Japan's Universal Health Care System: A Comprehensive Overview
Japan is renowned for its citizens' longevity, a phenomenon often attributed to the country's high-quality medical care system. The Japanese healthcare system is consistently ranked among the best globally, securing the 13th position in CEOWORLD’s Health Care Index. This article delves into the intricacies of Japan's universal health care system, exploring its structure, benefits, challenges, and unique characteristics.
Introduction to Japan's Healthcare System
The Japanese medical system operates under a universal healthcare framework, ensuring that all citizens and residents have access to medical services. This system, known as Social Health Insurance (SHI), began in 1927 with an employee health plan and has evolved to cover a wide range of the population. The system is a key pillar for a just and equitable society. Japan is promoting Universal Healthcare Coverage in other major economies. In 2017, 30 countries adopted the Tokyo Declaration on UHC, pledging to accelerate their efforts to achieve UHC by 2030.
Eligibility and Coverage
All citizens and residents of Japan are eligible to use the public system, including foreigners who intend to stay in the country for over three months. This inclusive approach ensures that a vast majority of the population has access to necessary medical services. Those who work for a small business, are self-employed, or are unemployed are eligible for the NHI plan. Most expats and digital nomads would be categorized as self-employed and need to pay into the NHI.
While not completely free, the system covers 70% of costs after monthly premiums, with patients typically paying around 30% of their medical fees, depending on their income level. Due to this, most people tend to carry private insurance. There are very few treatments that are not covered by health insurance, and services covered are provided in an extremely fair, equal, and inexpensive manner.
Structure and Decentralization
Japan’s healthcare system is decentralized, with its 47 prefectures responsible for making and following healthcare rules and budgets. In addition to general healthcare services, local governments also oversee nursing care programs. People aged 40 and older pay an extra 2% into their health insurance plans to help fund long-term care services. As the number of elderly people increases, the need for nursing and long-term care services is expected to grow significantly.
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Social Health Insurance (SHI) and National Health Insurance (NHI)
Japan’s public healthcare system is known as Social Health Insurance (SHI). SHI applies to everyone who is employed full-time with a medium or large company. Anyone who is not qualified under SHI receives coverage through the National Health Insurance (NHI) plan.
If you are eligible for coverage through SHI, accessing healthcare in Japan is relatively easy. However, the process is more tedious for NHI. You’ll need to visit your regional NHI office to handle the paperwork. Once you get your Japanese Health Insurance card, you can use the public system.
Accessing Healthcare Services
With insurance, an average consultation costs between $33 and $66 USD (5,000 and 10,000 JPY) at a clinic and $66 and $100 (10,000 and 15,000 JPY) at a hospital. Most residents do not have a primary general practitioner since most physicians tend to have a sub-specialty.
Key Features of the Japanese Healthcare System
Several key features distinguish Japan’s healthcare system from those of other developed countries:
Preventative Care Focus
Notably, the system heavily focuses on preventative care, such as early detection and routine medical check-ups, which helps people stay healthy and live longer. This emphasis on prevention contributes to the country's high life expectancy.
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Government Regulation
The system is also regularly reviewed, with medical fees set by a government committee that includes physicians. This helps to control costs and ensure fair pricing for medical services. The national government regulates nearly all aspects of the SHIS. National government sets the SHIS fee schedule and gives subsidies to local governments (municipalities and prefectures), insurers, and providers. Japan’s prefectures implement national regulations, manage residence-based regional insurance (for example, by setting contributions and pool funds), and develop regional health care delivery networks with their own budgets and funds allocated by the national government.
Restrictions on For-Profit Organizations
In Japan, for-profit organizations are not allowed to run hospitals or clinics. Physicians make the governing and administrative decisions in hospitals and must also own and operate clinics.
No License Renewals for Physicians and Nurses
Japanese physicians and nurses are not required to go through license renewals.
Free Access and Patient Choice
Under the Japanese medical insurance system, patients have a high degree of freedom of choice, making it difficult to provide comprehensive and continuous health management from initial diagnosis and treatment (primary care), specialized treatment, to supporting a return to home, providing nursing care and lifestyle support. In Japan's free access system, patients are entirely responsible for deciding whether or not to go to a doctor, which doctor to go to, and which department to go to, without any advice or assistance from professional medical personnel. Patients are free to select physicians or facilities of their choice and cannot be denied coverage.
Medical Team Approach
In Japan, healthcare takes a "patient-centeredness" approach to prioritize providing rational medicine for patients under the initiative of medical doctors.
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Challenges and Criticisms
Despite its many strengths, the Japanese healthcare system faces several challenges:
Aging Population
As mentioned, Japanese citizens have one of the longest life expectancies in the world. However, the country’s healthcare system is constantly looking at ways to serve its large and aging population better. By 2050, it is projected that 40% of Japanese people will be over 65 years old. This demographic shift places increasing strain on the system. Japan is already one of the world's most aged societies, its population declining by 800,000 to 1,000,000 people every year.
Uneven Distribution of Physicians
Japan also has a unique situation where physicians prefer to work in rural locations over urban ones. Doctors claim rural assignments offer a high quality of life and a less stressful work environment.
Language Barriers
Lastly, language barriers are a significant problem for non-native Japanese speakers. While many hospitals around the world have English-speaking staff, this is not always the case in Japan. Many foreigners are surprised to learn this can be an issue even in large metropolitan areas. Therefore, hiring an interpreter for appointments is a smart move.
Mental Healthcare System
Additionally, the country lacks a robust mental healthcare system. Practices discontinued in other countries, such as isolation or restraints, are still common in Japan.
Bloated Outpatient Care
Free access with a high degree of freedom leads to bloated outpatient care. It means "if you wait for three hours, you can see a doctor on the same day.
Overworked Healthcare Workers
Since the achievement of universal health insurance, Japan has not developed enough human and material resources to meet exploding medical needs. The history of medical care demand has been handled mainly by private medical institutions with minimal facilities and manpower. Hospital doctors and staff are chronically overworked, but unable to provide concentrated inpatient care; diagnosis responsibilities are undifferentiated and hospitals are unable to keep up with changes in the kinds of diseases that patients present.
Misuse of Emergency Rooms and Ambulance Services
Most people tend to go directly to the specialist they need. Patients with multiple symptoms turn to hospitals, where many specialists work. This leads to overcrowded emergency rooms filled with non-urgent cases, contributing to longer wait times. There is also a problem with misuse of ambulance services, with many people taking ambulances to hospitals with minor issues not requiring an ambulance.
Cost-Containment Measures
The government has controlled costs over decades using the national uniform fee schedule for reimbursement. The government is also able to reduce fees when the economy stagnates. Fees for all health care services are set every two years by negotiations between the health ministry and physicians. The negotiations determine the fee for every medical procedure and medication, and fees are identical across the country. To cut costs, Japan uses generic drugs. Prices of generic drugs have gradually decreased. The fee schedule includes financial incentives to improve clinical decision-making. For example, if a physician prescribes more than six drugs to a patient on a regular basis, the physician receives a reduced fee for writing the prescription. Prefectures regulate the number of hospital beds using national guidelines. The national Cost-Containment Plan for Health Care, introduced in 2008 and revised every five years, is intended to control costs by promoting healthy behaviors, shortening hospital stays through care coordination and home care development, and promoting the efficient use of pharmaceuticals.
The Role of Private Health Insurance
Although the majority (more than 70%) of the population holds some form of secondary, voluntary private health insurance, private plans play only a supplementary or complementary role. Historically, private insurance developed as a supplement to life insurance.
International Perspectives
Japan's healthcare system is highly regarded internationally. The World Health Organization report in 2000, a Newsweek feature in 2010, and The Lancet in 2011, international media and organizations speak highly of Japan's healthcare delivery system. Japan’s initiative for global health With such a history and system of insured health care, Japan issued the Basic Policy for Peace and Health in 2015, and based on its own experience, has shown a commitment to strengthen the necessary support for mainstreaming universal health coverage in the international community.
The Future of Healthcare in Japan
As Japan becomes a "super-aged" society with individuals over 65 making up over 30% of the population, the nature of medical care will have to undergo major changes. Medical care's basic function must still be the treatment and cure of patients, but the system will also have to provide support. That means conceiving of care in a way that treats a person's life with dignity and does not sacrifice life for treatment.
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