250% of GDP, and debt service consuming a further 24% of spending, the government is looking desperately for ways to cut costs. It reckons caring for people at home is one of its best options.

日本人的预期(㊙)寿命是84岁，为世界最(🗳)高。这对其国民来说是个(🥧)好消息，但也意味着老(🤭)年(❄)人在总(📽)人口中的比重越来越高。日本(🚗)65岁以(📀)上的老年人足足占了总人口的(㊗)28%，而美国和德国(⛪)的这一比例分别为15%和21%。老年人越多，相应的医疗保健支出也(📀)越高。去年，除去为公共医疗保险计划征收的费用，政府在医疗保健(⛔)和护理上的预算达15万亿日元（合1380亿美元，占(👨)政府总支出的15%）。由于公共债务达到GDP的250%，偿债支出又占了总支出的24%，政府正在想方设法(😅)削减成本。政府认为居家照护是最好(🌍)的选择之一。

All Japanese pay a monthly premium to the public insurance scheme, either through their employer or the local municipality. In return they are entitled to treatment and drugs from public and private doctors and hospitals, although they must also pay a portion of the cost of treatment (a co-payment, in American parlance), subject to a cap. In 2000 Japan introduced an additional public insurance scheme for long-term care for those over 65, into which people must pay from the age of 40. It works the same way. The premiums and co-payments cover around 60% of the cost of the services provided; the government pays for the rest. And it is the old who cost the most. The government reckons that the average annual cost of health care for someone over 75 is ¥942,000, compared with just ¥221,000 for everyone else.

所有日本人每个月都通过雇主或市(🍂)政当(🕰)局向公共保险计划缴纳保险费。由此他们可以享受公立和私人医疗机构提供的治疗和药物，不过仍须自付一部分治疗费（用美国的说法是共付额），金额有上限。2000年，日本又推出了一项专为65岁以上老年人(🕓)提(🕎)供长期照护服务的(🎗)公共保险计划。该计划要求民众必(🥌)须从40岁开始缴费。其运作方式与普通公共保险计划相同。大约60%的医疗保健支出(🚶)由保险费和共付额支付，剩下的由政府承担。而在全部(🦀)医疗支出上，老年人占了大头。政府估计75岁以上的老年人平均每年的医疗支出是94.2万日元，而其余人群仅为22.1万日元。

By the standards of ageing nations, Japan has managed to curb medical costs fairly well, says Naoki Ikegami of St Luke’s International University in Tokyo. The government sets fees for services to keep costs down (although that encourages providers to perform unnecessary procedures to make more money: Japan has more CT scanners relative to its population than any other country). It has also promoted the use of generic drugs, which are cheaper.

东(🥄)京圣(🌳)路加国际大学（St Luke’s International University）的池上直树表示，按照老龄化国家的标准，日本在设法控制医疗支出方面已经做得不错了。日本政府对各类医疗服务设定价格以降低(🖼)成本（不过这助长了医疗机构(😧)为多赚钱而实施不必要的检查；按人口平均，日本拥(🌔)有的CT机数(🌧)量比其他任何国家都多）。政府还提倡民众使用相对便宜的非(🏠)专利药物。

Life-giving, budget-busting

延续生命，削减预算

Nonetheless, the country has crept up to sixth place in the OECD’s ranking of the share of GDP spent on health care, behind France and America, but ahead of Italy and South Korea—two other ageing countries (see chart). It is not just that the number of old people is increasing; spending per person is rising, too, as people live longer with diseases like Alzheimer’(🕚)s and diabetes.

尽管如此，在经合组织对医疗保健支出占(🧦)GDP比(🍯)重的排名中(〽)，日本已攀升至第六(🥨)位，在法国和美国之后，却排在另外两个老龄化国家意大利和韩国的前面（见图(🔠)表）。这(🤵)不仅仅是因为老年人的数量在增加，随着老年痴呆(⛪)症和糖尿(🛬)病等患者的存(🆘)活期更长，人均医疗保健支出也在增长。

Japan has promoted home care for many years, but it is pushing it harder now. The policy is especially beneficial given that the average hospital stay in Japan is three times longer than in the Netherlands, for instance. The health ministry reckons that 1m people will receive care at home in 2025—one-and-a-half times the current total. The number of special nursing units exclusively for home visits has risen from 7,473 in 2014 to 10,418 in 2018.

日本提倡居家照护已有多年，但现在正在加大推动力度。例如，鉴于(🌓)日本的平均住院时间是荷兰的(🍙)三倍，居家照护政策尤为有用。厚生省估计，到2025年，在家接受照护者将达到100万，是目前数字的1.5倍。专(🎻)门提供出诊服务的特殊(😕)护理机构的数量已从2014年的7473个增加到2018年的10,418个。

Last year a government panel suggested raising the amount doctors are paid for home visits and making consultations conducted via video-conferencing services eligible, too. It also proposed new rules to encourage care at home. Hospitals should be obliged to talk to social services when they discharge a patient, for example.

去年，一个政府专(🍪)家组建议提高医生的出诊费用，以及提供视频问诊服务。另外专家组还提出了一些(🥝)鼓励在家照护的新规定，例如医院让病人出院时必须与社会福利机构沟通。

Some municipalities are already offering good care in the community. Onomichi, a small provincial city that is even older than the country as a whole, is one. Its medical facilities have 15-minute “care conferences” with doctors, nurses, family members and even dentists, to discuss how they will go about looking after people. “It used to be hard for hospitals to tell a patient to return home as there was no system for that; that has changed,” says Hisashi Katayama, a doctor.

一(🍋)些城市的照护服务已经在社区开展得有声有色，比如历史甚(📌)至早于日本建国的小城尾道（Onomichi）。它的医(🤜)疗服务包含由医生、护士、家属甚至牙医参加的15分(🚱)钟“照护会议”，讨论如何着手照顾病人。“过去，因为没有这样的系统，医院很难让病人出院回家，现(🚹)在就不一样(🌺)了。”医生片山寿表示。

Community care for specific diseases is improving, too. Take dementia, which currently affects 5m Japanese (4% of the population), and will afflict 6-7% by 2030. Rather than provide only institutional care and medicine, some towns, such as Matsudo, north-east of Tokyo, have set up cafés to offer advice and companionship to patients and their carers. Day centres that give respite to families tending to elderly relatives are common. Much more could be done: only 13% of Japanese die at home, although most say they want to.

社区对特殊疾病的护理也在改(➖)善。以老年痴呆症(🛹)为例，目前日本有500万患者，占总人口的4%，而到2030年将升至6%至7%。在东京东北部的松户（Matsudo）等城镇，不只有社会公共机构提供照护和医(⏱)疗服务，还开设了为病人及其照护者提供建议和联谊的咖啡馆。随处可见的日间照料中心可以让那些照顾老人的家属们(🗡)有一些喘息的机会。尽管大多(😞)数人表示希望自己(🐮)能(⛳)在家中辞世，但只有13%的日本人得偿所愿，因此能做的事(🔨)情还有很多(🍺)。

But more widespread home care will not be enough to make Japan’s health care affordable. The government of Shinzo Abe wants to revamp the social-security system, which it reckons will help reduce health-care costs. Raising the retirement age, for example, will keep people active, healthier and paying tax for longer. The government also wants to try to reduce the incidence of diseases that affect older people, but have their origins in behaviour at a younger age. “We have tended to focus on the old, but we need to look at the younger to prevent disease,” says Kazumi Nishikawa of the economy ministry. He is particularly focused on giving people more information on what causes diabetes, which is on the rise in Japan, or exercises that can stem the progression of dementia.

但是，居家照护的进一步普及并不足以减轻日本的医疗负担。安倍政府希望改革社会保障体系，认为这将有助于降低医疗保(✊)健支出。例如，延迟退休会让人们保(🐢)持活跃、更健康，纳税的时间也会更长。政府还希望尽力减少那些因年轻时的不良行为所致的中老年疾病的发病率。经济(🚘)产业省的西川和见表示：“我们向来都更关注老年人，但我们也需要(♋)关(🥁)心年轻人来预防疾(🧔)病。”他特别(🥞)强调(💉)要向民众普及更多有关糖尿病病因的知识（日本糖尿病发病呈上升趋势），或者是可以防止痴呆症恶化的运动。

People are likely to have to pay more for health care, too. Co-payments for many of those over 75 are only 10%, compared with 30% for everyone else. The government should start by doubling that to 20%, says Shigefumi Kawamoto, managing director of Kenporen, the national federation of health-insurance societies. “Some elderly people don’t have resources, but many do,” he avers. The government could exclude some items from coverage, he says, such as over-the-counter drugs.

民众很可能也得为医疗保健支付更多(🕎)费用。75岁以上的老年人中，许多人的共付额比例仅为(🖨)10%，而其余人群为30%。国(🧔)家医疗保险组织(🥔)联合(🕧)会（Kenporen）的常(🕧)务理事河本滋史表示，政府首先应该将(🎩)这一比例提高(🎨)一倍(💵)，达到20%。他(🚾)断言，“有些老年人没有财力，但(🌯)很多老年人有。”他指出(🧝)，政府可(😕)以将非处方药之类的项目(💞)排除在保险(🤶)范围之外。

Meanwhile, back in Kunitachi, Dr Miyazaki talks to Reiko about her husband’s condition. She is worried that her husband is getting worse, she says, and is anxious between visits. The doctor promises to come weekly from now on.

回到国立市。宫崎之男与玲子讨论了(🎭)她丈夫的病情。玲子说自己担心丈夫每况愈下，在没有医生探视的时(👞)候自己就很焦虑。医生答应以后他会每周(🕸)上门一次。

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