8 UHC（Universal Health Coverage）という理念は堅持しつつ、医療財政の持続可能性を高める観点から、給付範囲等の見直しを行い、疾病別・薬剤別の自己負担の導入を検討する。後期高齢者医療制度においては、引き続き減少が見込まれる現役世代の負担能力に配慮し、医療財政の持続可能性を高めつつ世代間の負担平準化を図る観点から、後期高齢者医療制度に医療版マクロ経済スライドの導入を検討する。 While rmly supporting the principle of UHC (Universal Health Coverage), it is important for the sustainability of health care nancing that Japan reviews its rationale for the extent of insurance benefits, and considers a framework for determining out-of-pocket expenses based on the particular illness or medicine, not age. Medical insurance for persons over seventy-ve should consider the shrinking working population and its capacity to support the growing insurance costs. Japan should consider introduction of a macro economic slide ‘health version’ for over seventy-fives, in order to increase the sustainability of health care financing and level out the burden between generations.■ 現状の問題点・政治が痛みを伴う改革を断行し、給付と負担のバランスを調整すべきだが、選挙との関係で容易でなく、給付調整等の脱政治化が必要。・税や保険料などで賄う社会保障給付費は現在120兆円程度だが、内閣府などの推計によると、2040年度には1.5倍の約190兆円に増加する（例：GDP比は2018年度で21.5％だが、2040年度には約24％に増加）。・財務省が2018年4月に改訂した「我が国の財政に関する長期推計」によると、医療・介護費のGDP比は2020年度の約9％から、2060年度に約14％に上昇する。この約5%㌽の増加は、現在のGDPの感覚で約28兆円（消費税換算で約11％）にも相当する。・「大きなリスクは共助、小さなリスクは自助」というのが社会保障の基本哲学の一つだが、現行の窓口負担は年齢別となっており、治療の必要性や負担能力などの点から、患者の多様な実態を十分反映していない。■ Current Issues・ The government needs to take assertive action on what will be a politically painful revision of the welfare system. The balance of insurance payouts and financial burden should be adjusted, not to accrue favor in elections, but in a manner that is effective and free from party politics. ・ The social welfare benefits covered by tax and insurance (e.g. health costs, care, pension) currently cost around 120 trillion yen. According to calculations by the Cabinet and other ministries, these costs will increase by 1.5 times to approximately 190 trillion yen in 2040 (e.g. social welfare share of GDP was 21.5% in 2018, but is expected to reach 24% in 2040). ・ Japan’s long scal predictions, revised by MOF in April 2018, raised the percentage cost of health and health care as part of total GDP from 9% in 2020 to 14% in 2060. This 5 percentage point increase would equate to roughly 28 trillion yen (in the case of a consumption tax increase we would need to raise that gure by an additional 11%) in terms of current GDP—a signicant challenge for nancial resources.・ A basic principle of social welfare is that large risks are borne with assistance and small risks are borne by individuals. The existing system determines subsidies by age-group and does not adequately reect patients’ individual circumstances such as the necessity of treatment and their nancial resources.提言 4Proposal 4医療保険の負担適正化の実現Achieve an appropriate division of burden for health insurance
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