Japan, U.S. confront health care uncertainty

By Fumihiko Abe / Yomiuri Shimbun Senior WriterEver since the inauguration of U.S. President Donald Trump’s Republican administration early this year, I’ve kept a close eye on the fate of Obamacare.

Obamacare is the United States’ first ever “comprehensive national health care system” aimed at insuring tens of millions of citizens who lack either public or private coverage. It was implemented under the leadership of former President Barack Obama in 2014.

Though Japan first achieved universal health insurance coverage more than 50 years ago, it shares a number of historic links with the United States regarding national health care.

In the United States, the Republican Party has traditionally opposed a universal health care system, claiming it will lead to the “rise of big government.” Trump promised during the campaign to scrap Obamacare and has sought an alternative plan. Even now, battles over the issue persist.

Obama’s health care reforms, which were adopted in spite of the Republican Party’s resistance, have been called a once-in-a-century accomplishment. Yet while antipathy to universal health care is part of the United States’ mindset, it also swayed Japan’s health care in the past.

When the Allied Forces occupied an impoverished Japan after World War II, regionally based national health insurance plans and employee insurance plans, most of them supported by companies, were available. However, many regions lacked national health insurance and about 40 percent of the population was uninsured.

In 1947, a U.S. research team visited Japan with the aim of developing a social security system for the country. A report submitted to the General Headquarters of the Allied Forces (GHQ) proposed universal health care for all Japanese.

However, the American Medical Association (AMA), which wielded tremendous political power at the time, strongly opposed the report. The organization dispatched its own research team to Japan to issue an opposing report, which claimed that universal health care would “socialize” Japan.

In the United States, Democratic President Harry Truman had expressed a desire to introduce universal health care; the AMA’s report on Japan’s health care system aimed to undercut such moves back home.

According to former Sapporo Medical University Prof. Nobuo Maeda, an expert on postwar medical history, GHQ’s Public Health and Welfare Section had expressed understanding for the role of national insurance in Japan’s recovery. However, it also gave consideration to developments in the United States and refrained from actively supporting pro-universal health care reports.

Despite this initial resistance, Japan gradually embraced national insurance and became the world’s first country to establish a universal health care system in 1961.

Troubles ahead

However, continually rising medical costs signal trouble for the country’s universal health care system.

While antiuniversal health care sentiment exists, there are definitely also those who wish to preserve such a system. How has the state of health care in Japan changed?

Iwate Prefecture established universal health care at the prefectural level before any other prefecture. Susumu Masuda, a doctor from the prefecture, told me about his tenure as director of Sawauchi Hospital, a national insurance hospital in Sawauchi village in the prefecture, which is now part of the town of Nishiwaga.

Back then, many villages in Iwate Prefecture lacked doctors, and Sawauchi did not open its first hospital until 1954, nine years after the end of World War II.

“Employees of the national health system collected an insurance tax [fee] from villagers by persuading them that they could receive proper medical care,” Masuda, 83, said. “The village mayor also put a lot of effort into recruiting physicians.”

Sawauchi, which had about 6,000 people, faced special circumstances as the local hospital had not charged elderly people outpatient clinic fees for 60 years.

Some patients tried to take home plasters and other items because they thought they were free. Masuda said he had to constantly counsel against such behavior, saying: “Please use these things sparingly, as they are purchased with money collected from everyone. I’ll give them to you only when it’s really necessary.”

Masuda became known for his “charismatic local medical care” and his leadership and other efforts on health-related ventures. What does he think of the current health care system?

His response was rather critical: “Doctors and patients only think of health care as buying and selling medical services. There is no dialogue between them. Under these circumstances, doctors approve unnecessary tests, while patients try to get more drugs than they need because the burden on patients is low thanks to public insurance.”

If patients do not have a strong sense of “health care as a public good,” staunching the rise in medical costs could be difficult.

Discussions are to be held on revising medical and nursing cost payment systems. Both the United States and Japan need to decide what kind of medical system to embrace going forward.



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