What is the role of government?




Government regulates nearly all aspects of the universal Statutory Health Insurance System (SHIS). The national and local governments are required by law to ensure a system that efficiently provides good-quality medical care. National government sets the SHIS fee schedule and gives subsidies to local governments, insurers, and providers. It also establishes and enforces detailed regulations for insurers and providers. Japan’s 47 prefectures (regions) implement those regulations and develop regional health care delivery with their own budgets and funds allocated by the national government. More than 1,700 municipalities operate components of the SHIS and organize health promotion activities for their residents.1

Who is covered and how is insurance financed?

Publicly financed health insurance: The SHIS, comprising more than 3,400 insurers, provides universal primary coverage.2 In 2013, estimated total health expenditure amounted to approximately 11 percent of GDP, 84.3 percent of which was publicly financed, mainly through the SHIS.3 Taxes, premiums, and user charges accounted for about 42 percent, 42 percent, and 13 percent of the current health expenditures, respectively.4

Citizens are mandated to enroll in one of the SHIS plans based on age, employment status, and/or place of residence as are resident non-citizens; undocumented immigrants and visitors are not covered. Insurance premiums vary between types of insurance funds and municipalities. Government employees are covered by their own insurers (known as Mutual Aid Societies) as are some groups of professionals (e.g., doctors in private practice). Those who fail to keep up their enrollment must pay up to two years’ worth of premiums when they reenter the system. Means-tested public assistance covers health care for its recipients. Citizens and resident non-citizens enrolled in the SHIS age 40 and over are mandatorily enrolled in long-term care insurance.

Private health insurance: Although the majority of the population holds some form of private health insurance, it plays only a supplementary or complementary role. It developed historically as a supplement to life insurance and provides additional income in case of sickness, mainly in the form of lump-sum payments when insured persons are hospitalized or diagnosed with cancer or another specified chronic disease, or through payment of daily amounts during hospitalization over a defined period. Since the early 2000s, the number of standalone medical insurance policies has increased.5

Part of an individual’s life insurance premium and medical and long-term care insurance premiums can be deducted from taxable income.6 Small discounts can be applied to those employees whose employers have collective contracts with insurance companies. Both for-profit and nonprofit organizations operate private health insurance.

The provision of privately funded health care has been limited to services such as orthodontics. Treatment of traffic accident injuries is not covered by the SHIS, but by compulsory and, usually, voluntary automobile insurance.

What is covered?

Services: All SHIS plans provide the same benefits package, which is determined by the national government, usually following a decision by the Central Social Insurance Medical Council, a governmental body. The package covers hospital, primary, specialty, and mental health care as well as approved prescription drugs, home care services by medical institutions, hospice care, physiotherapy, and most dental care. It does not cover corrective lenses unless recommended by physicians for children under age 9, or optometry services provided by non-physicians. Home care services by nonmedical institutions are covered by long-term care insurance. Preventive measures, including screening, health education, and counseling, are covered by health insurance plans, while cancer screenings are delivered by municipalities.

Cost-sharing and out-of-pocket spending: All enrollees have to pay a 30 percent coinsurance for services and goods received, except for children up to around age 6 (20%), adults ages 70 to 74 with lower incomes (20%), and those age 75 and older with lower incomes (10%). There are no deductibles. Copayments for children's health care are often subsidized by local governments. Annual expenditures on health services and goods can be deducted from taxable income, including copayments and payments between JPY100,000 (USD952) and JPY2 million (USD19,000) for balance billing and over-the-counter drugs.7 In 2013, out-of-pocket payments for cost-sharing accounted for 13 percent of current health expenditures.8 Providers are prohibited from charging extra fees except for some services specified by the Ministry of Health, Labor and Welfare (MHLW), including amenity beds, experimental treatments, the outpatient services of large multispecialty hospitals, after-hours services, and hospitalizations of 180 days or more.

Safety net: Catastrophic coverage stipulates a monthly out-of-pocket threshold, which varies according to enrollee age and income—for example, JPY80,100 (USD763) for people under age 70 with a modest income; above this threshold, a 1 percent coinsurance rate applies. There is a ceiling for low-income people, who do not pay more than JPY35,400 (USD337) a month. Subsidies (mostly restricted to low-income households) reduce the burden of cost-sharing for people with disabilities, mental illnesses, and specified chronic conditions. There is an annual household health and long-term care out-of-pocket payments ceiling, which varies between JPY340,000 (USD3,238) and JPY2.12 million (USD20,190) per enrollee according to income and age, above which such payments can be reimbursed. Enrollees with employer-based insurance who are on parental leave are exempt from payment of premiums. Enrollees in Citizens Health Insurance (for the unemployed, the self-employed, and retirees) who have low incomes, and those with moderate incomes who face sharp, unexpected income reductions, are eligible for reduced premium payments. Reduced coinsurance rates apply to patients with 306 designated long-term diseases, varying by income, when using designated health care providers. Some providers are allowed to reduce coinsurance for low-income people through the Free/Lower Medical Care Program. Means-tested public assistance covers health services for their beneficiaries.9



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