Japan Today
book review

A look at the emergence and development of the Japanese national health insurance system

By Rotem Kowner, University of Haifa

Japan currently enjoys one of the world’s best health systems. While it is by no means perfect, as suggested by critiques raised against some of the country’s medical practices, especially in the field of mental health, the end results it has managed to attain are undeniably impressive.

Health indicators for Japan are quite enviable indeed. The country boasts the world’s longest life expectancy at birth (84.2 years in 2018; and no less than 5.7 years longer than in the U.S.), as well as the world’s third lowest infant mortality rate. The Japanese also have the lowest rate of heart disease in the OECD, and the lowest level of dementia in the developed world. Similarly, the percentage of obese people in Japan (about 3.3 percent in 2014) is about three times less than its U.S. equivalent. While some of these figures are associated with a specific diet, there is little doubt that the existence of a national health insurance (NHI) institution plays a major role in a country’s medical treatment apparatus and in the health status of its citizens as whole.

The role of an accessible and affordable healthcare system is very obvious in present-day Japan. Its existence explains, in part, why the Japanese visit a medical doctor nearly 14 times a year—more than four times as often as Americans. However, this was not always the case. At the beginning of the 20th century, the vast majority of the Japanese were not covered by health insurance and visit to a medical doctor, let alone a hospital, was often considered a substantial financial burden. Japan’s first health insurance system was introduced in 1922, and began to cover laborers five years later, although farmers had to wait until 1938. The current NHI system, which is managed by local municipal governments, was introduced in 1961.

The scholarship on this topic, which is largely in Japanese, has examined the causes for the emergence of the Japanese NHI system and has tended to separate domestic politics from international relations. Some of these studies emphasized the all-embracing mobilization during World War II as a major catalyst for the emergence of a national health system, whereas others argued it was the outcome of directives by the Supreme Commander for the Allied Powers (SCAP) during the postwar era rather than an indigenous recognition of the need for it.

Yoneyuki Sugita’s new book, "Japan’s Shifting Status in the World and the Development of Japan’s Medical Insurance Systems," reexamines the emergence and development of the Japanese NHI system and adds substantially to the current scholarship on this topic. Sugita is a professor of history at Osaka University, who specializes in postwar history and Japan-U.S. relations. In the course of the last decade, and based on his previous areas of expertise, he has turned his attention to Japan’s social welfare and medical insurance systems. In dealing with the emergence of Japan’s NHI system, Sugita offers a novel perspective that appears to solve some of the previous disagreements on the issue. He argues for a symbiotic relationship between the development of an NHI system and Japan’s status in international society, and especially during the period beginning in the early 1920s and ending in the late 1940s.

The historical outlook of Sugita’s book is broad and meticulous. By taking the 1922 Japanese health insurance law, the wartime healthcare reforms, as well as the impact of the 1949 financial and monetary contraction policy (known as the Dodge Line) into account, his view relativizes the importance of World War II as a single watershed in the emergence of an NHI system in Japan. It also connects it to a larger arena of international developments and repercussions that took place and exerted effects before and after the war. I personally find the link between Japan’s rise to world power status immediately after World War I and the implementation of internal social policies to be highly insightful. Future studies may join Sugita in regarding the 1920s as more crucial in shaping Japanese modernity than has been considered thus far.

Altogether, Sugita’s book is a fresh and much desired contribution to the literature on public health policy in Japan in general and to the emergence of the NHI in particular. It addresses a lacuna in the Anglophone literature on public health policy in Japan, but, more importantly, it also offers a balanced perspective that seems to bridge earlier biases and contradicting views. Finally, those interested in a comparative perspective on the emergence of public health systems in general will certainly benefit from this book too.

"Japan’s Shifting Status in the World and the Development of Japan’s Medical Insurance Systems"

By Yoneyuki Sugita. Singapore: Springer, 2019. 247 pages. Hardcover.

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This is no question that Japan’s national health system is very good.  It has saved my life and wallet a number of times over the decades. A few things need to be clarified here.

Japanese law stipulates everyone must have health insurance.  The law regulates the cost of medical services and prices of medications.  Price gouging is not allowed.  In general, you pay 30% for services and medications.

Japan has private alternatives to the National Health Insurance System.  For years I was on a private insurance system.  I recently changed to National Health Insurance.  The transition took a few minutes at the local city office.

Importantly, Japan has a single payer system.   Your insurance card can be used for all public hospitals and practically all private medical care givers.

You are insured for pre-existing conditions and the single payer system covers everything dental to mental.  

There problems and glitches in the Japanese medical system.  I’ve experiences a few, but only a few.

Note that every advanced nation, except the United States, has some form of socialized medicine.

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We have been on NHI and love it!! The USA would do well to study and implement a similar, maybe exact, system! But noooooo, all USA wants to do is look to Europe and Canada! It's been my understanding that NHI is based on family size and income for premiums. Ours was very affordable. In USA before I retired, I was paying $1,250.00 per month for two! And still had to fight with company for payment, and had to still pay the deductible and 20% up to $10,000.

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