Japan's health care

 Japan's health care system is characterized by universal coverage, free choice of health care providers by patients, a multi-payer, employment-based system of financing, and a predominant role for private hospitals and fee-for-service practice. Virtually all residents of Japan are covered without regard to any medical problems they may have (so-called predisposing conditions) or to their actuarial risk of succumbing to illness. Premiums are based on income and ability to pay. Although there is strong government regulation of health care financing and the operation of health insurance, control of the delivery of care is left largely to medical professionals and there appears to be no public concern about health care rationing.

    Like the Australian, Canadian and many European health care systems, Japan's national health insurance program is compulsory. But Japan surpasses all 24 member countries of the Organization for Economic Cooperation and Development (OECD) in life expectancy at birth and also has the lowest infant mortality rate (Appendix 1, Table 1).¹ It achieves these successes at a cost of only 6.6 percent of gross domestic product, $1,267 per capita - half that of the United States (Table 1) .

    Japanese-style national health insurance raises a fascinating question: how has Japan reduced financial barriers of access to medical care and achieved a No. 1 ranking on health status at a cost that is among the lowest of wealthy industrialized nations?² In addressing this question, we begin with a comparative analysis of health care resources and the use of medical care in Japan, the United States and other OECD countries. Next, we review the financing and organization of medical care in Japan, evaluate some strengths and weaknesses of the health care system, and explore possible lessons for health care reform in the United States.

     In adopting this comparative approach to health care reform in the United States, we have relied on an extensive review of the English-language literature on Japan's health care system and on information presented at the Japan Society's April 30 conference, "Making Universal Health Care Affordable: How Japan Does It."³ We do not presume to have analyzed Japan's health care system in depth. For example, we remain intrigued by Japan's exemplary health status and by such societal values and traditions as egalitarianism and consensus- building upon which the health system is built. We have aimed, in earnest, to raise more questions than we are able to answer. We hope that these questions may lend a sense of perspective to the on-going public debate on health care reform in the United States.

NOTES:
¹For comparisons between Japan and the other OECD countries, see the Tables in Appendix 1.
²This is a reference to Vogel's (1979) classic book, Japan as Number One: Lessons for America. (Cambridge: Harvard University Press).
³We also refer the reader to a previous monograph on health and medicine in Japan and America based on a conference organized by the Japan Society in 1978 (Reich and Kao, 1978).