1. Background
Second edition

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Background ｜ Japan’s geography and demographics

Japan is an island nation in eastern Asia with an area of 377,887 square kilometers that is comprised of over 6,800
islands, including Honshu, Hokkaido, Kyushu, Shikoku, and Okinawa. Japan contains 47 self-governing
administrative divisions referred to as prefectures.
The total population hovers around 127 million people, with about 90%
living in urban areas. As of 2015, about 36.5% of the total population
resided in Tokyo, Kanagawa Prefecture, Osaka, Aichi Prefecture, orSaitama Prefecture. Among these, the largest proportion was in Tokyo,
which was home to 10.7% of the total population of Japan.1.

An ageing population with a declining birthrate 2,3
An ageing population coupled with a low birth rate are two major
concerns facing Japan and its healthcare system.
Those aged 65 and over comprised 27.3% of the total population as of
October 1, 2016. This figure is expected to approach 40% by 2060.
The old-age dependency ratio (the ratio of people aged 65 and over topeople between the ages of 15 and 64) in 2015 was highest in Akita
Prefecture (60.7) and Kochi Prefecture (59.2), and lowest in Okinawa
Prefecture (31.2) and Tokyo (34.3).
The overall fertility rate in Japan was 1.45 in 2015. This rate was lowest inTokyo (1.24) and highest in Okinawa (1.96).

Life expectancy and main causes of mortality
The people of Japan enjoy one of the highest life expectancies in theworld, with the average being 91.35 years for females and 84.95 years formales.4 Mortality rates for the top nine causes of death in 2015 are listed
in the following table (according to data from the Ministry of Health,Labour and Welfare (MHLW) and the Organisation for Economic Cooperation and Development (OECD)).
According to the World Health Organization (WHO), 79% of all deaths
were related to non-communicable diseases (NCDs) in 2014. Amongst
these, 30% of deaths were caused by cancers, 29%, by cardiovasculardiseases, and 12%, by other NCDs.5＜Column＞Ageing in TokyoJapan is not ageing across all regions at
the same rate. Large metropolitan areas,such as Tokyo, Osaka, and Nagoya are at
the forefront of aging in Japan.
According to Tai Takahashi*, between
2010 and 2025, the population of those
aged 75 and over will grow by 7 million
people, more than half of whom willreside in the Greater Tokyo Area (Tokyo,
Kanagawa, Chiba, and Saitama), Osaka,
and Nagoya. These three regions,however, comprise a mere 2% of Japan’s
total land area, underscoring the urban
nature of Japan’s “super-ageing society.”
Takahashi also points out that Tokyo
faces serious additional challenges
regarding the number of care facility
beds, which is equal to just half thenational average. This shortage may
become increasingly serious as the
population continues to age.
*Reference: “Regional Differences in thePeak of Healthcare Demand and theLevel of Medical-Social Resources:
Rebuilding a Medical-Social Service
Delivery Structure,” Presentation byProfessor Tai Takahashi of theInternational University of Health andWelfare at the 9th Meeting of theCommittee on National Social Security
Reform, 2013.

1 Statistics Bureau, Ministry of Internal Affairs and Communications (14 April 2017). Demographic forecast. (accessed 15 September 2017) Retrieved from:http://www.stat.go.jp/data/jinsui/2016np/index.htm#a05k28-b
2 Cabinet Office (2017). White paper on ageing society. (accessed 24 July 2017) Retrieved from: http://www8.cao.go.jp/kourei/whitepaper/w2017/zenbun/29pdf_index.html
3
Director General for Policy Planning and Evaluation, Ministry of Health Labour and Welfare (2017). Vital statistics in Japan. (accessed 24 July 2017)Retrieved from: http://www.mhlw.go.jp/toukei/list/dl/81-1a2.pdf
4 Cabinet Office (2017). White paper on ageing society. (accessed 24 July 2017) Retrieved from: http://www8.cao.go.jp/kourei/whitepaper/w2017/zenbun/29pdf_index.html
5World Health Organization (2014). Noncommunicable diseases country profiles 2014: Japan. (accessed 24 July 2017) Retrieved from:http://www.who.int/nmh/countries/jpn_en.pdf?ua=1© 2019 Health and Global Policy InstituteCause of death

Mortality rate
(per 100,000)6290.3

OECD average mortality rate
(per 100,000)7*
211

Heart disease

156.5

122

Pneumonia

97.8

n/a

Cerebrovasculardisease
Senility

94.1

69

55.5

n/a

Accident

31.5

n/a

Suicide20.7

12.4 in 2011

Liver disease

12.7

n/a

Tuberculosis

1.7

n/a

Cancer*Where available

Ranked by the burden that each disease places on the lives of sufferers as
measured in DALYs (Disability-Adjusted Life Years)*, the most critical diseases
within the Japanese population are cancers, cardiovascular diseases, diabetes,
neuro-psychiatric diseases, musculoskeletal diseases, respiratory diseases,
other NCDs, external injuries, and infectious diseases.8It is expected that theburden of life-style related diseases and degenerative diseases will increase
alongside demographic changes such as ageing.
The World Bank estimated in 2015 that the under 5 mortality rate (U5MR) forJapan stood at 3 per 1,000 live births and the maternal mortality ratio was 6
per 100,000 live births. These figures reflect a decrease of nearly 50% whencompared to data from 1990.9*DALYs are an indicator of disease burden which assesses the amount of harmcaused to health by specific diseases and injuries. DALYs are calculated byadding the total of years of life lost (YLL) due to premature death and the yearsof life lived with disability (YLD).

＜Column＞A population on track
to decline, with low expectations
for growth even among the
population aged 65 and over
Between 2010 and 2040, thepopulation aged 65 and over will
increase by 9 million. Over thesame time period, the population
under age 65 will decrease by 30
million. Starting sometime aroundthe year 2040, it is expected thatgrowth in the older population willplateau, while the working
population will sharply decrease,causing the overall population toshrink by around 15%. This will
increase the proportion of people
aged 65 and over in Japanesesociety.

6

Ministry of Health Labour and Welfare (2017). Vital statistics in Japan. (accessed 2 February 2018) Retrieved from:http://www.mhlw.go.jp/toukei/list/dl/81-1a2.pdf
7 OECD (2015). Health at a Glance 2015: OECD Indicators. Paris: OECD Publishing, 2015.
8 World Health Organization (2015). Japan: WHO statistical profile. (accessed 24 July 2017) Retrieved from: http://who.int/gho/countries/jpn.pdf?ua=1
9
The World Bank (2015). Mortality rate, under-5 (per 1,000 live births). (accessed 24 July 2017) Retrieved fromhttp://data.worldbank.org/indicator/SH.DYN.MORT© 2019 Health and Global Policy Institute1.2

Background ｜ The history of public healthcare insurance

The current Japanese healthcare system can be best understood by reviewing its origins. The public healthinsurance program in Japan is a combination of three separately developed structures—the employment-based
health insurance system, the residence-based National Health Insurance system, and the medical insurance
system for those aged 75 and over. Today, these three structures combined form the basis of one of the largest
healthcare insurance programs in the world, covering nearly all Japanese citizens and long-term residents, over
127 million people. In light of historical circumstances and following numerous revisions to the Health Insurance
Act since its introduction in 1922, these insurance systems are administered by a variety of insurers.

The history of the public health insurance program in JapanThe beginnings of Japan’s system of public health insurance system
After sweeping through England from the second half of the 18th century and throughout the 19th century, theindustrial revolution finally reached Japan. Japan’s industrial revolution began in earnest when state-owned
enterprises were privatized in the second half of the 19th century. Just like the rest of the world, this caused a
sharp increase in the number of Japanese laborers working in environments such as coal mines and factories. As
a result, issues surrounding the improvement of working conditions and the protection of workers’ rights became
urgent due to labor movements and social movements. This led to the enactment of the Factory Act in 1916, which
regulated employment and compelled factory owners to provide support to workers in the event of workplace
injury or fatality.
However, labor movements started by labor unions were based on socialism, and resistance to socialism remained
a major hurdle for the Japanese government. The government did not view the labor movement as entirely
dangerous. It distinguished between moderate reform and radical reform and worked to prevent confrontations
between social classes by permitting moderate labor movements using a Bismarck-style “Carrot and stick”
approach. The “stick” in this approach refers to actions that suppressed labor movements. The first “carrot”
appeared in 1922, when the Health Insurance Act came into effect. The main purpose of this act was to provide
compensation to workers or their families in the event that a worker had a workplace accident or fell ill while noton the job. The concept of the Health Insurance Act itself dates back to the 1890s, when Minister of Home Affairs
Shinpei Goto started discussions within the government after recently returning to Japan from a study trip toGermany. However, the topic did not become a priority issue for the government, so many years of effort wererequired before it was finally enacted. Also, at the time, health insurance for laborers was considered morestrongly an industrial policy rather than a medical policy, so it was under the jurisdiction of the same ministry as
the Factory Act, the Ministry of Agriculture and Commerce.
Meanwhile, the Great Depression began in the United States in 1929. Shockwaves were sent through Japan’s
farming communities when export prices for agricultural products to the U.S. fell one after another, starting with
exports of raw silk thread. An additional blow fell when a bumper crop in 1930 sent the price of rice plummeting,further compounding the economic problems already facing Japan’s farming communities. Entering the 1930s,
farming communities became an important source of manpower for the Japanese military, so the health andnutritional status of their people became an issue of military strength. The Ministry of Home Affairs began toconsider establishing an insurance system for the general populace starting with those in farming villages thatwould provide wide coverage for people who were not employees. It is said this decision was based upon the factthat the long-established “Jorei” system for providing community healthcare similar to medical aid associations
already existed in every region of Japan, particularly in farming communities. The decision was also influenced by
the fact that the Health Insurance System that had been created for employees was already starting to show
© 2019 Health and Global Policy Instituteresults. It is also said that the Japanese government made this decision after seeing the results of similar systems
in Sweden and Denmark.
The former National Health Insurance Act was submitted to the Diet in 1937, but ended up classified as unresolved andrejected after the dissolution of the House of Representatives. When the Ministry of Health and Welfare (now the
Ministry of Health, Labour and Welfare) was formed the following January, in 1938, income restrictions that had been
an insurance prerequisite were abolished, and insurance became available to non-employees. The condition that
insurance be employment-based was also abolished for both the insured and those not covered by employee insurance.
This system was replaced by a system in which insurance was provided through location-based insurance associations
that viewed municipalities as independent units. This formed the basis of the current system of residence-based
National Health Insurance that was enacted in March 1938.
The successful establishment of universal health coverage(UHC)
After World War II ended in 1945, the Supreme Commander for the Allied Powers (SCAP) issued the "Three principles
of public assistance" for Japan, making the government responsible for ensuring equality and minimum standards ofliving. This meant the government had to be more proactive in maintaining the health of the people. In 1948, theprevious National Health Insurance system was revised, making it a rule that the insured were under the jurisdiction of
local governments rather than regional associations. However, given the economic situation after the war, there werestill problems that prevented National Health Insurance from becoming widespread. Even by 1956, one-third of the
population of Japan was still unenrolled in any form of health insurance. Due to this, the then Prime Minister Ichiro
Hatoyama declared the establishment of "Comprehensive health insurance that covers all citizens" in his annual speechon policy guidelines. This was a massive step forward in theeffort to insure everyone. The current National Health Insurance＜Column＞Free healthcare for people aged
Law was enacted in 1958. It made regional governments legally
70 and over: The “biggest mistake” in the
responsible for the administration of insurance associations andhistory of health policy in Japan
compelled all citizens to enroll in the public insurance scheme if
Free healthcare for the elderly is now
they were not already covered by employee's insurance or aconsidered by the Government of Japan to be
Mutual Aid Association (MAA). That same year, a new Public
the “biggest mistake in the history of health
Health Insurance act was enacted. After a grace period of 3
policy in Japan” (according to a former MHLW
years, public health insurance unions were established in all
official). While drastically improving access tomunicipalities, allowing Japan to successfully achieve a world,11 ,12
10
healthcare among the older population, theclass system of universal healthcare in 1961.
system resulted in over-provision of care andmedical products, including pharmaceuticals.
Coverage for the older population
In 1973, Japan forged a unique health insurance structure for Older patients flooded hospital waiting rooms
its older population, reallocating public funds to subsidize the to the extent that they essentially became
30% of costs typically covered by patients within the NHI cost- centers of social activity for some people.
During that era, it was not uncommon to hearsharing scheme and effectively making healthcare free fortwo older people in a waiting room joke, “Ms.
people aged 70 and over.13 Japan simultaneously introduced
a high-cost medical care benefit system which at first covered Yamada isn’t here today. She must not be
only family members of employees via the employment- feeling well!” The moral hazards created bybased health insurance, not extending to employees free healthcare were so extreme that thethemselves. Later, employees along with their families came government moved to revise the policy forto enjoy the benefits of this system via National Health people aged 70 and over, re-requiring costInsurance, when employment-based health insurance finally sharing. However, this proved tremendously
grew to also cover employees. Between 1973 and 1980, difficult politically, with the entire processultimately taking 30 years.
10 Kitayama, T. (2011). Explaining the Institutional Change of Health Politics in Japan: Localities Nationalized?. Yukikaku Publishing Co., Ltd.
11 Sakaguchi, T. (1977). The History of Japan’s Social Insurance Systems. Keiso Shobo
12 Yoshihara, K., & Wada, M. (2008). The History of Japan’s Health Insurance Systems. Toyo Keizai Inc.
13

Ministry of Health, Labour and Welfare (2016). The status of medical care for the elderly. (accessed 29 January 2018) Retrieved fromhttp://www.mhlw.go.jp/file/05-Shingikai-12601000-Seisakutoukatsukan-Sanjikanshitsu_Shakaihoshoutantou/0000125580.pdf© 2019 Health and Global Policy Institutehealthcare spending for people aged 70 and over increased more than fourfold, leading to sustainability concerns
and the eventual passage of the 1982 Public Aid for the Aged Act. This act, implemented in 1983, put an end to
free healthcare for the elderly by requiring that they pay small copayments.14 In addition, this legislation helped
to subsidize the NHI program by transferring revenue from employment-based health insurance to NHI. As a result,the Public Aid for the Aged Act is considered one of the most critical pieces of healthcare legislation in the historyof Japanese health policy.

The Health Services Scheme for the Aged and the medical care system for the retired
The Public Aid for the Aged Act of 1982 created the basis for the Health Services Scheme for the Aged. This scheme,
which was administered by municipalities, covers people aged 75 and over as well as those bedridden aged 65
and over (People aged 70 or over born prior to September 30, 1932, were covered by the Health Services Scheme
for the Aged). Funding for the scheme was provided by contributions from medical insurers, public funds, andpartial contributions by the insured. This scheme was in place for nearly 25 years, only being revised in 2008. There
were many reasons for the revision. Chief among them was the lack of transparency regarding distribution of
medical expense burden between the young and the old. Through the scheme, a part of every premium
contributed by the members of any health insurance plan was transferred to municipal governments. In otherwords, the groups collecting premiums (insurance schemes) were not the same as the groups paying contributions(municipalities), making it difficult to know how contributions were actually spent. This scheme was finallydiscontinued in April 2008 alongside the creation of the Medical Insurance System for the Latter-Stage Elderly
targeting people aged 75 and over.15 The cost-sharing details between the young and the old are much moretransparent in this system. Furthermore, this system established governmental unions in prefectural associations
across the country to act as central locations for the collection and payment of insurance premiums. This system
also has clearly defined regulations regarding the responsibilities of management and the use of public finances.
In addition to the previously mentioned systems, in 1984, the Government created the Retired Persons Healthcare
System to relieve the building pressure on public finances brought on by increasing numbers of retirees leaving
employment-based insurance schemes and coming under the coverage of NHI. The Retired Persons Healthcare
System covered people aged 65 and under who were enrolled in NHI, people on employee pensions for overtwenty years, and people who elected to receive retirement pensions after the age of forty and had done so for
10 years or more. Dependents were also covered by this system if they satisfied a fixed set of accreditation criteria.
This system was administered by municipal governments, and funding was sourced from premiums contributedby system members, as well as premiums paid to employment-based health insurance plans. The Retired Persons
Healthcare System itself was discontinued following the establishment of the Medical Insurance System for the
Latter-Stage Elderly in April 200816.

A new medical insurance system framework for the older population
The 2006 reform of the Japanese medical system is tremendously important when trying to understand healthpolicy in Japan. This reform created a new healthcare system for people aged 75 and over. A number of reasons
led to the creation of this new system. The first was related to Japan’s residence-based insurance, a part of NHI
that covers people residing in Japan who are not enrolled in employment-based health insurance plans. The healthinsurance system was set up such that when people retired who had formerly been enrolled in employment-based
health insurance plans, they would then be enrolled in Community Health Care Plans.17 Since people generally
retire at older ages, the average age of the population enrolled in NHI (via these plans) grew older and older as
14 Ikegami Naoki (2014). Universal Health Coverage for Comprehensive and Sustainable Development – Synthesis of research in 11 countries. Japan Center

for International Exchange. (accessed 29 January 2018) Retrieved from http://www.jcie.or.jp/japan/pub/publst/1453/1453all.pdf
15 Ministry of Health, Labour and Welfare. Changes to the healthcare system for the elderly. (accessed 22 August 2017) Retrieved fromhttp://www.mhlw.go.jp/bunya/shakaihosho/iryouseido01/info02d-25.html
16 Ministry of Health, Labour and Welfare. Amendments to the medical insurance system. (accessed 22 August 2017) Retrieved fromhttp://www.mhlw.go.jp/bunya/shakaihosho/iryouseido01/taikou05.html
17 Ministry of Health, Labour and Welfare. The medical insurance system of Japan. (accessed 22 August 2017) Retrieved fromhttp://www.mhlw.go.jp/file/06-Seisakujouhou-12400000-Hokenkyoku/0000172084.pdf© 2019 Health and Global Policy Institutetime passed. This shift placed enormous financial pressure on the NHI since older people tend to incur greater
medical expenses. The 2006 reform aimed to respond to this structural challenge by establishing a framework thatallowed people aged 75 and over to be supported by society as a whole. Specifically, a new system was set up
requiring people aged 75 and over to cover 10% of their medical expenses, while the remaining 90% is covered by
the working population and public funds. A framework was also created by insurers to adjust costs for people
aged 65 to 74 by having them enroll in either Community Health Care Plans or employment-based healthinsurance. The framework for those aged 75 and over came to be known as the Medical Insurance System for the
Latter-Stage Elderly, while the framework for those aged 65 to 74 supports people considered to be “Early-stage”
elderly.

The Long-Term Care Insurance System
Prior to the establishment of the Long-Term Care Insurance System, welfare and medical care for the elderly weredelivered via separate systems. In terms of welfare, municipal governments selected the types of services people
were eligible for as well as the institutions from which they could receive the services. Service recipients had nosay in these matters. Service fees were decided according to the incomes of recipients and the incomes of theirdependents, leading to heavy burdens for middle-class households. As for medical care for people aged 75 andover, a lack of infrastructure for welfare services limited society’s ability to provide long-term care to people inneed of services, including daily care in hospitals and care related to specific medical treatments which required
longer periods of hospitalization.18
As the Japanese population has aged, the focus of the healthcare field has shifted from acute illnesses toward theprovision of integrated and continuous medical and nursing care for those with chronic conditions. Fewer andfewer families are now living with their elderly relatives compared to in the past, and the average age of family
members providing care to elderly relatives is increasing. The combined effect was an increase in the number ofpeople with no option for medical care but a long-term hospital stay, which put a strain on public finances. The
Long-Term Care Insurance Act of 1997 was created to address this issue. This act established the Long-Term Care
Insurance System, which covers all people aged 65 and over, as well as people aged 40 and over who are in needof long-term care. This system gives users the freedom to select the type of services they need, as well as theirservice providers. This act also created the position of “Care Managers” who are able to assist users in selecting
care providers.19 Users are charged 10% of the medical fees for the services they select, irrespective of theirincome (although above a certain level of income, they are charged 20%). The system differs from NHI bymandating a “maximum amount of financial support.” After a certain level of support, users must cover the costsof all excess services.

Other healthcare legislation
Implemented in 1948, the seminal Medical Care Act defined criteria for the basic medical services to be provided
by public hospitals. 20 The Medical Care Act has since undergone eight revisions in order to better align theprovision of medical facilities with community needs as well as to introduce the system of Medical Care Plans.
A more recent piece of major health policy legislation is the Health Care System Reform Act of 2015, whichchanged the shape of the healthcare insurance system. This act, which will go into effect in 2018, moves oversightof the residence-based NHI from the municipal level to the prefectural level. To support the transition, this act
provides prefectures with increased authority and responsibility related to financing and healthcare delivery

18 Ministry of Health, Labour and Welfare (2015). The current state of the public nursing-care insurance system and its future role. (access 22 August 2017)Retrieved from http://www.mhlw.go.jp/file/06-Seisakujouhou-12300000-Roukenkyoku/201602kaigohokenntoha_2.pdf
19 Ikegami Naoki (2017). Medical care in Japan; Its history and organization – Direction of future reforms. Nikkei Book Publishing Company.
20
Ministry of Health, Labour and Welfare (2007). 2007 White Paper of the Ministry of Health, Labour, and Welfare. (accessed 29 January 2018) Retrieved
from http://www.mhlw.go.jp/wp/hakusyo/kousei/07/dl/0101.pdf© 2019 Health and Global Policy Institutesystems. As one MHLW official put it, it is “the biggest change to healthcare in Japan since the establishment of
the modern healthcare system.”© 2019 Health and Global Policy Institute1.3

Overview of major legislation

Year

PolicyDetails

1922

Establishment of the Health
Insurance Act

・Provided health insurance to employees with a certain level ofincome1938

Establishment of the National
Health Insurance Act

・Established National Health Insurance (NHI), a residence-based
insurance program for farmers, the self-employed, the retired,
and the non-employed, administered by municipal governments
on a voluntary basis

1939
1942

Establishment of the Ministry of
Health and Welfare
Establishment of Health
Insurance for Employees Act
Health Insurance Act amended

・Provided health insurance to employees working at financial
companies etc.
・Integrated the Health Insurance Act and Health Insurance For
Employees Act
・Introduced a system of partial cost-sharing

1948

Establishment of the Medical
Care Act・Legislated the establishment and management of hospitals,
clinics, and other facilities, as well as their scope and number of
personnel

1958

National Health Insurance Act
amended・Mandated that all municipalities establish and administer
residence-based NHI programs
・NHI became compulsory for those not covered by other plans

1961

Universal Healthcare achieved

・Landmark achievement in Japanese health policy history madepossible through the expansion of NHI after all municipalities
were mandated to administer a NHI program in 1959
・Out-of-pocket responsibility becomes 0% for insured people
with employee insurance, 50% for dependents, and 30% for
those enrolled in NHI・Establishment of high-cost medical expense system

1963
1972

Establishment of the Act on
Social Welfare for the Elderly

・Establishment of special elderly care homes

Act on Social Welfare for the
Elderly amended

・Created a new structure for those 70 and over and made care
free for nearly all people age 70 and over・Legislation related to home help

・Reduced copayments within NHI for other enrollees
1973

Health Insurance Act amended

・Establishment of medical expenses for the elderly payment
system・Fixed rate of state aid for Government-Managed Health
Insurance

1982

Public Aid for the Aged Act・Retracted free care for those aged 70 and over by imposing asmall co-payment© 2019 Health and Global Policy Institute・Stipulated coverage of medical expenses for the elderly via
fiscal adjustment among insurers. Treated people aged 70 andover separately from the existing health insurance system,
subsidizing costs via public funding (national government 2/3,
prefectural governments 1/6, municipal governments 1/6) andcontributions from insurers in the existing health insurance
system.
1985

The first revision to the 1948
Medical Care Act

・Introduced regional medical planning for the management of
hospital beds

1990

“Eight Acts” 21related to welfare
amended・Municipalities were obligated to formulate municipal
healthcare plans for the elderly

1993

The second revision to the 1948
Medical Care Act

・Specified “advanced care hospitals” and created a new
structure for “health facilities for long-term recuperation”

1997

Establishment of the Long-TermCare Insurance Act

・Launched a mandatory social insurance program that covers
care for older people with health issues, partially relieves
caregiver burdens, and addresses the needs of the aging
population

The third revision to the 1948
Medical Care Act

・Launched the regional medical care support hospital system

Partial revision of the Health
Insurance Act

・High-cost medical expense system amended

2000

・Set general regulations for informed consent
・Revised the upper limit for health insurance premium rates
・Abolished out-of-pocket expenditures on medicine related tothe elderly
・Revised a portion of expenditures related to the elderly

The fourth revision to the 1948
Medical Care Act

・Introduced a bed classification system that required hospitals toreport hospital bed use under the categories of “general” or“treatment”
・Implemented 2-year mandatory clinical training period for
doctor licensing
・Made medical safety management systems legally mandatory
for all medical facilities

2002

Partial revision of the Health
Insurance Act

・Revised out-of-pocket expenditures
・Introduced total compensation system for health insurance
premiums
・Increased insurance premium rate for Government-Managed
Health Insurance
・Revised calculation method for medical expense contributions
for the elderly
・Other measures, including those to strengthening the financial
foundation of NHI

21 Eight welfare-related acts: (1) Act on Social Welfare for the Elderly, (2) Act on Welfare for Physically Disabled Persons, (3) Act on Welfare for Mentally

Retarded Persons, (4) Child Welfare Act, (5) Act on Welfare for Mothers with Dependents and for Widows, (6) Social Welfare Act, (7) Aid for the Aged Act,and (8) Social Welfare and Medical Business Corporation Act© 2019 Health and Global Policy Institute2005Long-Term Care Insurance Act
amended・Established preventive benefit and regional support projects forthe creation of a preventative medicine system
・Following a review of facility benefits, it become no longer
possible to use benefits for expenses relate to food and housing
at long-term care facilities. A supplementary benefits program
for low income users is set up
・Created of community-based services to establish new service
systems, enhance residential services, improve the integrated
community care system, strengthen support for middle-income
households, and coordinate medical care and nursing care /establish a clearer division of roles
・Established insurance fees for primary beneficiaries thatreflected, in detail, the ability of that person to pay expenses,
following a review of the state of medical expenditures and the
management system for such expenditures. Also revised thelong-term care licensing system, strengthened insurer functions,and revised cost-sharing schemes and other issues.

2006

Health Care Reform Act

・Established a new medical care service system targeted atpeople aged 75 and over・Establish a public corporation to hand over the administrationof Government-Managed Health Insurance for employees of
SMEs from the national Government to the prefectural
governments

Partial revision of the Health
Insurance Act

・Formulated a medical cost optimization plan to optimize
medical expenses over the medium- to long-term, such as
lifestyle disease measures and the correction of long-term
hospitalization fees
・Revised the content and scope of insurance benefits
・Abolished medical facilities that only provided long-term care・Established a new medical care service system for the elderly

2008

The fifth revision to the 1948
Medical Care Act

・Promoted public information about healthcare facilities at theprefecture level

Long-Term Care Insurance Act
and Act on Social Welfare for the
Elderly amended

・Created a business management system under laws andregulations for nursing care service providers
・Issued advance notification on the suspension or abolition ofnursing care service providers
・Made the clarification of services at the time of a nursing careservice provider suspension or abolition mandatory.

2008

Cabinet Order to revise part ofenforcement ordinance for the
Health Insurance Act etc.

・Revised the calculation criteria for high-cost medical expenses

Summary Report of the National
Conference on Social Security

・Established the introduction of a hospital bed function
reporting system and a vision for community care・Established requirements for payment related to high cost longterm care and calculation standards related to nursing care・Called for the strengthening of the roles of prefectures andtransitioning of NHI management to prefectures© 2019 Health and Global Policy Institute・Revised the medical corporation system and social welfare
corporation system
・Called for collaboration between medical care and nursing careand construction of an integrated community care system
・Called for Financial support to promote the reform of theprovision of medical and nursing care services
・Called for a studies on training general practitioners,
communicating information to the public, the duties of medical
professionals, and the establishment of team medical care.
Emphasized that data should be continuously collected andperiodically reevaluated.
・Called for the stabilization of the health insurance system,
ensuring fairness in cost-sharing related to insurance premiums
・Called for prioritization and efficiency improvements related to
medical benefits (a correction of the range of eligible medical
treatment etc.)
2009

2011

Cabinet Order to revise part ofenforcement ordinance for the
Health Insurance Act
Establishment of the Act Revisinga Portion of the Long-Term Care
Insurance Act to Strengthen theFoundation of Long-Term Care
Services

・Revised the Childbirth Lump-Sum Allowance and benefit for thechildbirth of a family member (increase of 40,000 yen)・Strengthened collaborations between medical and nursing careproviders. Promoted comprehensive support (integrated
community care system) for caregivers etc. who cooperate withmedical care, nursing care, prevention, housing, and living
support services.
・Established Long-Term Care Service Plans based on anunderstanding of the regional needs and issues in the places
where people live, created a 24-hour regular and periodic careservices and complex services
・Extended the date for the elimination of hospital beds used only
for long-term care・Promoted the supply of housing with in-home care services forthe elderly

2012

National Health Insurance Act
amended・Transferred the financial administration of NHI programs fromthe municipal level to the prefectural level to strengthen thefinancial basis of NHI

2013

Partial revision of the Health
Insurance Act and other acts

・Took measures including the two-year extension of fiscal
support for the Japan Health Insurance Association which waspreviously in place from 2010 to 2012 (These include: 1.
government subsidies, and 2. methods by which insurers could
handle money owed to support healthcare for those age 75 andover)・Raised the share of healthcare expenditures incurred by theJapan Health Insurance Association that were covered byGovernment subsidies from 13% to 16.4% for two years© 2019 Health and Global Policy InstituteEstablishment of social security
reform program

・Clarified items to be examined for a reform of the healthcare
system and the long-term care insurance system
・Established a system for the reporting of hospital bed functions
・Considered all aspects of the total compensation ratios forsupporting people aged 75 and over・Revised out-of-pocket expenditures among people aged 70 to
74 years old
・Revised the high-cost medical expenditure system

2014

Establishment of the Law to theRelated Acts for Securing
Comprehensive Medical andLong-Term Care in theCommunity

・Set up new funds within prefectures that utilize consumption
tax revenue to promote strong collaboration between medicalcare and nursing care・Created the requirement that medical institutions report thefunctions of hospital beds (beds for intensive , acute, recovery, orchronic patients) to prefectural governors in order to ensure theefficient and effective provision of healthcare in each
community. Also created the requirement that prefectures
formulate a regional medical vision for their local healthcare
systems based on that.
・Enhanced community support projects and shifted funds forpreventative medicine benefits to community support projects inorder to foster a comprehensive regional care system and ensure
fair cost-sharing.

2014

Cabinet Order to revise part ofenforcement ordinance for the
Health Insurance Act

・Revised the Childbirth Lump-Sum Allowance.

The sixth revision to the 1948
Medical Care Act

・Promoted integrate care and the analysis of hospital bed
information through the creation of the Bed Classification System
and Integrated Community-based Care Plan

・Revised criteria for calculating high-cost medical care benefits
and combined medical treatment costs for high-cost long-term
care・Introduced measures to address physician and nurse shortages
・Introduced a classification renewal system for hospitals
recognized as “advanced treatment hospitals”
・Introduced measures to improve the work environment for
healthcare workers
・Promoted home healthcare
・Promoted the improvement of the clinical trial system
・Introduced a system to investigate medical accidents
・Revised the healthcare corporations system
Establishment of Act for Securing
Comprehensive Medical andLong-Term Care・Implemented measures aimed at ensuring the efficient andeffective provision of medical care at the community level
・Established the integrated community care system and revised
cost-sharing to be more fair.

© 2019 Health and Global Policy Institute2015

Establishment of the Act Revisinga Portion of the National Health
Insurance Act to Build a
Sustainable Health Insurance
System・Transferred responsibility for the fiscal management of NHIfrom municipal governments to prefectural governments

The seventh revision to the 1948
Medical Care Act

・Established a system for the creation of corporations topromote regional medical collaborations

・Increased insurance premiums for employees of large
corporations and civil servants・Established "patient offer system" that allows users to cover
medical expenses through a combination of insurance benefits
and out-of-pocket funding.

・Revised the medical corporation system
2017

The eighth revision to the 1948
Medical Care Act

・Established regulations on governance reforms at advanced
treatment hospitals
・Established restrictions on what medical institution websites,
publications, and so on, can say (restrictions on false or
exaggerated claims).

2017

Cabinet Order to revise part ofenforcement ordinance for the
Health Insurance Act
Establishment of the Act Revisinga Portion of the Long-Term Care
Insurance Act to Strengthen the
Integrated Community Care
System・Revised calculation criteria for high-cost medical expenditures
among insured people over 70 years old
・Created a system to make it possible for municipal governments
to make use of insurer functions and work toward helping
patients live independently and toward preventing sick patientsfrom growing worse.
・Established a new kind of nursing-care insurance facility thatcombines functions such as daily medical management and endof-life care and terminal care with living facilities.
・Set out requirements for people using Long-Term Care
Insurance with high-cost medical expenditures who werepreviously asked to cover 20% of their expenses to now cover
30%.

2018

Prefectural Unitization of NHI・Transferred responsibility for fiscal management of NHI frommunicipal governments to prefectural governments.

© 2019 Health and Global Policy Institute