**2. Accessibility to medical and healthcare as public goods**

It is believed that the better access by ICT will improve information barrier-free, grassroots information dissemination, and information sharing. Better human healthcare will be achieved by increasing the accessibility of healthcare information. While this optimism is believed, real-world healthcare has been severely affected by the shared information among the healthcare industries, professionals, and academia.

If information is not transmitted correctly without distorting the truth, lifethreatening situations occur frequently. However, healthcare is usually neglected because it is only demanded when a person becomes unhealthy. Therefore, the supplier can behave to get the best benefit from diseases. What's worse is that the higher the need, the more urgent it is.

Due to the above circumstances, the healthcare provider is likely to take selfinterest behavior. To curb such behavior, better access to information does not solve the problem. This is because the information is cleverly rewritten to suit the interest of mainstream in the healthcare industry without being noticed. In this chapter, I'll take a few such mysterious cases and explain why.

#### **2.1 Inclusion of total healthcare by the mainstream in healthcare**

According to the Merriam-Webster Dictionary, healthcare is efforts made to maintain or restore physical, mental, or emotional well-being especially by trained and licensed professionals. There are mainstreams and adjuncts among professionals. The mainstream is the most influential actor and is in a privileged position. To maintain privilege, it is common for mainstream people to try to establish a hegemonic position by involving their adjuncts.

In healthcare, medical care is at the center and all other healthcare areas are adjuncts. In medical care, treatment is at the center of the center, and prevention is one of adjuncts. Considering the pursuit of profits and strengthening of the position of medical care providers, it is better to increase the number of patients without prevention even if some patients must die. As a supporting evidence, in the pharmaceutical industry, it is an implicit understanding that the companies should not develop drugs that eliminate diseases, because the market will disappear like smallpox market by its vaccine. That is why RNA vaccine, which works faster and more effective than ordinary protein vaccines, did not take place until it was urgently approved as a corona vaccine. If RNA is used to produce stem cells, iPS cells (induced pluripotent stem cells), pluripotent stem cells, regenerative medicine for diseases including aging care and immunotherapy for the treatment of cancer will advance dramatically. Complete treatment of disease, organ regeneration, and immortal medicine have been hampered by mainstream groups to professionals. Mainstream has denied such a wonderful future as disease-free and immortal medical care.

The medical professionals should be humble about the dignity of life. When new facts are discovered, it is up to the mainstream to spread or not. The mainstream instantly includes new discoveries that can deny the mainstream. However, the mainstream attacks and denies the new discovery which can coexist with the mainstream. The reasons and causes for such absurd things to happen are for the benefit of the mainstream. Various inhumane obstacles occur, so the details are described below,

#### **2.2 The difference in accessibility to medical care between Japan and the US**

The openness of medical care is the exact opposite in Japan and the US. In Japan, not only paramedics but the nurses only can watch the patients die until the doctor arrives. Oppositely, in the US, medical practice is open to medical assistants and

#### *Medical Hegemony and Healthcare: Centrality in Healthcare DOI: http://dx.doi.org/10.5772/intechopen.99174*

paramedics. They can take life-saving measures for emergency patients who are clearly likely to die if left untreated.

Why does such a difference between the two countries occur? In short, it depends on whether the market is free or regulated. The American way seeks efficiency through a free and open market. The Japanese government operates policies assuming that medical care is at the center and others are adjuncts. This is derived from the fundamental differences in public policies between the two countries.

The U.S. government and its local agency, the U.S. embassy, have repeatedly demanded the Japanese government to open and liberalize the medical and healthcare market, but with no success, while promoting the reasons for the free-open market. For American businesses to enter the Japanese market, it is essential to deregulate the Japanese market. The U.S., which had been the world's factory until Japan emerged, has attempted to take an initiative to the world's industry by securities financing. Therefore, the US government must protect the domestic market from foreign countries but ask free and open markets to foreign governments for maintaining a global hegemony. Such American diplomacy is well-known as a double standard. The importance of the role of government is strongly asserted by American economists. It is the American way to manage social welfare services such as medical care based on the principle of competition that works in an open market. Consequently, the gap about accessibility to medical care between Japan and the U. S. has been still expanding. **Table 1** shows the accessibilities to medical care by costs for treating appendectomy in major countries.

According to the Japan Medical Association, the US is the country with the widest medical disparity in the world. "Public medical insurance in the US is limited to "Medicare" for the elderly aged 65 and over and persons with disabilities, and "Medicaid" for low-income earners. The active generation, which is not covered by these two, is mainly covered by private medical insurance. The so-called "Obama Care" obliges people who do not have public medical insurance to join a private insurance company, but there are only a limited number of medical institutions available for medical examination. Many people are still uninsured in order not to be able to pay the insurance premium. There is a big disparity in the medical care provided" [1].


*Source: Japan Medical Association Homepage: "World Medical Care and Safety 2010" [1].*

#### **Table 1.**

*Costs for treating appendectomy in major countries (accessibilities to medical care by costs).*

#### *Healthcare Access*

In Japan, medicine and healthcare are recognized as public goods. The government has, therefore, an obligation to protect the domestic market from free-competitive destruction. Japan attaches great importance to accessibility that anyone can access anywhere and fair use of medical care as public goods. The Government of Japan is responsible for ensuring that all the people can receive the necessary medical care. Therefore, a fundamental difference between the two countries exists in the medical care and healthcare.

Until around 1955, about 30 million people, mainly farmers, self-employed, and employees of micro enterprises, which is about one-third of the population, were uninsured in Japan, which was a social problem. However, the National Health Insurance Law was enacted in 1958, and the National Health Insurance business began in municipalities nationwide in 1961, establishing a system that allows "anyone," "anywhere," and "anytime" to receive insurance medical care [2].

Japanese Ministry of Health, Labor and Welfare has declared that the role of this system as a safety net is essential as follows:

"Under the universal health insurance system, Japan has realized a medical system that allows anyone to receive medical care securely and has achieved the world's highest average life expectancy and healthcare standards. We will continue to aim for a sustainable public medical insurance system in response to the declining birthrate, increase in the aging population, population, and changes in the economic situation" [3].

#### **2.3 The centralization power by mainstream in the US**

From the social side, mainstream blocks the entry of others to strengthen its power. Mainstreamers can get various benefits and others are excluded. Partial optimization for mainstream results in the lack of total optimization as shown in **Table 1**. On the economic side, mainstreams amplify their interests while blocking the entry. This accelerates the centralization by mainstream, that starts to have a gravitational force that attracts various things. Mainstreamers begin to exert hegemonic influence to stakeholders and concessions authorized by the government create a chain of interests.

From the standpoint of the government and the market, initially, everything starts with a good idea for society, but policies act to fix benefits. They compete for the pie of government budgets. Governmental policies will be taken to ensure vested interests. Historically, the economy has set the direction for government. In the US, the globalized economy has gained centrality, set the direction of government, and could therefore gain the hegemony in the healthcare. Thus, as a result, a mechanism has been created in which mainstreamers increase profit and the public does not get the lowest benefits in the world.

#### **2.4 The power of centrality to the publicity in the US**

On the publicity in the US, at the center of political economy, the centrality determines everything through funding for politicians, the media, university professors, and researchers. It is well known that every public good is commercialized in the US by the logic, that competition in the market is better than government control.

The situation surrounding the potentially life-threatening medical care is dire and irreversible. A typical example is Medicaid. Medicaid is a government medical benefit system for low-income people who have difficulty in taking out private medical insurances (including persons with disabilities and pregnant women who are recipients of supplementary income security). The cost of Medicaid is increasing from 1980s' when market fundamentalism was applied to medical care, as shown in **Figure 1**.

#### **Figure 1.**

*Public healthcare insurances and social security expenses in the United States (Wikipedia) [Internet]. 2021. Available from: https://commons.wikimedia.org/wiki/File:Medicare,\_Medicaid,\_and\_social\_security\_ spending.png [accessed: 2021-6-7 including citations in the text below].*

Regarding medical expenses in the US, according to the Medicare Medicaid Service Center in the US, medical expenses in the US in 2018 totaled \$ 3.6 trillion, and \$ 11,172 per capita. It accounts for 17.7% of GDP. The medical cost per capita in Japan is \$ 2,920 (321,100 yen), which is almost four times higher.

Even though medical expenses and the US government spending on per capita are the highest in the world, it is far from a universal service that allows people to live safely, securely. Only the US and Mexico have failed to achieve universal healthcare in OECD countries [4]. The lack of medical insurance in the US causes 45,000 to 48,000 unnecessary deaths each year [5, 6]. About 25 percent of young citizens have filed for bankruptcy due to high medical costs, and 43 percent of them have sold real estate for that purpose [7].

In the US, the power of centrality introduces market principles to what is in publicity, and businesses succeed in profiting from the people and the government, resulting in poverty and pressure on the government's finances.

### **3. Accessibility and medical hegemony**

#### **3.1 Accessibility to healthcare**

As mentioned above, there is a negative correlation between the degree of inequality and accessibility. What makes the difference between Japan and the US? Japan focuses on protecting people. Japan is a country that values dignity for life and ethics. In the US as well, business executives were highly aware of high moral aspirations, wide moral foundation [8] and public institutions [9] for people and society till 1950s'.

Due to the championship of huge securities financing capital, globalization has been progressing in the US. As the securities financing business has played a central role in the US economy, the US have assumed that free competition in the market would solve social problems. Free competition strategy has helped the US securities financing industry rule its economic and political hegemony in the global market.

The US spends the most on healthcare in high-income countries. Total medical expenses per capita has been continuously rising from 1981 [10]. **Table 2** shows the ranking of medical expenses per capita. The total medical expense per capita in the US is 2.22 times that of Japan, 2.60 times that of the United Kingdom, and


#### **Table 2.**

*Ranking of medical expenses per capita in 2018.*

2.65 times that of the OECD average. Total medical expense of the US is the highest, despite the worst medical care for the public.

In Japan, Japan's Big Bang package was done from April 1, 1998 to March 2001. The first liberalization removes barriers for foreign companies to buy or to sell Japanese companies. As a result, shareholders started to ask high dividend on stock. Restructuring was carried out as companies prioritized immediate profits over the future. The unemployment rate in Japan is steadily increasing, and the number of non-regular employees is also increasing, which is a factor of disparity.

Regarding healthcare system, Japanese public opinion and the government have not chosen the policies to widen the inequality, because the right to life is guaranteed by the Constitution as well as the right to live a healthy and cultural life. On the contrary, there is no right-to-life clause in the US Constitution.

#### **3.2 Affordability and timeliness determine the health of people**

According to WHO (the World Health Organization), a well-functioning healthcare system requires a steady financing mechanism, a properly-trained and adequately-paid workforce, well-maintained facilities, and access to reliable information to base decisions on. These include the care process (preventative care measures, safe care, coordinated care, and engagement and patient preferences),

access (affordability and timeliness), administrative efficiency, equity, and healthcare outcomes (population health, mortality amenable to healthcare, and diseasespecific health outcomes) [11]. Based on these five measures, WHO publishes health system rankings "Measuring Overall Health System Performance for 191 Countries" as shown in **Table 3**.

Yet the U.S. population has poorer health than other countries. Life expectancy, after improving for several decades, worsened in recent years for some populations, aggravated by the opioid crisis. In addition, as the baby boom population ages, more people in the US—and all over the world—are living with age-related disabilities and chronic disease, placing pressure on healthcare systems to respond [12].

A study by The Commonwealth Fund [12] used these metrics to rank 11 countries based on their quality of healthcare. The top-ranked countries are the United Kingdom, Australia, and the Netherlands. Regarding care process, the US also performs above the 11-country average on preventive measures like mammography screening and older adult influenza immunization rates. However, the US performs poorly on several coordination measures, including information flows among primary care providers, specialist and social service providers. The US also lags other countries on avoidable hospital admissions.

Among them, the US ranks last on Access. The performance of the U.S. is the worst in all countries on the affordability subdomain, scoring. According to these discussions, there is no dispute that affordability and timeliness are key elements of accessibility. And these factors determine the health of the people in a nation.

#### **3.3 Centralized power of mainstream and innovation**

Because of the Japanese strict national licensing system, medical insurance companies lacked the willingness to take on new challenges. Take advantage of the opportunity not to change anything, cancer insurance had come from the US. The typical success case of the US was the monopoly of cancer insurance in the Japanese market by Aflac, a small US insurer, which prevented Japanese insurance companies not to enter the market from1972 to 2001. The US has repeatedly made demands for the US industries, as Japan has always been reluctant and weak against the demands of the US. Japan-US insurance talks held at the same time as the talks to break the trade conflict between Japan and the US. At that time, the original purpose was trade negotiations, but regardless of that, the US securities financing industries, which have economic and political central influence in the US, aimed to enter the Japanese market. It is agreed that cancer insurance and medical insurance cannot be sold by Japanese major life insurance companies and non-life insurance companies in Japan. As a result, Japanese insurance companies have been unable to enter the market for a long time, and Aflac, which entered the Japanese cancer insurance market in 1974, maintains an overwhelming market share.

By this time, the US had already shifted its focus from manufacturing to securities financing. During this period, policy had shifted to increase international influence through the securities financing industries for overwhelming the industrialized nation of Japan. Economists had gotten influential power on federal policymaking since the late 1960s, leading the US in the wrong direction about domestic healthcare system and fostering social disparity. The big problem was that many economists unconditionally believed that free competition and free trade were best. Many economists sacrifice welfare and prioritize efficiency.

It is the American way to manage social welfare services such as medical care based on the principle of competition that works in an open market. This has made the healthcare industry inefficient, as afore mentioned in the former sections. The cost of treatment for common illnesses became unusually high after 1980. Disparity


**Table 3.**

*Ranking of well-functioning national healthcare systems in 2021 (by WHO) [10].*

#### *Medical Hegemony and Healthcare: Centrality in Healthcare DOI: http://dx.doi.org/10.5772/intechopen.99174*

expanded among professionals as well. Low quality doctors go to poor areas. Excellent doctors who can get a high salary gather in the area where rich people live. Medical disparities are further widening due to the phenomenon of cream skimming, which businesses only enter profitable areas. Medical disparity is a detrimental effect of free competition. Therefore, there will be many medical refugees who cannot receive the necessary medical care like developing countries.

On the other hand, Japan attaches great importance to fairness in accessibility that anyone can access anywhere. To give the simplest example, in Japan, anyone can be treated equally by a well-known doctor in any hospital without appointment. As a code of ethics to guarantee the access, doctors are prohibited by law from refusing to see a patient.

It looks like the government is providing good healthcare, but it won't do anything new. Therefore, organizations that should promote innovation can defend themselves. Such a thing was permitted within the authorities, so the approved ranking of anti-corona vaccines was the last among developed countries. In addition to the delay in approval of the vaccine against the anti-cervical cancer virus, which has confirmed clear efficacy and had been approved in advanced countries, it has not been approved for use by men. This is because the head of the vaccine department of the authorities continued to extend approval to the next person in charge for fear of side effects.

The John Maddox Prize is an award given by "Nature" to those who have contributed to the dissemination of science and scientific evidence for the public good. In 2017, it was presented to Riko Muranaka, a medical doctor and journalist who has continued to send out information to verify the safety of the HPV vaccine. Nature described the HPV vaccine as "recognized by the scientific community and medical community as a key to preventing cervical cancer and other cancers and endorsed by the WHO (World Health Organization)." Moreover, in Japan the vaccine has been subject to a national misinformation campaign to discredit its benefits, results in vaccination rates falling from 70% to less than 1%. " Nature evaluated her activities as "spreading science and scientific evidence for the public interest while facing difficulties and hostility," and selected from 100 candidates from 25 countries. Ms. Muranaka said, "I think it's powerless to see that the situation has not changed even though I've written so much." The biggest problem is not being there. The nation must take responsibility for the lives of its people. " Nature severely criticized the situation in Japan, saying that "a false information campaign that undermines the reliability of this vaccine was carried out nationwide" [13]. The data to disseminate false information was deliberately forged by an authoritative university professor who received research funding from the authorities to create fake data to deny.

For public interest, universal services should be obliged by the government to provide benefits to all, regardless of wealth, social class, men and women of all ages, or region. Even in Japan, where bioethics and publicity are the top priorities, the reality is beyond imagination. Professionals try to be central by acting for their own benefit. Once power is centralized, it is a virtue within the mainstream to not change unless it is related to their own interests.

#### **3.4 Lack of accessibility due to medical hegemony**

The US government and scholars argue that if regulators decide everything, they will not be able to provide adequate medical care to the public. This is because regulation would make it as if there was only one monopoly and would not try for customers [14]. Mainstream scholars such as Michael Porter have argued that better medical care should be provided in the competition. In fact, the most advanced medical care is being developed and provided in the US. As a result, the

most expensive medical ecosystem in the world and the lowest accessibility among developed countries has been created.

**Figure 2** shows the annual change in the monopoly of American hospitals. An HHI (Herfindahl–Hirschman Index) score is the sum of the squares of the market share of each player in a market. For example, in a market where there is only one hospital — a monopoly — with 100 percent market share, that market's HHI score is 10,000 (100 squared). A market with only two hospitals, in which one has 60 percent share and the other 40 percent, has an HHI of 5,200 (60 squared plus 40 squared). The Federal Trade Commission considers markets to be "highly concentrated" if their HHI scores are 2,500 or higher. In other industries, such as airlines or cell-phone carriers, the FTC routinely seeks to block mergers that would increase HHI scores above 2,500. In the hospital industry, however, the median market HHI exceeded 2,500 in the year 2000 and reached 2,800 in 2013 [15].

A new wave of hospital mergers is driving market concentration higher. The blue bars denote the number of merger and acquisition transactions in a given year; in the 1990s, penetration of managed-care insurers, with a mandate for more aggressive cost control, led hospitals to merge in response, strengthening their market power over the insurers. The Federal Trade Commission (FTC) and the US. Department of Justice (DOJ) normally consider markets with an HHI above 1,500 as "moderately concentrated" and markets with HHI above 2,500 as "highly concentrated," triggering antitrust litigation. However, consolidated hospital markets have largely avoided antitrust litigation. In 21th century, more than half of the hospital markets in the US have an HHI above 2,500, meaning that the FTC and DOJ would consider them to be "highly concentrated" (Sources: A. Roy/FREOPP analysis and graphics, Robert Wood Johnson Foundation, Martin Gaynor, Irving Levin Associates, HHS ASPE.) [15].

#### **Figure 2.**

*Annual trends in the degree of monopoly by large hospitals in the US (source: "Avik Roy, The Foundation for Research on Equal Opportunity").*

Market concentration contributes to raising the profit margin not only in the medical industry but also in the healthcare industry to get the highest interest rates in the world. In conclusion, the medical industry, which has increased its centrality by concentrating, is the most profitable in the world. The influence of this medical hegemony has resulted in poor accessibility to healthcare in general.
