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Japan's health care system delivers the goods

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By David Chester

Health insurance reform in the U.S. has been, and continues to be, a complicated affair. Before, during and after the passage of the Patient Protection and Affordable Care Act (aka “Obamacare”), the amount of furious blogging, protest, screaming and yelling was almost surreal. But in Japan, I have never witnessed such turmoil, and I doubt I ever will. Contrary to my first impressions, the national health care system works well — and the U.S. would do well to emulate it.

When I arrived in Tokyo 16 years ago, I still had my expensive Blue Shield insurance, assuming I would only be in Japan a year or two. One of my first instances of culture shock was learning that enrolling in the national health insurance system was considered mandatory (although that’s not to say everybody does), and that the level of coverage was the same for all. As for the premiums, while the amount might vary based on which ward I lived in, the Japanese government otherwise determined how much I would pay based on my salary.

My first few years here were great salary-wise, and as a result, I ended up paying nearly the maximum for my Japanese health insurance — over 500,000 yen annually. Based on my age, my excellent health and the type of work I did, this didn’t make any sense to me, and I spent many hours discussing this with the personnel at my ward office. Needless to say, this led nowhere.

Meanwhile, as I stayed on in Japan, my U.S. premiums increased year after year. As the insurance company constantly reminded me, “Costs for medical care continue to rise,” and there was “no choice” but to pass those costs on to customers. At one point, I was spending over 1 million yen a year to cover my health insurance in both countries.

Eventually, like many other Westerners I knew, I stopped paying my Japanese health insurance premiums. After a few months, I started receiving letters from the ward office with angry red kanji demanding I pay up. My friends told me to ignore the letters. “Eventually they’ll just write you off,” they said. Better yet, “Move to another town and don’t register for health insurance; they’ll never know.” I still see this type of “advice” littered all over gaijin discussion forums. Maybe everyone else has been lucky—I wasn’t.

When I went to America for six months to take care of my sick mother, the ward office found out my bank account info—to this day, I don’t know how—and took 1 million yen to cover unpaid premiums. From that point on, my premiums would be automatically deducted from my account. If I wanted to stay in Japan, I had to find a way to live in harmony with the system. I investigated all kinds of alternatives, but finally decided the best thing for me was to accept it. I let go of my precious American insurance, which had become cost-prohibitive—and soon after I did, I began to discover the value of the Japanese scheme.

When you apply for health insurance in Japan, you aren’t given a blood test or interrogated about your health history. This means, in essence, that even if you have cancer or are HIV-positive, you won’t be denied coverage. Once in the system, you don’t have to wait in fear to find out whether certain procedures or tests will be approved by some God-like doctors in ivory towers. You can also choose your doctor and/or the facility where you want to be treated.

Another valuable feature of national health insurance in Japan is, the less you earn, the less you pay—and you still get the same level of care and coverage. In America, insurance companies bide their time until you get older so they can raise your premium dramatically, all without the least concern for how you will pay for it.

It’s true that, statistically speaking, the older you get, the more health problems you have. But why should anyone have to go broke to pay for health insurance—or, worse, go without? When I first came here, I thought it was insane that I should have to pay more for premiums because I was earning more. But now that the work isn’t coming in like it used to, my premiums are actually affordable.

More importantly, there are now more excellent clinics that have English-speaking doctors who accept national health insurance (at the same time, there are some “private practice” doctors for the foreign community that do not). This year I had a number of procedures done, including an MRI (that I requested). It cost about 10,000 yen, as opposed to $1,500, and in the States I would have had to have been “approved” before the doctor could have ordered one. Here in Japan, I ask, I receive.

David Chester is a professional songwriter, voiceover actor, screenwriter and filmmaker based in Tokyo.

This commentary originally appeared in Metropolis magazine (www.metropolis.co.jp).

© Japan Today

©2020 GPlusMedia Inc.

38 Comments
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I agree that National Public Health Insurance can be expensive, but it is helpful. I've had dental procedures done here in Japan for less than $100 that would have costs hundreds in the US.

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Agree socialized/goverment NHS is expensive in most places but it pays off when you truly need it.

Like I said before it don't cover cosmetics, etc but id did help when my body collapsed due to stress, overwork and depression as it did for my wife's cancer. Also as said before it don't cover all so a top-up scheme is needed but that is true for most medical schemes.

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It is not only the costs of insurance that is a whopper--my buddy in Tally is now paying 650 a month and he is healthy, but a little old. That is a normal cost now with Blue Shield. And getting small stuff paid like a 30 dollar prescription can be a real pain--arguing with doctors and insurance secretaries. It is amazing the Congress does not at least give people the OPTION of joining in on a national health scheme but it goes to show you what a corporatacy the US is! Owned and operated solely for the benefit of the new corporate trusts.

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Funny, I don't usually see people on discussion forums advising people just to ignore their insurance payments- what I do quite often see though is things like "OMG the ward office emptied my account without warning me!!". It stands to reason that they would have a method for collecting unpaid insurance premiums since it is actually a kind of tax.

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Ive lived in the US and the UK, and I find the Japanese system is an excellent "happy medium" between the two. HOWEVER - I think it would be MUCH cheaper for the government and ultimately the tax payers themselves if the doctors didnt have the power they currenly have to screw the system so obviously and so badly without anyone monitoring them.

I and everyone I know have had a shocking number of completely unnecessary tests (an MRI for suspected appendicitis???! A Gastroscopy for mild indigestion??! A CT scan on a 3 year old for an enlarged lymph node??!) and I am pretty sure everyone will agree the amount of drugs that get pushed on you every time you visit the doctor is insane.

I love that I can pretty much request and get any test I want, but I don`t see how this system is going to be able to continue in its current form that much longer.

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Ahh, if I could count the myths about socialized medicine that are actually believed in the US, I would be a rich man.

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kira kira, very good point! wayyy too many drugs are dished out here & more often than not, they tell you they're not sure what the problem is, but take all these drugs anyway. also, many of the elderly take huge advantage of the system. going to hospitals just because they're lonely or a bit cold in the winter in their houses.govt. should put something in place where the elderly would have places to go in these instances overall though, a very good system & 1 reason i most likely will have to stay here. couldn't afford health care back home.

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The Japanese system is not perfect - - but it is the BEST to date among developed countries. It has the best rate of curing treatable diseases, as well.

sourpuss >Ahh, if I could count the myths about socialized medicine that are actually believed in the US, I would be a rich man

TRUE ! : ) Though Japanese health system is really only sort of half-socialized medicine.

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@Apsara, I presume that "without warning me" is because whoever this is does not read Japanese, and let all the notices with the big red letters accumulate on the coffee table.

My only beef with the system is the payment cap, which I think is 500,000 yen, no matter how many gazillions of yen you make. I think it should be a pregressive system no matter how much you make. That would help balance the health insurance deficit. I do like it that they reimburse all payments you make that exceed a cap depending on your income.

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Japanese national health insurance should cover childbirth 100%.

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My friends told me to ignore the letters.

Sounds like someone needed better friends.

It's always the young, healthy folk who are raking it in who complain that the national insurance is expensive, that they don't get out what they pay in, that the oldies are getting a free ride. Then they get older, things start to creak and income drops, and they finally realise what it's all about.

If you're young and healthy and raking it in, be thankful for your blessings and pay up with a smile. (Though the regional discrepancy thing should be fixed, I think, and the system at present seems overly burdensome on middle-earners. Maybe if Mr Chester's 'friends' paid their fair share, premiums overall would be cheaper.)

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*american_bengoshi at 11:40 AM JST - 30th September Japanese national health insurance should cover childbirth 100%.

*it covers up to ¥400,000 now for births i believe, which was more than enough for both of our kids.

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When my son was born we got 300.000Yen from the ward which covered 90% of the cost(standard delivery and private room). Next ward over paid 400.000yen.

We went to a special birthing clinic that was about 10 min walk from apartment.

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Japanese health coverage is way better than the US hands down. But just to rant a little; it shoud cover child birth. I live in the most expensive ward and our babies each cost almost Y 1 mio for the birth. The ward paid Y 500,000. So that is not good but the health care for children is free and that rocks.

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"the ward office found out my bank account info—to this day, I don’t know how—and took 1 million yen to cover unpaid premiums."

That is pretty freaking scary! I bet they don't do this to Japanese. You should have consulted a lawyer, especially if you were already covered by your US insurance. They probably used that money for the year-end city hall party.

"This means, in essence, that even if you have cancer or are HIV-positive, you won’t be denied coverage."

This is true, but are you aware that there is a whole lot of stuff not covered? My father in law has cancer and is out of pocket several tens of millions of yen for a new treatment not covered. Also, I have never seen an American standing on a corner asking for money to go to another country for an organ transplant. Japan ain't bad if you don't ask many questions or challenge the doctor in any way, live near an urban hospital, don't mind weak medicines that don't work.

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I bet they don't do this to Japanese.

And I would be willing to bet that they do.

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My daughter was born 7 weeks ago. The total cost to us - 13000 yen.

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My daughter was born 7 weeks ago. The total cost to us - 13000 yen.

Congratulations on the birth of your daughter? But did she not receive any clinic checks? Blood tests? My appointments were anywhere between 5k and 10k a time, plus tests, plus the costs of delivery.

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I was hospitalized in large room with 3 meals for 40 days years ago. I was very sick, not cancer. I had to pay 30 percent of total medical cost. I also had cheap private medical insurance "Aflac" at that time. This insurance covered the 30 percent. So Actually I did not pay for the sickness. I had a few days vacation "Onsen" and went back to work.

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kirakira25 & porter

I have no idea where you two live or where you went but I think that maybe some doctors pull a fast one on you (and yes there are unscrupulous doctors everywhere).

@porter: ¥1 mill that sound like you had some 5 star hotel I just checked and a certain international hospital in Tsukiji with private rooms choice of meals and LDR system doesn't charge that high nor does the University hospital near me not even for Aqua birthing, WOW I would love to know where you went to know where to avoid.

@kirakira25: The one thing many do not realize is that once you register at the ward office that you or your spouse is pregnant you receive a mother child booklet that has a whole lot of checkup spaces to fill and many think you must fill them but the facts are only certain ones are actually necessary and those are covered including a certain number of ultrasounds any more are not covered and not necessary unless their is a problem and in that case you can get reimbursed if you push a bit.

Some doctors and dentists in Japan have ways of milking the system and patience by making them return often for things that could be done in one shot like changing a bandage and putting on antibiotic cream after a bad cut with stitches. Last year the insurance system said it would no longer pay for this type of pure money grabbing practice and now will only pay if the doctor spends at least a certain amount of time with each patient.

So gone are the old standard "come back tomorrow to change your bandage" that took 2 or 3 minutes and you could have done it your self and save yourself time and money.

Like any place that is private and is for profit some in this system will try anything to make more.

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Porter, even the newest, cleanest hospitals don't charge a mil per birth. The hospital my wife went to (big, middle of Tokyo) was a bit pricey at 0.5 mil. Of course most of that is covered by the ward.

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Folks you should be aware that the out of pocket expenses that you have to pay ( the 30%) has a monthly limit of around ¥35,000 for lower income and ¥68,000 for higher income earners.

Now through experience the "Kokumin Hoken" (ward insurance) reimbursed the difference with no problems but I sort of had to remind the "Shakai Hoken" (what most employers use) of the fact and it took longer.

If you live in Tokyo most of this is available in the free "Living in Tokyo" booklet at your ward office in multiple languages.

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1 mil per birth sounds like he might have gone to one of the overseas english clinics.

As for most expensive ward doubt it, unless you are in Musahino-shi which has the highest income and residential taxes of all of Japan and even there a good birth won't cost more than 0.4mil.

I think many foreigners are not aware that much of the 30% can be claimed back from BOTH goverment medical and even top-up schemes.

Takes some paper-work and between 1~3 months to get the refunds.

Agree that the old system where a doctor was paid per consultation and not for the actual work left a lot to be desired, hence the 30 minute appointments at dentists, etc.

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@kirakira25, pre-delivery baby checks, blood tests, and what not cost about 3000-5000 yen a pop. So I'm guessing roughly 40 to 50 000 in total. still not bad IMO.

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BTW as I understand it, in the USA they discharge you in around 48 hours after birth and I hear it is the same in most places in Canada any longer without a specific medical reason and the insurance no longer pays.

In Japan for the first child it is customary to stay 7 days and for the next children 5 days, now if you insisted on leaving after 48 hours like the USA and Canada then you would actually make money once you receive the approximately ¥300,000 for the city.

So there is your western style birth fully covered!

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Socialized medicine WORKS.

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@P.S. No, all monies spent are paid back. In total. Where I work I also got birth money from the everyone pays into fund, which is nice. Wow, people putting in to help not only themselves but others, who'd have thought it aye?

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I kind of feel sorry for you Americans who only have your own "healthcare" system as a yardstick, and thus think the Japanese system is the bees knees. Yes, it is better than the American system (several African nations are probably better than the U.S. system) but I wouldn't run around singing Japan's health system's praises too much... Try needing an organ transplant, for instance - or having to shell out "gift money" to "impoverished" Japanese doctors who hold out their hands after performing operations... happened to my parents-in-law.

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"Hold out their hands for gift money"? Those days are long gone ... Japanese hospitals have strict policies and have had a zero tolerance of 'gifts' for years. This must have happened a long time ago. I say "sing the praises", there are far more choices with an abundance of clinics and hospitals. The hospitals are generally better equipped and the doctors usually well trained. A silly and outdated policy on organ transplants is admittedly a problem, so are the waiting periods for new drug trails. House calls are out which is a negative point. Otherwise this is a damn fine system and with medical tourists from China about to start, about to become just a wee bit more crowded.

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Addendum: The zero tolerance was a nation-wide JMA initiative and if you read Japanese, you'll see a sign usually at the reception desk advising that 'gifts will not be accepted by staff'. These have been around for years.

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"Hold out their hands for gift money"? Those days are long gone ... Japanese hospitals have strict policies and have had a zero tolerance of 'gifts' for years. This must have happened a long time ago.

Nuts again -just 3 years ago. Was pricey too - If I recall maybe 12-man? I'm sure those signs were in the Red-Cross Hospital here too - but hey, a "gift" is a gift! I was pretty angry when I found out my father-in-law had paid this cash after his wife had just had a cancer removed... I hope this practice eventually stops everywhere, even in rural Japan. You are right about the standards being good here - I have never had any complaints and for the most part the docs have always been helpful. Almost enough to make me wanna join Japanese Health Insurance!

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PS The payment of the extra money, I was told, ensured that the doctor made more "regular visits" to check up post-op. This practice would lead to a doctor being struck off by the Medical Board in my country Australia... let's hope Japan starts firing all doctors who are still following tradition and still accept these "gifts".

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BurakuminDes: Sorry, No offense but I find this hard to believe. The JMA has a very strict policy outlined and enforced by hospitals everywhere. Did it happen years ago? Sure, I heard many stories not to mention the large 'gifts' from gangster groups to lawyers everywhere. The kickbacks from medical salespeople is also a thing of the past, on the surface at least. Any doctor accepting dough would be in serious trouble if caught these days. I suspect lawyers being lawyers have I suspect found a way to circumvent these minor inconveniences.

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I also find it hard to believe.

When I stayed 6 weeks at my local Red Cross Hospital it would never have happened. Granted the Nurses were cute and hot. Still meet some at times.

Neither did it happen with my wife at the NCC when she needed a breast reduction operation and we got the best surgeon in the house(no extra fee).

In both cases the doctors were top-notch and did their normal rounds, etc.

Not saying it ain't happening but it is more likely the rare exception than the rule these days.

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Guys - it happens still in some places and was def. happening in the Red Cross Hospital up here in Fukushima 3 years ago. Maybe the system has changed radically in the past 3 years since my in-laws paid this "gift money". I sure hope so! I have asked around my Japanese friends and wife and they also know the deal. As we all know, rules in Japan are not exactly always followed - there is a way around every one of them! Imagine being a Japanese surgeon in the 80s... what a golden age that mustve been!

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I have been in Japan for 20 years. I have used both the kokumin kenko hoken and now the shakai hoken systems. Both have a 30% deductible, which is peanuts compared to what many of my American friends have to pay for their operations.

The system here works.

However...

As the elderly population is dramatically increasing, the system is undergoing heavy stresses because there are not enough young people working to cover the expenses required to pay for elderly healthcare in Japan. This is a very big topic at the moment, and one which we are all watching closely to see how the government chooses to handle this oncoming freight train to avoid a head-on-collision with disaster.

Regarding the Fukushima hospital...

Perhaps someone should blow the whistle on the Fukushima hospital as they seem to be unaware that regulations regarding "accepting and giving gifts" are pretty strict these days. This is not limited to hospitals, of course. Giving and receiving gifts of any type in business is now very strongly frowned upon (finally!) and can lead to injunctions, investigations and arrest.

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Perhaps someone should blow the whistle on the Fukushima hospital as they seem to be unaware that regulations regarding "accepting and giving gifts" are pretty strict these days.

I will look into it TheBigRiceBowl - I am hoping they have now conformed to regulations. Maybe they were just the last of the backwaters to have kept this unethical tradition.

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However... As the elderly population is dramatically increasing, the system is undergoing heavy stresses because there are not enough young people working to cover the expenses required to pay for elderly healthcare in Japan. This is a very big topic at the moment, and one which we are all watching closely to see how the government chooses to handle this oncoming freight train to avoid a head-on-collision with disaster.

With low insurer co-pay and universal coverage, the system does seem too good to be true, and as BigRiceBowl points out, it is. The huge amount of money paid in by the baby-boomers has been squandered (the huge fund just sitting there was just too appealing to politicians and bureaucrats not to 'utilize.') Now the system is on the verge of collapse, with no one having any idea of how to make up for the shortfall that will increase with the years.

Reluctance to face-up to Japan's changing role in the global economy and slipping position into a third-rank economy, easily slipping further in coming years, and all sorts of "intangible barriers" propped up to prevent immigration (of workers and accordingly tax payers) into the country, the only direction for Japanese medicine is to increase charges, and transfer more burden onto the backs of the insured. If and when a 'collapse' of the system occurs, we may see a direction to a "free market" in medicine in Japan in the future, something more like the American system in which those who can pay can get care.

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