NHI as an instrument for achieving UHC in nonDMCs: Japan

Disclaimer: The views expressed in this paper/presentation are the views of the author
and do not necessarily reflect the views or policies of the Asian Development Bank
(ADB), or its Board of Governors, or the governments they represent. ADB does not
guarantee the accuracy of the data included in this paper and accepts no responsibility
for any consequence of their use. Terminology used may not necessarily be consistent
with ADB official terms.

Naoki Ikegami, MD, MA, PhD

St Lukes International University
nikegami@a5.keio.jp
For more information: Free download
http://documents.worldbank.org/curated/en/2014/0
9/20278271/universal-health-coverage-inclusivesustainable-development-lessons-japan
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1. How did Japan achieve UHC? (1)

Importance of historical factors and delivery system
Policy from 1868: Westernize the country under the
Emperor and focus on industry and military
Maintain access to primary care, but contain costs
Medical licenses were given to all established
practitioners and their sons if 25 years or elder in 1884
Government built hospitals only for teaching, the military,
and isolating communicable diseases
Most hospitals built by physicians and financed by
charging patients: Hospitals were mainly only for the rich
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How did Japan achieve UHC? (2)

Establishment of employment-based health
insurance (EHI) in 1922
To prevent socialist revolution
To make workers more productive
Gradually expanded to all employees and their family

Establishment of municipality-based Citizens

Health Insurance (CHI) in 1938
To improve the health of draftees: War with China
Half of Japans population were in farming households
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How did Japan achieve UHC? (3)

WW II: Expand coverage in warfare state
Post-war reconstruction: From warfare state to
welfare state
UHC: Popular election slogan
Movement started in 1956
To enroll the remaining 1/3 not yet insured
Not insured: Mainly self-employed living in big cities
Tokyo was among the last municipalities to establish CHI

Population coverage achieved in 1961

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Expansion of population coverage

Percent of population

100%
80%

CHI

None

60%
40%

GMHI

20%

SMHI
MAA

0%

'27 '31 '39 '40 '43 '49 '53 '58 '61 '70 '80 '90

Year
[Source: Yasuo Takagi (1994) Kokuminkenkohoken to chiiki fukushi: choki-nyuin no zehi to kokuho-anteika taisaku no
jissai to mondaiten Quarterly of Social Security Research 30(3):239
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Note: Figures for periods during World War II are estimates.

Achieving the three axis of UHC

(1) Population
1927: EHI Manual
workers (3%)
1938: CHI Old Act
(Municipalitys option)
1939: EHI expanded to
white collar &
dependents
1958: CHI New Act
(Municipalities must
start CHI and
individuals must enroll)
1961: Universal
coverage

(2) Services
1927: EHI Fee
schedule
1943: EHI Fee
schedule unified
1952: CHI
subsidy fixed at
20% of costs
1959: CHI
adopts EHI fee
schedule All
have the same
benefits

(3) Costs
1927: No copay for
employees
1930s: 50% for rest
1960s: Gradual
decreases in copay
for non-employees
1973: No copay for
70+; catastrophic
coverage for all
2003: 30% for all
except 70+ & <7
6

Flow of money in the 4 tiers of the SHI

programs

Tax
Premiums

Employer

Employee

75 and over

Others

10%
1st ~3rd tier
programs

40%

50%
Government

1st Tier
Large companies: 1348
Public sector: 78
Seamen: 1

2nd Tier
National Health
Insurance
Association: 1

3rd Tier
Citizens Health Insurance: 1742
CHI Unions: 166

4th Tier
47 Prefectures
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As of April 2010

Compensating for disparities among SHI plans

Disparities in income levels: Subsidies from tax
CHI: 41-75% (average 50%) financed by subsidies
Enrolls self-employed, irregularly employed, retirees<75

NHIA (National Health Insurance Association): 16.4%

Enrolls employees of small to medium companies

Disparities in the proportion of elders enrolled

Elders 65-74: Transfer payment from employment-based
insurance (EHI) to municipality-based CHI programs
Elders 75+: 50% financed by subsidies, 40% from premiums of
all other programs (remaining 10% from enrollees)

Despite these mechanisms, more than threefold

difference in the % of income levied as premiums

Disparities have increased with the growth of service

industry in SMHI and decrease of farmers in CHI

Lessons positive and negative

Positive lessons
National emergency is a door opener for UHC
Focus on the poor and primary care, then scale-up
(scaling down from the top is impossible)
Rural communities may be easier than urban

Negative lessons
Over 3000 social health insurance plans
Plans should have been unified when economy was good
But plans with low premium rates have opposed
unification
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Challenges
Denominator remains the same
Stagnant economy: No GDP growth for 20 years

While numerator continues to increase

Health expenditures increase 2~3% per year due to
aging and advances in technology

Relative burden of healthcare has increased

Main reason why Japan is 3rd in % of health to GDP
Who will pay: the next generation
National debt is twice the GDP

Cost control by fee schedule has mitigated increase

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