Onozaki: In response to the snap election, it appears that the political parties rushed to formulate their manifestos, but there seems to be less commitment in contrast to the past “Manifesto election” with all of the political parties proposing low-key policies. Each political party gave their manifestos names such as “Critical Policy” or “General Election Policy,” but in our discussion we will refer to them all as “manifestos.” 

First, what is your impression of the manifestos presented by the political parties?

Miyata: Frankly, the parties fall short of proposing policies in the areas of healthcare, care, and social security, which are important to the public. Social security issues are not being addressed.  

Onozaki: Various opinion polls found that employment and the economy were issues that affect how the public votes. This election does not appear to address any healthcare and social security issues and, instead, appears to be a mere vote of confidence of the Abe Administration. Now, let us review the policies proposed by each political party.

Miyata: First, within the manifesto of the Liberal Democratic Party (LDP), the non-profit healthcare holding company-style is a rather important one in my opinion. Given the current increase in the number of hospitals and beds, it aims to integrate and reorganize hospitals according to the circumstances in local areas and features of local hospitals. The last National Diet session approved the healthcare reform laws that established a general community-based care system. In that care system, the LDP’s proposed system will play a major role.  

Onozaki: The revision also aims to establish sustainable social security and health insurance reform. Discussion over sustainability cannot be evaded.  

Miyata: This time, in place of sales tax hike deferral, the priority is expected to be measures to address the declining birth rate. In addition, the pension scheme will receive prioritized funding. In this current environment, securing the funds necessary for healthcare policy may become extremely difficult and the shortage in physicians may worsen. In this scenario, some local areas may have to integrate some healthcare organizations. Moreover, none of the LDP’s manifestoes even touch on the issue of NHI drug pricing. I recall that adding premiums for new drugs was mentioned in a previous manifesto. 

Onozaki: Certainly, there is no mention at all of annual drug price revision, which previously drew public attention. 

Miyata: While Japan has an 8 trillion yen market for drug costs, the distribution of generic products is regrettably far behind other industrialized countries. The prices remain prohibitively high for chronic disease drugs that have long been on the NHI tariff list and should have been already replaced by generic drugs. Regarding these issues, LDP’s manifestos do not specify as to how the party will gradually reduce healthcare costs, which presents some concern. 

In addition, the pharmaceutical affairs laws were revised, which was one of the landmark regulatory reforms proposed, and in place the Pharmaceutical Product and Medical Device Laws were enacted in November. The Medical Service Law and Care Insurance Law have also been collectively revised. However, due to the early closure of the last extraordinary Diet session, the proposed reforms did not extend to some regulations such as legislative bills for designated national strategic districts and laws concerning clinical laboratory technicians. Still, the regulatory reforms should be completed as soon as possible. 

Onozaki: Overall, so-called reform policies are few among the proposals put forward by the political parties. The 2005 manifesto proposed by the Democratic Party of Japan (DPJ) went into depth on healthcare policies that drew attention from healthcare policy makers. While they committed to fulfill anticancer measures and improve local healthcare quality, the then-DPJ went so far as to say that the current party would not pursue other initiatives, such as the optimized remuneration for medical services and elimination of excessive and inappropriate care remuneration. Their manifestoes had strong reform images. Few parties present policies to that level of depth. Komeito’s plan proposes R&D for innovative healthcare technology and utilization of health ICT with Japan Agency for Medical Research and Development (AMED) at the authoritative center, giving the overall impression that are addressing healthcare. 

Miyata: Komeito has always had focus on healthcare policy, and the fact that Komeito runs the coalition government with LDP may have positive implications. Legislation related to AMED, cancer, and rare diseases will soon come into effect, but these proposals are factored in the sales tax hike. I wonder where they will derive the funding. Komeito does not say much about their ideas for funding such resources. This uncertainty raises concerns. 

Miyata: Proposals from Japan Restoration Party (JRP) include healthcare cost reductions, health service improvement, and tax breaks that result from the “my-number” registration system and data utilization. The party needs to take an advantage of the fact that the Osaka Governor and city mayor are from JRP, which enables them to construct a model of the proposed scheme in regions in western Japan to demonstrate feasibility; otherwise their proposal lacks the power of persuasion to gain nationwide support. 

The Party for Future Generation (PFG) is one of the few parties that mentions public assistance issues. For example, they propose that non-Japanese residents experiencing poverty should be supported with a separate scheme. This poses difficult challenges as to how public assistance should be managed within the current framework of social security, and the plan lacks feasibility. 

Onozaki: Except for PFG and JRP, the other political parties use words such as “expansion,” “fulfillment,” and “moving forward” without specifying ways to fund these initiatives. Adding to this, apart from LDP, Komeito, DPJ and Japan Communist Party (JSP), the other political parties do not address healthcare issues in their manifestos. They explained that the snap election was decided too soon to prepare healthcare-related manifestoes, but, frankly speaking, it might have simply revealed that they have not been seriously considering policies in this area. 

Miyata: I totally agree. The planned budget was already factored in the scheduled tax hike. Plans such as the reorganization of healthcare institutions and measures to address pensions and the low birth rate were based on the budget written into the tax increase. The government says they will prioritize issues related to the birth rate decline and the funding for this purpose may somehow come from issuing bonds. But other areas of healthcare will present extremely tough challenges. 

Onozaki: Originally, manifestos were not mere wish lists. They were positioned plans that were verifiable, evaluable, and specific with policies and the implementation structure to support its ideas. However, the DPJ’s symbolic manifestos put forward for the 2009 general election served as a turning point. DPJ was later caught in a trap created by its own manifesto and lost its political power. This serves to show that manifestoes may have limitations. In the world of politics where no one knows what the future holds, I believe that it was rather impossible from the beginning to promise to the public all the details such as funding resources and numerical targets, and to draw a roadmap pledging to the public that manifestos are their proposed contracts (to the public). 

Also, LDP and DPJ have a wide spectrum of politician views within their own parties and therefore it is common to find differing ideas among party members towards parties’ policies. Given such circumstances, some politicians may feel that they are wasting tremendous energy toward gaining consensus within the party on manifestos that fail to win the public trust and that nobody will read. 

Instead, what we expect from the political parties is to show us a clear direction in which the country should move toward, such as a national vision and basis for decisions and reform related to security, diplomacy, and social security issues. Then, Diet member candidates should clearly state their own opinions on policies through the election process. The lower house election will be the first one that incorporates web-based voting. Candidates now have more chances to declare their visions. This change might lead to the end of “manifesto-based election” era. 

Miyata: This time, LDP and Komeito’s manifestos are consistent in a positive sense, but in a negative sense also a step back. LDP’s general election policy leaflet for 2012 had some ambitious proposals for the creation of Japanese versions of NIH, FDA and CDC, but now their policies point to rather less ambitious proposals. 

Miyata: This election places its debate and focus on Abenomics, with mass media framing the election in such a manner. From this perspective, it may appear that social security may be fine. I believe that the real focal point for this election should be healthcare and social security. The sales tax hike is a policy that has potential to fund the debt-ridden government. It also, in the mid- to long-term, will prevent debt from being left to future generations while still managing health care and social security system issues. What is disappointing, however, is that the political parties are paying attention to the desires of the generation that is actively voting. The current population needs to consider future generations. 

Onozaki: What we see now is a “silver democracy.” The reality is that to win not only single-member districts for the Lower House elections, but also Upper House elections candidates have to propose policies that are friendly to everybody and that lead to no enemies. It is said that policies in aging countries tend to move towards a more conservative, moderate direction. Japan is an example of that trend, I feel. Japanese politics is after all a system governed by “lobby politics.” The system is made up of various organizations and local municipalities which lobby or campaign to members of the Diet who will in turn adapt their petitions. 

Miyata: It is quite disappointing. For this election, I believe that the major political parties can propose sales tax hikes and social security reform as major priorities, but we do not see that. It may result in the current system regrettably suffering an undesirable outcome. 

Onozaki: It is hard for us to expect distribution of benefits in the future. Furthermore, what is in question is the “distribution of losses.” Prioritizing one issue means abandoning another issue. Elections are meant to expose the various choices of issues, but the reality is that the election process does not allow for this. Instead, political parties can only say things that are “easy on the ears.” 

However, if the current administration stays in power for a long period of time, we can expect to see some bold reforms.  

Miyata: There is a high likelihood of seeing some bold regulatory reforms.  

Miyata: The impact of postponing the scheduled tax hike is not insignificant. This may possibly take a toll on physicians, nurses, and healthcare in general. In this precarious environment, however, what is surprising is that neither medical societies nor nurse associations have expressed their stances. University hospitals and principals of medical schools certainly feel a sense of crisis. Whether a tax hike deferral is justifiable is one major point of contention in the social security debate.  

Onozaki: The government says that as a result of the sales tax hike postponement they will decide policy priorities, but I am afraid that tough challenges lie ahead for healthcare.  

Miyata: That is true. The pharmaceutical and medical device industries will face a difficult time.  

Onozaki: In addition to healthcare, education is crucial, too. Public education expenditures are among the lowest worldwide. This idea may perhaps stem from the fact that I am among the generation of families with few children. Still, I think education and health are closely related. Educational disparities can lead to employment and economic disparities, which can consequently lead to a health gap. I believe that social determinants of health (SDH) should gain major consideration within policy. In that aspect, policies such as healthcare, education, city planning and employment should be interlinked and packaged comprehensively, rather than treating them as separate policies. Using this election as an opportunity, lawmakers and political parties should come up with such a comprehensive policy package as a principle or vision. This will vitalize the local areas, too.  

Miyata: I feel the same, too. Local revitalization also should receive more attention. None of the manifestos includes bold policies related to healthcare or education. I also feel that we may need political parties organized by the working generation who can show us forward looking visions. Disappointingly, none of the policies put forward by the major political parties like LDP and DPJ appear to be different from the others. Their neutral views and manifestos are not acceptable. 

Onozaki: After all, policy makers need to win their elections, and bureaucrats change every two years. Institutionally, this system does not encourage long-term political views. Given this reality, academia, think-tanks, and above all the public need to take a more active role in the issues for our future. 

Both of us have families with young children and, therefore, we may be prone to having these ideas. Yet, I see that political parties may be heeding the call to “fulfill the pension promise! Reduce healthcare cost burdens of the elderly 30 years down the road!” (laughter)

Miyata: To avoid such an unbalanced reality, we need to propose policies that always consider the future.