I’m an American living overseas, in Japan. I have been living here now for about 12 years. For Americans who are interested in improving America’s monstrous health care system, you should know that you are blessed with a huge, largely untapped resource: 6 million Americans living overseas.
Amongst those of us living in other industrialized countries, many of us have been participating in national health care schemes for years and have the ability to see beyond the America-is-better-at-everything attitude that often characterizes the internal health care debate in the US. We can actually compare US healthcare to what we have in our host countries.
I’d like to share with you all what we have in Japan. I am not a health care expert and in fact only recently looked up the meaning of Single Payer Health Care, which seems to be what we have in Japan. If someone who is more expert on the macro-workings of the system in Japan cares to comment or write their own, better, diary, we all stand to gain. I'm interested in giving U.S. based readers an idea what such a system looks like on the ground.
Single-payer national health insurance is a system in which a single public or quasi-public agency organizes health financing, but delivery of care remains largely private.
First, a little background. I own a small IT services and recruiting company in Tokyo. My handful of employees are enrolled in the system and in fact, companies are legally obligated to enroll their staff in the program. If you’re unemployed, a sole proprietor or if your employer is out of legal compliance and doesn’t enroll you, you can go to your local government office and enroll yourself at your own expense, anyway. Everyone who is either a Japanese national or has a valid, non-vacation visa is supposed to enroll.
As a business owner, the process was pretty straightforward. Initially I had to fill out some papers about the business. The amount of work required was fairly insignificant. I think I finished it in a few hours - even with language barriers. I can barely remember what was required but as I recall it was just some official documentation and bank information so they could make automatic, monthly deductions from the company account. As a side note, if you’re enrolled in the system, you are also automatically enrolled in the national pension scheme (social security). The National Pension scheme and Nat'l Health Insurance scheme are joined at the hips. You can't enroll in only one.
Once the company is registered in the health care system all I need to do when I hire someone is get some basic information from them: full name, address, birth date and social insurance #. I fill in a single form (!) with their salary information, put the company stamp on it and submit it to the social insurance office. About 15 minutes later, they issue a health insurance card that I give to the employee. When the employee quits, I get the card back from them, submit a paper to the social insurance office informing them that the employee has quit, return the card to them, and they stop deducting money from the company account for that person. If the former employee does not have their next job lined up already, they can go register themselves into the health care sytem at the local government office and pay for it out of pocket.
I’m single, as are most of my employees, but my understanding is that the health insurance card covers the enrollees entire family. The cost of health insurance coverage varies based on income, like Social Security in the US and the monthly deductions max out at around the annual income level of US$100,000, (US$1=JPY120). However, the price is the same regardless of whether a person is single or has a family. If you have 5 chilren and make $50,000/year, you'll pay the same amount as a single person who makes $50,000/year. Hey! That sounds like family-friendliness! Do you suppose this might be an angle that even a Conservative could love? People over the age of 40 also pay slightly higher rates. The cost is typically split 50%/50% between the employer and the employee (see table below).
With this national health insurance card, a person can basically go to any hospital – private or public, large or small - and to any doctor in Japan. Enrollees typically pay 10%~30% of the hospital bills out of pocket. The National Health Insurance system picks up the rest. As far as I know, standard medical procedures are generally covered. Cosmetic surgery and other such procedures are not covered. Dental is covered, braces are not. The Japanese government negotiates with drug makers and, as far as I know, most major medications are available and covered though the patient still pays a percentage (10%~30%?). Some medication is not covered. I seem to recall some controversy over whether Viagra would be covered when it first hit the market (I don’t think it is covered). I don't believe abortions - or the pill - are covered, either, just in case you're wondering. I don't think mental health and most alternative medicines are generally covered, either. FWIW, I generally only use the dentist, but a checkup typically costs me about $15 and all I do is fill out a single paper with basic information at the dentist office, present my card and pay after the checkup is complete. Trips to the doctor that I have taken are the same.
If people want to purchase supplemental health insurance from the private sector, they are free to do so. American insurance firms in Japan pioneered the field of cancer insurance and it’s a big market because even in Japan cancer treatment, hospital stays, etc. can get expensive.
So, how much does this National Health Care thing cost an enrollee every month you ask? Remember, the cost for each individual slides based on their income but is the same regardless of whether they are single or have a family. I have provided a simplified list below that approximates monthly costs in US dollar amounts):
Annual Income: Monthly Cost to Employer: Monthly Cost to Employee:
$10,000 $50 $50
$20,000 $75 $75
$30,000 $110 $110
$40,000 $140 $140
$50,000 $180 $180
$60,000 $200 $200
$70,000 $235 $235
$80,000 $260 $260
$90,000 $320 $320
$100,000+ $410 $410
Please note: since you’re also enrolled in the National Pension (Social Security) plan, you have an additional, separate amount deducted from your pay to cover the nat'l pension payments. Basically, it’s more than the health insurance component and a good rule of thumb is to expect the combined national pension and health insurance to be a bit less than 20% of your gross income, until you max out at $100,000 at which point the cost stays constant, again like Social Security in the US.
Is the Japanese National Health System the best system in the world? Probably not. There are a lot of old doctors, a lot of old crummy hospitals, Japanese people are probably over medicated and I doubt more exotic procedures (brain surgery?) are covered. The dentists often require multiple visits and I think it's because they simply want to earn more money.
I honestly don’t know how much it costs for unemployed people and self employed people to pay for their own insurance but let’s be conservative until told otherwise and assume that they bear the full cost. I still don’t think it’s unreasonable when considering how easy the system is to use and when compared to what you might find (or not find) in the US. Everyone is covered - even convenience store employees, gas station attendants, cleaners, etc. - and you aren't bombarded with misleading adds about health insurance like you are nowadays in the US. Damn you Humana!
All anyone needs to do is present their card at any hospital or dentist, fill out a simple form and pay 30% when they're done. If you’re looking for generally good health care, my personal opinion is that Japanese health care is better in general than in the US. The data seems to support that notion, as well. While they tend to eat healthier than Americans, Japanese people do live longer than Americans. It seems self evident to me that if you're able to make regular visits to the doctor and have access to reasonably priced medication, you'll probably live longer than if you have to avoid the doctor so you can eat, as some people apparently have to do in the US.
Lastly, from a macroeconomic perspective, Total Health Expenditures as a share of GDP were 8% in Japan in 2003 vs. 15.2% in the US . That's a staggering amount of paper pushing and advertisements that Americans are paying for.
A new poll shows that even a majority of Republicans support universal health care. The time to demand change is now. Democrats should own this issue.
I for one am hoping that the movie SiCKO wakes the American people up. We deserve better.
Contact your representatives and demand National Health Care, CONSTANTLY.
House of Representatives
Senate
