It is an obvious fact that healthcare systems in different countries differ. For this comparative essay, I chose the country of Japan, with the intention of comparing its healthcare system with ours, America.
Access
Japan has a universal, public statutory health insurance system (SHIS) that provides coverage regulated by the government. It is mandatory for all citizens of all ages and anyone who will be living in Japan for more than 90 days to enroll in a SHIS plan. 98.3% of the population is enrolled in SHIS, and the remaining 1.7% of Japanese citizens are low-income and are enrolled in a public social assistance program. The SHIS plan a person enrolls in is based on age, employment status, and/or residency. There is also private health insurance, but it is only supplemental or complementary to public health insurance. In the SHIS, the Japanese government sets the fee schedule and enforces regulations. Costs are simple and clearly laid out. Most citizens pay a 30% coinsurance for services. There is a reduced coinsurance of 20% for children aged 6 and younger and adults aged 70 to 74 with lower incomes and only 10% coinsurance for those aged 75 and older with lower incomes. There are no deductibles in SHIS, and copayments for children’s health care are often subsidized by the government. This simplistic fee schedule cannot be said of the United States, there is a vast array of fees and charges depending on what health coverage an individual has.
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The United States does not have a universal healthcare system. Health care coverage in the United States is a mixture of public and private, as well as for-profit and nonprofit insurers. Options include fee-for-service (FFS), preferred provider organization (PPO), point of service (POS), health maintenance organization (HMO), Medicare, Medicaid, and coverage from the Veterans Health Administration. A majority of US citizens have private insurance that is often provided through their employer, or they may buy it on their own. 12.5% of US adults are uninsured, and countless more are underinsured. Lack of health insurance is perhaps the greatest barrier to accessing health care services and has a tremendous negative effect on an individual’s overall health status.
The only thing close to a universal healthcare system in the United States is the Patient Protection and Affordable Care Act (PPACA), which was signed into law in 2010. Its goal was to expand health insurance coverage to Americans that were uninsured while controlling costs and improving the quality of healthcare. Since its beginning, it has been under scrutiny, and many parts have been amended, including removing the penalty fee for those that did not have health insurance. With the implementation of the PPACA, different plan options became available for people to obtain insurance, but private insurance is the primary health coverage for two-thirds of Americans (67%). Over half of all private insurance is through employers. Most employer plans cover their employees and give various options on the level of coverage and also the option to insure their family. Rarely an employer pays the entire premium. Most of the time the cost is shared between the employer and employee. Only 11% of private health insurance is purchased by individuals from for-profit and nonprofit carriers.
In America, retirees/seniors qualify for Medicare. It is a complex fee-for-service program consisting of parts, A-D. Part A provides hospital insurance and Part B medical insurance. Members can choose to get their coverage just through traditional Medicare, or they can choose to enroll in Part C which is a private health maintenance organization (HMO) called Medicare Advantage. Part D is also optional and is for prescription drug coverage. Medicare is financed through a combination of general federal taxes, a mandatory payroll tax that pays for Part A, and individual premiums.
The unemployed may qualify for Medicaid if their income is low. It is a jointly sponsored state and federal program that pays for medical services for persons who are elderly, poor, blind, or disabled, and for certain families with dependent children who meet specified income guidelines. Medicaid is obtained through the state of residency. The state then received federal matching for providing the health coverage.
Veterans can receive healthcare coverage from the Veterans Health Administration. It is America’s largest integrated healthcare system serving 9 million enrolled Veterans each year. Having other health insurance coverage like Medicare, Medicaid, or private insurance doesn’t affect getting VA healthcare benefits. Each veteran’s medical benefits package is unique. Covered benefits depend on the 'priority group' and the advice of the VA primary provider. Retiring veterans may also be eligible for TRICARE. It is a Medicare-wraparound coverage for those that have Medicare Part A and B.
There are two US government-run programs available to children from low-income households. Depending on income level, they may qualify for Medicaid or the Children’s Health Insurance Program (CHIP). CHIP is a state-administered public program created in 1997 for children in low-income families that earn too much to qualify for Medicaid but are unlikely to be able to afford private insurance. CHIP is funded through matching grants from the federal government to the states, and most states charge a low premium and have small copays, if any. Because it is state-administered, exactly how it works varies by state. For example, it is considered an extension of Medicaid in some states, while in others it is a separate program. Currently, 9.6 million children are covered by this program.
Coverage of Medications
In Japan, the coverage for medication for children, the unemployed, and the retired remain under the same rules as the coinsurance percentages. Clinics can dispense medication directly to the patients or they can go to the pharmacy. According to the Commonwealth Fund, the use of pharmacies has been growing. Price revisions for medications are also revised every 2 years. Usually, prices are lowered for new drugs that are selling more than expected, and for brand-name drugs when their generic counterparts become available. Prices of generic drugs have gradually decreased. Also, if a physician prescribes more than 6 drugs regularly to a patient, he receives a reduced fee as a way to improve clinical decision-making.
In the US, the coverage for medication for children, the unemployed, the and retired depends on the coverage they have. Retired individuals with Medicare have the option to purchase private prescription drug coverage under Medicare Part D. Part D covers most outpatient drugs, like those that you would get a prescription for and pick up at the pharmacy. Medicare Part B only covers very limited outpatient prescription drug benefits, like injections that need to be given by a medical professional. For Medicare Part D, copays and coinsurance vary by drug plan: $0–$5 for preferred generics, up to 50% for non-preferred drugs. For the unemployed that qualify for Medicaid, outpatient prescription drugs are an optional benefit under federal law, however, currently, all states provide drug coverage. For children with private health insurance, the copay for prescriptions depends on that specific insurance coverage. For low-income children, the copay for medications is reduced if part of CHIP or possibly free if on Medicaid. Vaccines are often free to uninsured and underinsured children.
Referral to See a Specialist
In Japan, there is no 'gatekeeper'. Children, the unemployed, and the retired do not need to get a referral to go see a specialist. The term 'general practice' in Japan is recent, but historically, there has been no distinction between primary care and specialty care. The fee schedule remains the same for all providers. Patients can see a specialist without a referral and most of the time on a walk-in basis.
A 'gatekeeper' is very common for healthcare coverage in the United States. American children, the unemployed, and the retired are often limited to specialty services if it is not deemed necessary or they cannot afford the excessive fees. PPO plans often can schedule an appointment with a specialist without permission from their primary care provider, but those with an HMO or government-sponsored plan do not have that option. Outpatient specialists are free to choose which form of insurance they will accept, or whether they will accept it at all. For example, not all specialists accept publicly insured patients, because of the relatively lower reimbursement rates set by Medicaid and Medicare. Access to specialists for beneficiaries of these programs—not to mention for people without any insurance—can therefore be particularly limited.
Coverage for Preexisting Conditions
In Japan, no one can be excluded from any coverage based on a preexisting condition. This also became true in the United States. Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a 'pre-existing condition', that is, a health problem you had before the date that new health coverage starts.
Finance Implications for Healthcare Delivery
In Japan, people benefit from the universal healthcare delivery system. All fees are determined by the government and therefore controlled. Even though most hospitals and medical offices are privately run, they are limited on what they can charge based on government regulations. This allows individuals to seek medical treatment and preventative services more often, thus leading to better health. Not only is health benefited but a person benefits financially as well. Unlike Americans, the Japanese do not need to worry that paying for healthcare will lead to financial ruin. A hospital stay is in the hundreds, whereas in the United States, it is in the thousand and can leave a person bankrupt. Americans often go without medical treatment simply based on the fact that they cannot afford it. Especially if they do not have health insurance, like in the circumstance of losing a job. In Japan, if a person loses their job their health coverage just switches from the employer to a community plan.
The negative financial implications of Japan’s healthcare structure fall on the providers. 50% of hospitals are in financial deficit. This is the opposite in America, where hospitals and doctors make a profit at the expense of the people. In America private practices can, and often do, refuse services to those with government-sponsored insurance like Medicaid. This is mostly due to the low reimbursement and the length of time to receive payment. This is not allowed in Japan. There are also disincentives for providers prescribing certain medications or services because the price is then lowered upon the next government review of fees. Again, this benefits the consumer, not the provider.
In America, both public and private insurers determine their benefit packages and cost-sharing structures as long as it is within federal and state regulations. Private insurers in America are for-profit, while Japan’s statutory health insurance system (SHIS) is a not-for-profit system. Insurers in Japan are not out to make a profit. Anything money not used is carried over to the next year, which could lead to premiums being reduced.
Conclusion
In summary, the comparative analysis covered in this essay has shown that the healthcare systems of Japan and America, although they share some common features, are nevertheless different. As for me, I would prefer the Japanese system, for its accessibility, simplicity, and orientation for the benefit of its population.
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