JAPAN | Summary
OVERVIEW
HISTORY
According to Japan Health Policy NOW, prior to the 1920s, a form of health and life insurance was offered to workers through what were known as private mutual aid associations for private sector workers and public mutual aid associations for public sector workers. Employers and workers could voluntarily contribute to these associations although benefits and contribution rates varied. This system transitioned to the current government regulated employment-based health insurance system in 1927, after the 1922 Health Insurance Law, which mandated that health insurance be offered to employees of firms with ten or more employees through what are known as corporate health insurance associations which then expanded to firms with more than 5 employees in 1934.4
The National Health Insurance Law was passed in 1938 which established the Residence-based National Health Insurance (NHI) giving health care governance to each of the 74 prefectures for their populations. The Ministry of Health and Welfare was also established in 1938. The NHI was also complicated by World War I and was not successful in covering the entire population because the local administration was not mandated to establish local programs. At this time only two-thirds of the population were insured until an amendment was made to the National Health Insurance Law in 1958 which mandated municipalities to have residence-based NHI programs. This led to full coverage of the populations by 1961.4
The vast discrepancies that existed between the conditions of the wealthy and the poor before World War II have been reduced, largely as a result of the agricultural land reforms between 1946 and 1950 and of the application of a graduated income tax. Social welfare services were vastly improved and expanded during the period of strong economic growth from the mid-1950s to the early 1970s. Programs include social insurance (health insurance, pension insurance, unemployment insurance, and worker’s accident compensation insurance), services for the elderly and the physically and mentally handicapped, and care for disadvantaged children.5
Between 1973 and 1980 health care spending for the older population increased more than fourfold leading to sustainability concerns and the eventual passage of the 1982 Health Care for the Aged Law. This law, which was implemented in 1983, put an end to free care for the elderly by requiring that older persons pay a small copayment. In addition, this legislation cross-subsidized the NHI program by transferring revenue from employment-based health insurance. The Long-term Care Insurance Act was passed in 1997 providing coverage for institutional-based care, home health care services, and community-based services for those over 65 as well as those between 40 and 64 with aging-related disabilities.4
HEALTH & HEALTH SYSTEM
The Commonweath Fund states that Japan’s Statutory Health Insurance System (SHIS) covers 98.3% of the population, while the separate Public Social Assistance Program, for impoverished people, covers the remaining. Citizens and resident noncitizens are required to enroll in a plan while immigrants and visitors do not have coverage options. There are two types of insurance in the SHIS: The employment-based plans which cover about 59% of the population and residence-based insurance plans which includes non-employed individuals under 75 which is 27% of the population. There is a health insurance plan that automatically covers all adults 75 and older which makes up 12.7% of the population. All SHIS plans provide the same benefits package which is determined by the national government6:
- Hospital visits
- Primary and specialty care
- Mental health care
- Approved prescription drugs
- Home care services
- Hospice care
- Physical therapy
- Most dental care
The system is mostly publicly financed through general tax revenue accounting for 84% of expenditures while self-pay accounts for 16%. Most plans require a 30% coinsurance for physicians visits, hospital inpatient care, and prescription drugs but safety nets do exist. There is reduced cost-sharing for young children, low-income older adults, those with specific chronic conditions, mental illness, and disabilities as well as no charges for low-income individuals receiving social assistance. More than 70% of the population has supplemental private insurance which functions as additional income in case of sickness. This is usually a lump sum or daily payments for a certain amount of time. Hospitals in Japan are mainly private, nonprofits with about 15% being public hospitals.
National and local government are required by law to ensure a system that efficiently provides quality medical care. The national government regulates nearly all aspects of the SHIS as well as insurers and providers. Japan has 47 local prefectures who implement these national regulations and manage the residence-based insurance plans. Over 1,700 municipalities are responsible for organizing health promotion activities for their residents and managing beneficiaries in the residence-based programs. These government agencies are also involved in health policy and delivery.
- The Ministry of Health, Labor and Welfare, which drafts policy documents and makes detailed regulations and rules once general policies are authorized
- The Social Security Council, which is in charge of developing national strategies on quality, safety, and cost control, and sets guidelines for determining provider fees
- The Central Social Insurance Medical Council, which defines the benefit package and fee schedule
- The Pharmaceutical and Medical Devices Agency, which reviews pharmaceuticals and medical devices for quality, efficacy, and safety
- The Central Social Insurance Medical Council, which sets the SHIS list of covered pharmaceuticals and their prices6
HEALTH INDICATORS & DEMOGRAPHICS
Due to Japan’s low birth rate and high life expectancy, the population has aged significantly since the mid-20th century. The number of individuals who seek medical services and treatments has shifted disproportionately to the elderly.5
- Fertility Rate: 1.4 live births per woman
- Life Expectancy (Female, Male): 88, 82
- Infant Mortality Rate: 1.6 deaths per 1,000 live births
- Child Mortality Rate: 2.2 per 1,000 live births
- Maternal Mortality Rate: 5 deaths per 100,000 live births
- Prevalence of Obesity: 4.4%
- Japanese: 98%
- Other: 2% (Other Asian nationalities, White, or Indigenous)
Note: Japan has strict immigration policies, which contribute to its racial and ethnic homogeneity
- 0-14 years: 12.7%
- 15-24 years: 9.6%
- 25-54 years: 37.3%
- 55-64 years: 12%
- 65 years and over: 28.4%
Note: Nearly 30% of Japan is 65+
References
1 The World Bank. (2020). Japan . Data. https://data.worldbank.org/country/japan.
2 The World Bank. (2017). Current health expenditure (% of GDP). Data. https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS.
3 Japan Demographics. Worldometer. (2020). https://www.worldometers.info/demographics/japan-demographics/.
4 Health and Global Policy Institute . Historical Overview. Japan Health Policy NOW. http://japanhpn.org/en/historical/.
5 Watanabe, A. Japan. In K. Masamoto (Ed.), Encyclopedia Britannica. essay. https://www.britannica.com/place/Japan.
6 Tikkanen, R. (2020, June 5). Japan. Commonwealth Fund. https://www.commonwealthfund.org/international-health-policy-center/coun....
7 Japan Population (LIVE). Worldometer. (2020). https://www.worldometers.info/world-population/japan-population/.
8 Geography Now! Japan. (2017). YouTube. https://www.youtube.com/watch?v=j3XpfBChLyk.
9 Japan Age structure. Japan Age structure - Demographics. (2020). https://www.indexmundi.com/japan/age_structure.html.
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