Japan’s health care system and the American debate about national care

16Sep09

Part I: Japan v. U.S.A. — a health-care death match

My annual trip back to the United States took a surreal turn as certain sectors of the American populace turned out for town hall meetings on health care to tell their representatives to “Keep your government hands off my Medicare.” The mind-boggling irrationality of what passes for debate about health care in the United States becomes even more bizarre when right wingers begin to present successful national health systems from around the world as if they were somehow abject failures, even though statistically it’s clear that the U.S. needs to do a bit of work if it wants to rise from the bottom of the rankings when it comes to health care comparisons with the other major industrialized nations of the world.

One of the reasons that the health care debate in the U.S. is so disconcerting is that in countries like Japan, France, and England the idea of national health care is simply a non-issue.  What debates there are aren’t about whether or not to have a national system, but rather about how the systems in place can be made to function more cost effectively and provide better care to more people.  Far from being discontent with the health care system in Japan when taken as a whole, my colleagues and students are constantly expressing their confusion about why Americans seem to be afraid of the obvious benefits of a national health care system, and they are aghast when they first discover that there are around 45 million uninsured Americans in the United States.  Although there are several very real problems with the Japanese national health care system, it boggles the mind when people point to these problems as an argument against national health care.  The imperfections in Japan’s system definitely warrant some criticism but I have yet to hear a single Japanese person say that the solution to these problems is to move to an American system of purely privatized (and highly unregulated) health care.  Instead of throwing the baby out with the bath water, the obvious solution is to try to fix those areas of the health care system that are problematic, while holding on to those aspects of the system that place it 10th on the World Health Organization’s list of world health systems (the U.S. ranks 37th, in case you were wondering).

Part II: How I learned to stop worrying and start loving the Kokumin-Kenkō-Hoken

I’ve been living in Japan for over four years now and my experiences with the Japanese health care system have been universally positive.  During my first year in Japan I was covered by the Kokumin-Kenkō-Hoken 国民健康保険 (national health insurance — i.e. “the public option”).  Since I had no registered income in Japan for the year prior to signing up with the national health insurance system I ended up paying the absolute minimum  amount (the amount you pay into the national system is calculated as a percentage of your previous year’s income).  I ended up paying 18,000 yen for a year’s worth of insurance, or the equivalent of around 180 U.S. dollars.  This allowed me to see any doctor I chose with no limitation on consultations or on treatment.  Of course, there were co-pays involved depending on the services that I needed, but these were so incredibly low as to be practically non-existent.  For example, a consultation with a doctor would run me between 300 and 700 yen (three to seven U.S. dollars) and a two-week prescription for antibiotics might end up costing about 1,500 yen (about fifteen dollars).  In my second year of living in Japan new rules came into place and I was required to sign up with the insurance program offered by the university that I work for (supplementary insurance is available if you feel that the university insurance is insufficient).  Now I pay somewhere between 100 and 300 dollars a month for my health insurance (I’m not sure exactly what the precise amount is since it’s taken out of my paycheck automatically and it doesn’t make enough of a dent in my earnings for me to spend very much time thinking about it).  As with a great many employers in Japan, the university that I work for requires its employees to take an annual medical exam (at no expense to the individual).  This exam includes a host of standard tests (urine, blood, etc.), as well as a mandatory chest x-ray for teachers (tuberculosis is a problem in Japan, as is lung cancer).  What this means, of course, is that doctors are able to offer preventative medical advice about lifestyle choices based on the readings they get from your annual exams, in addition to the obvious benefit of catching medical problems early enough that they can be dealt with at the stage when treatment is most effective — i.e., before symptoms escalate to the point of an emergency room visit.

Part III: Japanese health care may not be Utopia, but compared to the downsides of the U.S. system, it might be the next thing to Paradise

Recently there have been several articles and blog entries posted that are critical of the Japanese health care system, including one that claims that the Japanese system of health care is “no Utopia.” The main criticisms leveled seem to be about the perceived quality of health care offered, lack of access to new and innovative drugs, and long waits for relatively harried and unresponsive doctors.  I myself am a generally healthy person, so when I go to see the doctor in Japan it’s almost always about something that’s an easy fix.  Growing up I had no health insurance (my first real health insurance came as a graduate student at Berkeley) but I only had to see the doctor a few times and these visits were covered by the Medi-Cal system.  In other words, I haven’t had a lot of experience of my own with serious medical conditions (I’ve never even broken a bone), though I once did have my elbow swell up to the size of a baseball with some kind of strange infection at that was expertly taken care of by the university medical services.

Since I’ve been living in Japan I’ve had nothing but good experiences with the Japanese medical system and even though I have had two waits of longer than an hour, I was still able to see the doctor on the same day without an appointment and get the treatment that I needed. On the days when I had made a prior appointment I was able to see the doctor within 15 minutes of the appointed time (comparable to the States, except for one time in Berkeley when I was left waiting in the examination room for about 45 minutes before the doctor showed up).  My visits to the doctor are unconscionably cheap, the doctors are always nice enough (though it’s true they don’t spend a lot of time with pleasantries), and they’ve listened to and addressed my questions.  Whenever I’ve had medicine prescribed it’s been cheap and done the trick.  When friends from abroad have come to visit they’ve had similar experiences (including being amazed at the incredibly cheap doctor bills).  I have had the proverbial three-minute doctor visit (which was indeed a blunt instrument), but it worked —prescription given, problem solved.

Let’s compare this experience to that of friends and relatives of mine back in California.  A good friend of mine (who I will call “Jen” from now on) became uninsured when she passed the age at which she was still covered by her father’s health insurance.  Jen had a minor, but uncomfortable, infection which she knew could be dealt with immediately using antibiotics.  Jen began calling around for a general practitioner that she could see but she was told time and time again that “Dr. So-and-so isn’t taking any new patients now.”  Realize that Jen, though uninsured, had money available and was willing to pay full price for a doctor’s consultation and a prescription.  She ended up spending over half a day combing the phonebook to find a doctor that could see her, and the earliest appointment she could get was for two days later.  It cost her 200 dollars, U.S., for the consultation, even though it took less than 15 minutes and she was the one who told her doctor what the problem was.  Then she had to pay for the antibiotics.  Contrast that with my own experience with a sinus infection.  I came to the hospital with no appointment and was directed to the ear-nose-throat specialists.  I did have to wait almost two hours (luckily I brought a book), but I was finally seen by the doctor who checked my sinuses, sent me for an x-ray to confirm that I had a sinus infection, and then prescribed antibiotics for me.  The total cost out of my own pocket?  About 3,500 yen, or 35 bucks in U.S. currency.  I had a followup appointment the next week.  I had to wait for about 15 minutes, the doctor asked me how I was doing and checked my sinuses again, saw that the medication was doing the trick, and sent me away.  Cost? 300 yen (about three U.S. dollars).

My relative, “Jenny,” was uninsured and had very little money to her name (not many members of my family are particularly well-to-do).  She needed to be seen about a cut on her foot that had become infected, but because of budget constraints the local government had recently closed down all of their low-income medical clinics.  This meant that Jenny had to go to the emergency room of the hospital since that was the only place to get care if you didn’t have insurance.  In order to be guaranteed care at the emergency room Jenny had to get there at seven in the morning and wait in line with other poor people who needed medical attention but didn’t have money or insurance to get it elsewhere.  Some of the people — people with children with bad coughs, for example — were there for their second day in a row, since they had been unable to be seen on the first day.  Jenny had to wait for seven hours before she was given antibiotics for her foot, and a proper bandage.  During that time she had to wait with actual emergency patients, one of whom was bleeding from a knife wound.   I know two people who have worked in the ER and both of them absolutely hate this aspect of the American health care system — it not only clogs up the emergency room, making it harder for the doctors to do their jobs in a real emergency, but it also ends up costing the taxpayer a heap of money because emergency services are always more expensive than general medical services.

In Japan there is a genuine problem with people getting turned away from emergency care (sometimes at multiple hospitals, sometimes resulting in death) and the lack of doctors in rural areas is a problem too. But the difference in comparison with the Sates is that there is already a functional system that is in place in Japan, and this system can be tinkered with, if there’s political and social will. In the States there is simply no system in place at all.  If you’ve got money to buy insurance, of course, you’ll probably be fine, or, oops . . . perhaps not.

Part IV: Do you feel lucky, punk?  Well, do you?

Let me be absolutely clear — If I had to choose between spending the rest of my days with the Japanese health care system as it stands now or spending the rest of my days with the U.S. health care system as it stands now, I would unequivocally and without hesitation choose the Japanese system.  But don’t take my word for it — check out the Americans Abroad Know About National Health Care site, a site that collects stories about the positive health care experiences of Americans living abroad.  This site was started by a person living in Japan, so a majority of the stories that are told here are stories about the Japanese health care system.  Dozens and dozens of anecdotes, and all of them positive.  Testimonials to the truth about national health care around the world and the fact that national systems for providing health care really do work.

(The photograph at the top of the post is of the Toyonaka Municipal Hospital, located right down the street from my house.)



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