Japan

E. Ann Yeh

Masakazu Seino

Introduction

In 1994, Japanese government officials introduced a new vision of social welfare for the 21st century.⁸ Central to this vision was the issue of how to handle problems that stem from the growing population of elderly individuals, many of whom will soon become disabled and utilize health care services to a greater degree than their younger counterparts. These concerns are not limited to the elderly, but extend to all disabled individuals. How these people will be cared for and who will be responsible for their care are questions that need to be addressed.

With these concerns in mind, this chapter examines the current health care policies of the Japanese government, beginning with a review of health insurance in Japan. A discussion of national health care spending follows, along with a description of the organization and distribution of health care personnel. Health care services available to individuals with epilepsy are examined, with special reference to medical specialists treating epilepsy in Japan. The chapter concludes with a brief discussion of the contradictions inherent in current government policy.

Health Insurance

The health insurance system of Japan currently operates on the basic premise that all individuals should have access to affordable health care. However, the original impetus of the government for establishing a health insurance system was not the provision of affordable medical care, but rather the maintenance of a strong workforce. It was but one element of government efforts at nation building in the early 20th century.⁴ In 1960, the year that universal health care was instituted, 94.2% of the population of Japan was covered by health insurance. Since then, the proportion of insured individuals has increased annually. In 2002, virtually 100% of the Japanese population was covered by health insurance.¹⁰ Health insurance in Japan is of two main types: Employee insurance (60.3%) and National Health Insurance (NHI) (39.7%). Benefits include compensation for clinical visits and drugs.⁵

Employee Insurance

The number of individuals covered by employee insurance (either as a principal policy holder or as a dependent of a policy holder) grew from 48.5% of the population in 1960 to 60.3% of the population in 2002. There are four distinct categories of employee insurance: Government-managed insurance (46.9% of the total number of employee insurance policy holders), large enterprise insurance (40.0%), mutual aid associations (12.8%), and seamen’s insurance (0.3%). Insurance premiums of approximately 8.6% of an employee’s salary are deducted monthly. At present, 70% of the medical costs of both policy holders and their dependents are covered, while 80% of medical costs for children younger than 3 years of age and 90% of costs for individuals older than 70 years of age are covered.⁵

National Health Insurance

NHI was established in 1938. In 1960, health insurance coverage through NHI was extended to all residents of Japan not eligible for employee insurance—self-employed individuals, students, farmers, unemployed individuals, and part-time workers, among others. Benefits under NHI are far less comprehensive than those available under employee insurance; 70% of medical costs are covered. Premiums are scaled to income and assets, with an average household yearly payment of 163,842 yen. This amounted to 2.8% of the average national income in 2002. In 1984, a pensioner’s plan was introduced that increased benefits for retired persons to 80% of all hospital costs and 70% of outpatient costs of policy holders and to 80% of the hospital costs of dependents. In 2002, approximately 50,297,000 people, or 39.7% of the population of Japan, were insured through NHI.⁵

Payment for Hospital Services: Epilepsy and the General Population

According to a 2002 patient survey, on any given day in Japan, an estimated 7,929,000 people were either hospitalized or used outpatient services. Of these patients, 60.3% were covered by employee insurance (split almost evenly between policy holders [30.1%] and dependents [30.2%], and 39.7% by NHI).⁹

The proportions of types of health insurance used in medical consultations related to epilepsy differ somewhat. According to estimates by the Ministry of Health, Labor and Welfare (MHLW), 38% of visits by patients with epilepsy were paid for with NHI. In addition, although employee insurance was used by almost the same proportion of individuals (11.2%) as in the general population (10.7%), insurance for dependents with epilepsy was used with greater frequency (22.5%). As with the general population (1.8%), there were no clinical visits related to epilepsy that were paid for in full by patients. Health services for 9.2% of patients with epilepsy were paid for through publicly funded Medicaid (Seikatsu Hogo Hou) and through other public funds. These numbers are significantly higher than the proportion estimated for all hospital patients (0.5% under the Mental Health Act, 7.5% under the Social Welfare Act, and 6.1% through other public funds).¹⁰

These figures indicate that a significantly higher proportion of individuals visiting clinics and hospitals for problems related to epilepsy are self-employed or unemployed and receive some sort of public assistance. The relatively higher numbers of patients using insurance for dependents can be explained partially by the large proportion of people <25 years of age using hospital services for problems related to epilepsy (see Specialists Treating Epilepsy).

Budget Organization and Development

National spending on health care in Japan has increased rapidly since 1954, the year the Ministry of Health and Welfare (MHW) began keeping such records.⁵ That year, health care spending equaled 215.2 billion yen (1.871 billion U.S. dollars at the 2005 exchange rate of 115 yen per dollar). Medical costs in Japan have increased in tandem with the standard of living and national income. They have remained at approximately 5% to 6% of national income since 1975, ranging from 5.22% in 1975 to 6.42% in 1987.³ In 2002, 31.1 trillion yen, or 8.58% of the national income, was spent on health care.⁵ Normal births, medical checkups and public health measures, costs of prosthetic devices, and costs related to nursing homes are not included in these figures,⁵ nor are costs related to research.⁴

Health care spending as a proportion of national income appears to be low compared with the United States (13.9% in 2001), France (9.4%), Canada (9.4%), and Germany (10.8%).³ However, according to the Organization for Economic Cooperation and Development (OECD), spending in Japan is underestimated by about 25% because figures do not account for spending in categories included in other national estimates.¹² Even with the added 25%, the figures for Japan are low compared with these countries. With respect to the gross national product (GNP), health care spending in Japan, which was 7.4% of the GNP in 1998, was lower than that of countries such as the United States and France.⁵

Sources of payment for health care range from insurance (employee insurance and NHI) (44.9% of total), the Geriatric Act (34.37%), patient payments (15.3%), and government-sponsored plans (including welfare and the Mental Health Act, and others) (5.5%) (2002 figures).³

Regarding the sources of money spent on health care, in 2002, 51.7% came from insurance premiums, a figure that has risen steadily from 45.8% in 1954. Spending from public sources has risen from 16% in 1954; the current rate is 33% (25.1% from federal and 7.9% from regional sources). Patient payments account for 15.3%, and 0.2% comes from other sources.³

Whereas in 1955 10.2% of all medical payments came from Medicaid (Iryou Hogo/Seikatsu Hogo), the amount has dropped steadily and was 0.8% in 2002. In addition, medical costs borne by patients not using insurance dropped from 20.7% in 1955 to 1.3% in 2002. Employee insurance covered 60.3% of health care, and NHI covered 39.7% in 2002, proportions roughly equivalent to the relative number of individuals insured under these categories.⁵

Organization of Hospitals, Physicians, and Health Care Workers

Hospitals and Clinics

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