Japan's Health Care Universal, but M.D.s Cite Flaws

A young Japanese career woman, “Masako,” married her fiancé, “Naoki,” on May 19. She wore a tiara and a white wedding dress, and her eyes sparkled with excitement.

Masako—not her real name—had good reason to be joyful. In addition to marrying a successful young professional, she could look forward to spending many years with him since the Japanese have one of the longest life expectancies in the world.

Longevity among the people of Japan is historically due, in part, to a healthy lifestyle and genetics. But these days it also might be attributed to the high-quality medical care offered in Japan and to access to that care by everyone through a universal health insurance system.

Japan's universal health insurance system has been in place since 1961. It covers the entire population—that is, everyone must enroll in it, and everyone must contribute financially to it depending on their income and assets.

The system can be divided into three parts—employee health insurance, National Health Insurance, and a national health insurance plan for the elderly.

Employee health insurance covers people who work for companies, the government, or private schools. Premiums are based on an employee's monthly salary. The average contribution is about 4 percent of the salary, with the employee paying half and the employer paying half. Those covered must make copayments for inpatient and outpatient medical care. Copayments may also be required for prescription drugs. Costs are shared by the patients up to a certain ceiling, after which they receive full coverage.

National Health Insurance covers those who are self-employed (say, physicians in private practice) and those not employed. The premiums are based on income and assets. Similar to employee health insurance, individuals share costs up to a certain ceiling, after which they receive full coverage.

The health insurance program for the elderly is funded by contributions from employee health insurance, National Health Insurance, and the government.

Japan's universal health insurance system essentially pays for health care in Japan since private health insurance is rarely used there. Moreover, the amount of money the system reimburses doctors and other health care providers is tightly controlled by the Japanese Health Ministry down to the smallest detail. Every two years, the ministry and Japan's health care industry (which includes physicians) negotiate a fixed price for every procedure and every drug.

Japan's universal health insurance system has a number of benefits.

One is “access to high-quality treatment at a low individual cost for all Japanese citizens,” Masanori Nagamine, M.D., told Psychiatric News. Nagamine is a Japanese psychiatrist affiliated with the National Defense Medical College near Tokyo.

Another benefit, Nagamine said, is that “patients are able to select the hospitals or doctors they want to visit. They are not restricted by their insurance company. They do not need to see a general practitioner first.”

Nor does Japan's universal health insurance system discriminate against psychiatric patients, Tsuyoshi Akiyama, M.D., a clinical professor of neuropsychiatry at Tokyo University, reported. It covers psychiatric treatment provided not just in hospitals or by private-practice psychiatrists, but in group homes (which are developing slowly) and in community mental health clinics (which are starting to emerge).

In fact, Japan's universal health insurance system includes special provisions to make sure that the severely mentally ill who are also poor have access to psychiatric care, Hiroto Ito, Ph.D., told Psychiatric News. Ito is director of the Department of Social Psychiatry at Japan's National Institute of Mental Health in Tokyo. Under these provisions, Ito explained, patients who are both severely mentally ill and poor do not have to pay any health insurance premiums, and when they receive treatment, they have to pay only very small copays.

Furthermore, if psychiatric patients are poor, the Japanese government provides them with cost-of-living subsidies, Fumiko Hoeft, M.D., Ph.D., said in an interview. Hoeft is a Japanese psychiatrist now affiliated with Stanford University in California. Indeed, “When I worked as a psychiatrist in Japan,” she said, “sometimes hospitalized psychiatric patients wanted to treat me to lunch out of their subsidies.”