How does Japan care for its entire populace so well so cheaply?

[WanderingDave]

First, let me lay my cards on the table. I am pro universal healthcare in the United States. I'll not use a loaded phrase like "socialized" or "public sector" medicine, because I'm flexible and open to creative solutions about how it's governed and payed for. I should also mention that I'm a recent graduate of a US medical school, about to start a family medicine residency, lean liberal progressive in my political beliefs, and have traveled and lived abroad widely, mostly in East Asia.

I'll also admit that I'm not nearly as well-read on the debates surrounding universal coverage in the US as I should be, though I aim to change that soon.

While I most often hear the US's healthcare system contrasted with that of wealthy European countries or Canada, the system that intrigues me most is Japan. I've been an exchange student there and have a couple of good friends who are from there, but who don't work in healthcare and know little to nothing about it.

It appears to me that Japan manages to provide a nationalized system that covers its entire resident populace for all medically necessary services, for only nominal fees equivalent to what insured people in the US pay as co-pays. Despite spending only a third of what the US spends on healthcare, Japan manages the world's healthiest and longest-lived populace. And unlike Europe and Canada, income tax is not at all exorbitant. It would appear that good, cheap, universal healthcare is a great example of something that's "Japaneasy".

So how do they do it? If anyone hands me the platitude that they're a homogeneous country, I'm going to scream; this "explanation" seems to be invoked to explain anything the Japanese do well. (Egypt, Poland, and Lesotho are also ethnically homogeneous countries that don't manage to do what Japan does healthcare-wise.) Mostly, I consider this a non-starter because it's a property that can't be emulated in the US.

I'm also aware that Japan has a traditional diet that's nearly ideal. This is a big factor I'm sure -- people who eat very, very well just have fewer health problems that need attending to. This factor has very limited exportability, because national diets are not only a matter of national pride and comfort, but also at the mercy of what's geographically available and affordable to eat.

I note the cultural observation that being active and busy, and mindful of one's health, are taken as ethical duties in Japan. One is obliged to take care of oneself so as to be available, and as little of a burden as possible, to the greater group. Sure this helps. But many other group-oriented societies don't manage the health stats the Japanese do, including ones even more group-oriented than Japan. Clearly this factor would be hard to emulate in the individual freedom loving US, where people cherish the right to mess up their bodies as much as they see fit, and then expect the healthcare system to fix them without them having to lift a finger. (It's what them doctors are paid to do, ain't it?!)

No, what I'm after is what systemic policy factors contribute to Japan's system working so well, because these are the things that potentially are exportable to the US, and things we can indeed learn from.

I have a sneaking hunch that some of it comes down to the deep coffers and bountiful corporate tax revenue reaped from Japan's mighty manufacturing sector, which the US has long forsaken. If Honda and Matsu****a make so much money that they can essentially (through taxes) foot the bill for the nation's healthcare, then that solves a whole lot of the mystery, and frames the US's problem in a whole different way. Can anyone with more knowledge of the Japanese politico-economic structure verify or falsify this hunch?

Why is Japan not more talked about in US debates about healthcare? Say what you will about the nation's recent economic performance -- the fact remains that its populace remains the world's healthiest and arguably best cared for, which is all that really matters for the purposes of this discussion. It could very well be that the Japanese system has been thoroughly analyzed and it's been concluded that none of the factors that make it work can be emulated in the US. That was a US task force's conclusion on Japanese education in the 80s, after all.

---

Members don't see this ad.

 

[lizzy596]

I suspect cultural homogeneity plays a tremendous role

 

[jetta86s]

You were right. They never talked about healthcare in Japan. Reason being isthat, the government is not interested to try something new and foreign. Why?That’s easy, politics!

 

[AtlasCarraway]

I know you didn't ask for more cultural info, but these are just as relevant: lower crime rates, less drug use, lower obesity, fewer traffic accidents, lower HIV numbers.

I don't know if these numbers are up-to-date, but the patient pays 30% of their doctor's bill (this functions as a co-pay) and the insurance company will pick up the remainder. However, the most a patient will ever have to pay in a month is about the equivalent of $650; whatever remains for costs that month are the responsibility of the insurance company.

Like in the USA, the insurance companies are all private. Unlike the USA, they are all non-profits. All providers are private as well, as opposed to something like Britain's National Health Service. In total, there are over 3,000 plans available to anybody in Japan. An insurance company cannot deny any claims, and there are strict deadlines on how long they have to submit payment after being billed by a doctor/hospital.

You're onto something in mentioning companies like Honda; big companies are mandated to provide insurance for their employees (most companies split premiums 50/50 with their employees). Honda and Toyota both own hospitals exclusively for their own employees. There's not much like that in the US. Smaller companies usually have a similar setup as far as split copays go, but they usually receive a subsidy from the government to help pay these bills. And for the elderly/self-employed, there are plans available in which the individual patient splits the cost with the local government. Unemployed people and the poor are covered by the government.

There is an individual mandate. If you don't pay your premiums, you basically get a "slap on the wrist" sort of thing from the government with no real consequences...until you get sick. If that's the case, you have to pay back all of the premiums that you've missed over the last year. Your insurance plan won't pay your current bill until you do that.

The defining aspect of Japanese healthcare, though, is something called the Fee Schedule. The government directly negotiates prices with providers (using the term "negotiate" very loosely here) and publishes a universal list of billable costs for various procedures/services. This is why Japan only spends 8% of its GDP on healthcare costs. The system is awesome for patients (universal coverage, cheap, essentially no wait time), but the people getting screwed in Japan are the health professionals, hospitals, labs, and drug companies. For example, an appointment with a family doctor costs about $7. An overnight stay in a four-bed shared room is about $15. Ridiculously low, and the doctors have essentially no power to change it. Every two years, the JMA (medical association) meets with the Ministry of Health to negotiate these prices.

Essentially, it's a "multipayer" system that might as well be single-payer.

I think you'd be interested in "The Healing of America" by T.R. Reid. He examines the healthcare systems in the USA, Germany, England, Japan, Canada, and France. Easy to read:

http://www.amazon.com/The-Healing-America-Global-Cheaper/dp/1594202346