Public/Private Health Care Delivery in Japan: and Some Gaps in “Universal” Coverage

Abstract

Legal universal health coverage is not enough for ensuring equal access to health care. If coverage is not effective for those requiring health services, additional measures shall be considered along with the existing mix of public and private health care providers. This paper aims to describe and discuss how health care services are delivered to low-income people in a mixed delivery system in Japan, where a combination of a statutory health insurance system and a public assistance program legally covers all residents. In the late twentieth century, the national government rather suppressed expansion of public providers but stimulated private provision. It also designates private providers as public-interest medical institutions to provide services that would not be paid sufficiently by the insurance system, e.g., rural health services and emergency medicine. Consequently, different public/private mixes in different specialties exist in different regions, although private providers are dominant overall and public providers are supposed to take various complementary roles that would not be achieved with the market. With the collectively exhaustive combination of mandatory insurance and public assistance, issues around access to health care for low-income people are often marginalized, despite increasing poverty. In reality, however, some of them are not able to pay insurance premiums and face high amounts of charges by losing their coverage at the point of services. Meanwhile, restrictive conditions of public assistance make it difficult for people on the border line to use health care with the program. After describing policy measures, including the Free/Low Cost Medical Care Program, to address these issues, the paper argues that one of the most critical issues is mainstreaming the issue of access to health care for those in need.