Images of the devastation in northeastern Japan reminded me of the time I rode the Shinkansen—the bullet train that raced through Sendai, now torn by the earthquake, and on to the city of Morioka, where I was to learn how the country cared for its older citizens. I was a Fulbright Scholar studying why the Japanese health care system was so successful, and whether it offered any lessons for the U.S. E-mails from friends trapped in the havoc help explain why the country’s health system works so well.
Nancy, an American living in Japan, tells of not being able to get home from Tokyo where she had been at a meeting. She slept on the floor in the train station with a magazine under her. Someone offered her a newspaper to lie on; she said that helped. Yoko walked nine hours from her office in central Tokyo to reach her home. She says she is watching TV wondering what she, as a Japanese citizen, can do to help others. Mamiko rode her bicycle for three hours to get home. She tells me that the Japanese will get through this “with a smile.” Everyone is in the same pot. Indeed, the Japanese prime minister said Sunday, “If the nation works together, we will overcome.”
I am struck by these words, which reflect Japan’s social solidarity, the principle that undergirds its national health system and helps explain why the country has some of the best health stats in the world—statistics that the press and the public should remember next time the bogeyman of socialized medicine shows up on the campaign trail, as it inevitably will. I once heard a journalist say we should not write about the health systems of “those axis countries,” meaning, of course, Germany and Japan. But a brochure “A Profile of Older Japanese” from the International Longevity Center, where Mamiko and Yoko work, offers some numbers that say maybe we should.
Life expectancy at birth is higher in Japan than anywhere else—79.6 years for men and 86.4 years for women. In the U.S. it’s 75.4 years for men and 80.4 years for women. Per capita spending on health care in Japan is much lower—-$2729 compared to $7538 in the U.S. And get this: you can’t say spending is less because people don’t get to see a doctor. They do. In fact, sixty percent of people over age sixty-five visit a doctor at least once a month. That’s two to three times the rate for people in the U.S., France, and Germany. Right now we’re trying to control the nation’s health care bill by getting people to use fewer services, requiring them to pay more out-of-pocket as a deterrent to going to the doctor too much.
In Japan, health care providers don’t command the big bucks that docs in this country do. Japanese health care is a multi-payer system that actually acts as a single-payer system where the government negotiates one national fee schedule that helps keep prices low, explains T.R. Reid in his excellent book The Healing of America. That’s precisely the reason why American doctors and hospitals have for decades fought against any national health system that might succeed in reducing their income—a point pretty much forgotten in the Great Health Care Debate. It resurfaces obliquely every time a pol spouts off about socialized medicine.
In Japan, everyone is covered, and pays through a combination of taxes, social insurance premiums, and copayments. None of this stuff about having too much income to qualify for insurance. Those over age seventy pay smaller copayments than the general population, although the elderly with higher incomes pay the same copayments as those who are younger. In the U.S., we’re heading for a debate over making the elderly on Medicare pay a lot more by changing it from a system of social insurance to a voucher plan.
But the health system only partly explains why the Japanese are some of the healthiest people on the planet. I often give students a population health quiz. One question asks which country wins the health Olympics—the one with the highest life expectancy. The answer is Japan. The next question asks why. The answer is its social cohesion and relative parity of incomes—factors that researchers say are every bit as important in improving health as the kind of insurance system a country has.
Income disparity is not like it is in the U.S., with its ever-widening gaps between the top and the bottom. In Japan, a salaryman obviously earns more than a tea lady, and the head of Mitsubishi obviously earns more than a salaryman. But they all benefit from the same health care system. An MRI costs the same for each. They’re all in it together, as they are in resurrecting their country from this latest disaster.