Int. J. Environ. Res. Public Health 2010, 7, 1330-1341; doi:10.3390/ijerph7041330
OPEN ACCESSInternational Journal ofEnvironmental Research andPublic Health
ISSN 1660-4601
www.mdpi.com/journal/ijerph
ArticleBarriers to Health Care among the Elderly in Japan
Chiyoe Murata 1,*, Tetsuji Yamada 2, Chia-Ching Chen 3, Toshiyuki Ojima 1, Hiroshi Hirai 4 andKatsunori Kondo 4
1

2

3

4

Hamamatsu University School of Medicine, Department of Community Health and Preventive
Medicine, 1-20-1 Handayama, Higashiku, Hamamatsu, 431-3192, Japan;
E-Mail: ojima@hama-med.ac.jp
Rutgers University, Department of Economics and Center for Children and Childhood Studies,
Camden, NJ 08102, USA; E-Mail: tyamada@crab.rutgers.edu
New York Medical College, School of Health Sciences & Practice, Department of Epidemiology &Community Health, Valhalla, NY 10595, USA; E-Mail: ChiaChing_Chen@nymc.edu
Nihon Fukushi University, Center for Well-being and Society, 5-22-35 Chiyoda Nakaku Nagoya,
Aichi, 460-0012, Japan; E-Mails: k-hirai@n-fukushi.ac.jp (H.H.); kkondo@n-fukushi.ac.jp (K.K.)* Author to whom correspondence should be addressed; E-Mail: cmurata@hama-med.ac.jp;
Tel.: +81-53-435-2333; Fax: +81-53-435-2341.
Received: 21 December 2009; in revised form: 9 March 2010 / Accepted: 15 March 2010 /Published: 26 March 2010

Abstract: Japan is undergoing a set of health care reforms aimed at cutting rising healthcare costs and increasing the efficiency of health care delivery. This empirical study used alarge-scale community survey on 15,302 elderly people 65 years and older (56.0% women)
conducted in seven municipalities in 2006, to reveal clear-cut evidence of barriers tonecessary care. The reasons for not getting health care is attributed to health care cost for
the elderly with lower income, while higher income counterparts reported being busy or
having a condition not serious enough to seek care.
Keywords: cost burden; socioeconomic status (SES); barriers to health care

Int. J. Environ. Res. Public Health 2010, 7

1331

1. Introduction
In addition to unhealthy behaviors, such as smoking, poor diet, or lack of exercise, recent evidence
suggests that socioeconomic status is a key underlying factor that influences health. Various studies
consistently found that low socioeconomic status is associated with ill health [1-4]. Socioeconomic
status assessed by income, education, or occupation is associated with various health problems, such as
depression [1,2], hypertension, and functional status [3]. Mortality rates are also higher amongindividuals of low socioeconomic status [4]. To tackle such health disparities across different
socioeconomic strata, the World Health Organization (WHO) recently published a report entitled“Closing the gap in a generation: health equity through action on the social determinants of health,Final Report of the Commission on Social Determinants of Health” [5]. The report clearly states thatsuch inequalities in health arise out of the environment in which we live; grow up, work, and age. In
addition, countries at all levels of income, health and illness follow a social gradient: the lower thesocioeconomic position, the worse the health of the population is.
Although socioeconomic status is clearly associated to morbidity and mortality, structural links forsuch associations are less comprehensible. One such link might be knowledge. For example, education
provides knowledge and life skills necessary to gain access to information and resources that promotehealth. This is partly explained by the fact that unhealthy lifestyles are more prevalent among people oflow socioeconomic status [6]. Education also provides more opportunities for higher income that may
provide better living conditions, such as nutrition, housing, and schooling. Employment status isanother important factor in determining health. Unemployed individuals have worse health than theiremployed counterparts. Less educated people are more likely to be unemployed. Higher
socioeconomic status brings us necessary resources to cope with ill health [4,5,7]. Although theassociation between income and health is stronger in lower income brackets, such associations areobserved among richer populations as well. This is supported by a comparative study of 11 European
nations which observed health disparity across socioeconomic status groups even in relatively
egalitarian societies, such as Sweden or Norway [8]. Furthermore, redistributive policies play animportant role in reducing health disparity. A study by Navarro et al. analyzed data over a 50-year
period in OECD nations and found that redistributive policies have a salutary effect on infant mortality
or life expectancy at birth [9].
In addition to income, education, and occupation, access to health care is a vital determinant ofhealth regardless of the nation’s income level [5]. Yet, the access to care problem has not been fully
examined in richer nations. Among studies conducted in such nations, Shi and Stevens affirmed thatlower socioeconomic status individuals have poorer access to health care by using the national
representative sample in the US [10]. Access to care generally encompasses two dimensions. One is
physical access, such as the distance to health care facilities or transportation. Another is financial
access, such as cost of care or medication. Various studies demonstrated that when co-insurance
increased, those with lower income tended to stop going to doctors. Reimbursement under coinsurance system is based on percent basis. This is different from a co-payment, which is a fixed cash
amount paid to the beneficiary per procedure or per day in the hospital [11]. Although such systems
may offer financial protection, how such a system is framed may influence population health. A study
in Japan demonstrated that when co-insurance increased from 20% to 30%, a significant decrease inInt. J. Environ. Res. Public Health 2010, 71332

physician visits was observed among diabetic patients with no complications [12]. A comparative
study on three European nations (i.e., France, Germany, and Spain) detailed that an increase in patient
cost sharing reduced the frequency of physician visits, especially among people in lower social
classes [13]. Similar results are reported in other nations, such as South Korea or Taiwan [14,15].
These studies also underscored that while increases in patient cost sharing reduced visits to physicians,
hospital admissions increased especially among lower income people, suggesting that an increase inout of pocket expenditures might have a negative effect on health through lost opportunities fortimely care.
Brief description of Japanese National Health Insurance System
Japan has maintained a nationwide social health insurance system built on the German social healthinsurance model for more than 30 years. This system covers almost the entire population and isfinanced by premiums paid by insured persons, employers, and government compensation. The
relatively low-cost, universal health insurance system is recognized as a major achievement. Japanesecitizens receive services from any physician or hospital, with no difference in cost, and physicians are,in principle, free to treat or prescribe as they see fit. Under this system Japan’s low infant mortality
rate and high life expectancy at birth are among the best in the world [16]. However, pressures aremounting for health care reform to restrain future medical costs in the face of an increasing aging
population. In Japan, the National Health Insurance System reimburses on a percentage basis, and thepatient pays co-insurance. As the system currently pays 70% of the medical charges, patients (except
for children and the elderly) pay the remaining 30%.
Recently, however, there is an issue which requires attention. As of April, 2008, a new healthinsurance system was launched for the elderly 75 years and older. With the establishment of thissystem, the government intended to separate the elderly who need more medical attention and use ahigher portion of health care resources compared to younger generations. The government intends torestrain an increase in medical costs among the elderly. This system might pose barriers to necessarycare, especially among low income individuals.
In this paper, we discuss the associations between socioeconomic status and access to care by
investigating possible barriers to health care, examining the scope of health disparities across different
socioeconomic groups, and exploring factors which contribute to their associations among the elderly
in Japan.
2. Methods
2.1. Study Population
The present analysis is based on the Aichi Gerontological Evaluation Study (AGES) Project data.
The AGES Project is an on-going prospective cohort study that started in two municipalities in Aichi
Prefecture, Japan, in 1999. This project aims at investigating factors related to the loss of healthy
years, such as functional decline or cognitive impairment, among non-institutionalized elderly subjects
aged 65 years or older [17-19]. In 2003, the second wave of surveys was conducted on a random
sample of functionally independent, community-dwelling elderly subjects (i.e., who were not eligible

Int. J. Environ. Res. Public Health 2010, 71333

for public, long-term nursing care) in fifteen municipalities from three prefectures. During 2006 and2007, the third wave of surveys was conducted in nine municipalities from three prefectures. For thecurrent study, we used data from the third wave, which contains data on access to health care.
Overall response rate of the third wave survey (mailed questionnaire with three versions) was
60.8% and 39,765 elderly subjects completed the questionnaire. Subjects of the current study were
15,302 elderly people (6,737 men and 8,565 women) living in six municipalities from three prefectures
who provided complete data on age and sex, and answered the access to health care version of thesurvey. Mean age was 74.2 years (age range: 65–100). All respondents were literate and understood
the Japanese language well. As a general rule, proxy respondents were not permitted. The study
protocol and informed consent procedure were approved by the Ethics Committee in Research of
Human Subjects at Nihon Fukushi University.
2.2. Study Variables
The variable of interest is health care seeking behaviors. For health care seeking behaviors, we
asked if the elderly had a regular place to go when they were ill (regular source of health care), if they
had a regular dentist (regular source of dental care), if they underwent health check-ups in the past, andif they ever postponed or stopped seeking health care in the past year (delayed care). We also asked thereasons for not seeking care.
For health status, we used self-assessed health status, and diagnosed illnesses under treatment.
Self-assessed health was elicited by asking “What is your current health status: excellent, good, fair, or
poor?” with answers dichotomized into excellent/good or fair/poor. To evaluate functional status, thesurvey asked whether they had difficulty or needed someone’s assistance in performing any of thefollowing ADLs (activities of daily living): walking, bathing, and toileting (0 = without difficulty,
1 = can perform the activity with someone’s partial help, 2 = can’t perform the activity without help ofothers). Those scoring 0 were considered having no difficulty in performing any ADLs. Diagnosed
illnesses were ascertained by asking if they were currently receiving treatment for any of thefollowing: cancer, heart disease, stroke, hypertension, diabetes, obesity, hyperlipidemia, osteoporosis,
arthritis, trauma, respiratory illness, gastrointestinal illness, liver disease, mental illness, visual/hearing
impairment, dysphagia, urinary disease, sleep disorder, and others.
Health behaviors, such as smoking and drinking, were also assessed, since studies to date indicatedthat low socioeconomic status is associated with unhealthy lifestyles [6]. As the socioeconomic statusmeasure we used annual equivalized income computed by the square root of the number of people in
the household [20]. The purpose of such computation was to adjust the income for family size. Income
was defined as pre-tax annual household income, including regular salary, pensions, social security,
and any form of temporary earnings during the last year. For the analysis, equivalized income inJapanese yen (¥) was divided into tertiles (low: < ¥1.6 million, middle: ¥1.6 million ≤ ¥ < ¥2.5 million,
and high: ¥2.5 million ≤). As of December 2009, one US dollar ($) was the equivalent of ¥87.20
Japanese yen.

Int. J. Environ. Res. Public Health 2010, 71334

2.3. Statistical Analysis
We investigated univariate associations between income and health care seeking behaviors, healthstatus, and health behaviors using chi-square tests. In addition, age-adjusted associations were exploredby general linear modeling. General linear model is a general model that encompasses both analysis ofvariance and regression [21]. By using this method, we did analysis of covariance with age in years asa covariate. Finally, odds ratios for delayed care were calculated by adjusting for factors associatedwith delayed care in univariate analyses. All analyses were carried out using SPSS statistical package
for Windows version 13.0.
3. Results
3.1. Socioeconomic Status and Health
For the association between income and health status/behaviors, the mean percent of the top fiveillnesses under medical treatment reported by respondents were hypertension (38.7%), visual
impairment (16.8%), arthritis (16.3%), heart disease (13.2%), and diabetes (11.3%). Table 1 shows thatamong these, illnesses most frequently found in lower income individuals were hypertension (39.8%),
arthritis (19.2%), and visual impairment (17.9%). Overall, low income elderly subjects had more
illnesses requiring medical treatment than their higher income counterparts. As for self-assessed healthstatus, the elderly in the low income group were discernibly lower in health status than middle orhigher income groups. The higher percentage of elderly people with low income evidently represents
higher dependency in activities of daily living (ADLs) than middle and higher income elderly. We did
sub-analyses by gender as well (results are available upon request). Men had slightly more illnesses
such as cancer, heart disease, diabetes, or stroke, while women had more problems such as visual
impairment, ADL difficulty, and mental illnesses. No clear gender difference was observed regarding
the number of illnesses or conditions under treatment and self-assessed health.
Table 1. Association between health status and income (N = 15,302).

Self-assessed health status (fair/poor)

Income Tertile
Low Income
Middle(%)
Income (%)
34.6
26.2

Functional status (ADL dependence)

5.1

3.1

3.2

<0.001

Diagnosed illnesses under treatment

78.2

75.6

75.0

<0.010Heart disease

12.9

12.9

13.0

0.994

Stroke

2.7

2.2

1.8

<0.050Cancer

3.5

4.0

3.9

0.449

Hypertension

39.8

38.6

36.3

<0.010Obesity

4.9

3.8

3.2

<0.010Diabetes (Type 1＆2)

11.8

11.2

11.9

0.599

Health Status

High
Income (%)
22.1

P values<0.001

Int. J. Environ. Res. Public Health 2010, 7

1335
Table 1. Cont.

Gastrointestinal illness

9.2

7.4

6.9

<0.010Respiratory illness

3.6

3.7

3.2

0.439

Liver disease

2.9

2.8

2.5

0.503

Arthritis/neuralgia

19.2

13.9

13.9

<0.001

Osteoporosis

8.3

5.3

5.8

<0.001Visual impairment

17.9

15.2

15.3

<0.010Hearing impairment

9.6

6.3

5.5

<0.001

Urinary illness

11.5

8.3

7.3

<0.001

Sleep disorder

9.9

7.0

6.1

<0.001

Mental illness
Others

1.7
6.2

1.1
8.6

0.5
9.3

<0.001<0.001All figures in the table are percentages (not adjusted).
p < 0.001, p < 0.01, and p < 0.05 represent p values for statistically significant level of 95% for the
two-tailed test. N stands for the number of observations.

3.2. Socioeconomic Status, Health Care Seeking Behaviors, and Lifestyle
Table 2 displays health care seeking behaviors, which shows that more elderly subjects of lower
socioeconomic status never had health check-ups in the past. Although the percentage of those with aregular source of health care did not differ by socioeconomic status, the proportion of those having a
regular source of dental care is higher among higher income elderly. When asked if they ever stopped
or postponed necessary medical care in the past year (delayed care), more elderly subjects of low
socioeconomic status responded affirmatively. During the past year, about 10% (n = 1,536) of total
respondents reported that they did not receive the care they needed. Such tendency was the same both
among men and women (detailed results available upon request). More men had a regular source of
health/dental care compared to women (23.7% and 21.1% versus 17.4% and 16.9% among women,
respectively). As for lifestyle, fewer women smoked (2.3% versus 21.9% for men) or drank heavily(0% versus 0.9% for men). No marked differences by gender were observed regarding health check-up
or the experience of delayed care in the past year.
Table 2. Association between health care seeking behaviors, lifestyle, and income byage-adjusted % (N = 15,302).
Income tertile
Health care seeking behaviors
Regular source of health care (no)Regular source of dental care (no)Health check-up (never)Delayed care (yes)

Low Income
(%)
20.6
22.0
27.5
12.0

MiddleIncome (%)
22.2
17.2
20.7
9.1

High
Income (%)
20.1
16.4
17.4
8.3

P values
0.760
0.063
0.159
<0.050Int. J. Environ. Res. Public Health 2010, 7

1336
Table 2. Cont.

Health behaviors
Current smoking
Everyday drinking (3 Goa)≈540cc

12.4
0.8

11.8
0.4

11.6
0.4

0.524
0.335

All figures in the table are percentages adjusted for mean age using general linear model.
a: “Go” is a Japanese unit of measurement in which one Go is equivalent of 20g ethanol (pure alcohol).
p < 0.05 represents statistically significant level of 95% for the two-tailed test. N stands for the numberof observations.

3.3. Socioeconomic Status and Reasons for Delayed Health Care
Table 3 depicts reasons for the delay in seeking health care. The statistically significant mean
percent of reported reasons by all income levels were cost (24.4%), distance (13.5%), transportation(12.6%), busy (11.4%), and condition not serious enough (26.0%). When stratified by income, low
income elderly subjects were more likely to report issues about cost, distance, and transportation
problems, while higher income counterparts reported being busy and having a condition not serious
enough as a reason for delaying health care. Long waiting hours and dislike of doctors were notstatistically significant as reasons for delayed health care. The result of the high percentage (34.3%) of
delayed health care due to cost by the low income group demonstrates that low income elderly people
are more sensitive to the cost of health care, namely financial burden. The elderly with higher income
underestimate their own health problems, as shown by 32.1% for the middle income and 36.2% for thehigh income groups in variable “condition not serious enough”.
Table 3. Association between reasons for delayed health care and income (N = 1,536).

Reasons for delayed health careLong waiting hours
Cost
Distance
Don’t know where to go
Transportation problem
Dislike doctors
Busy
Condition not serious enough
OthersLow
Income
(%)
30.3
34.3
15.8
6.7
13.9
24.5
8.4
17.3
3.3

Income tertile
MiddleIncome
(%)
31.5
22.5
11.3
4.6
6.9
23.7
12.8
32.1
5.1

High
Income
(%)
27.6
13.8
9.2
3.8
7.2
23.4
13.1
36.2
6.2

P values
0.550<0.001<0.0500.170<0.0100.927
0.061<0.001
0.150

All figures in the table are percentages (not adjusted).
p < 0.001, p < 0.01, and p < 0.05 represent p values for statistically significant level of 95% for
the two-tailed test. N stands for the number of observations.

Int. J. Environ. Res. Public Health 2010, 71337

3.4. Factors Associated with Delayed Health Care by Income
Logistic regression analysis was conducted to examine the relationship between income levels anddelayed health care by adjusting for sex, age, marital status, illnesses, self-assessed health status,
smoking, drinking, and regular source of health/dental care, as shown in Table 4. All variables entered
here are suggested to be associated with health care seeking behaviors [5]. To test if education
confounded the association between income and delayed care, we further constructed model 2 byadding education. However, the association of income with delayed care did not change, indicatingthat income was associated with delayed care independent of educational background. Low income
elderly were 1.41 times more likely to experience delayed health care compared to their higher income
counterparts. This means that about 40% more of low income people stopped seeking care in the past
year compared to the highest income people. There were no significant differences by gender
regarding delayed care in both models.
Table 4. Odds ratios for delayed care (N = 15,302).
Model 1Model 2

Low Income

Middle Income

High Income

1.37 (1.16–1.61)
p < 0.001
1.41 (1.20–1.67)
p < 0.001

1.05 (0.89–1.23)
p = 0.937
1.07 (0.91–1.26)
p = 0.443

1.00--1.00---Model 1 was adjusted for sex, age, marital status, illnesses, self-assessed health status, smoking,drinking, and regular source of health/dental care.
Model 2 was further adjusted for education in addition to variables entered in the model 1.
P values are calculated with 95% confidence interval for logistic regression analyses.
High income is the reference category in logistic regression models.
N stands for the number of observations. The full results are available upon request.

4. Discussion and Implication
The purpose of this paper is to investigate whether difference in income level among the elderly
ages 65 years and older, is related to their delayed health care. By using the 3rd wave data of the Aichi
Gerontological Evaluation Study Project, we were able to illustrate specific barriers. The results
confirm that elderly subjects in the low income group had poorer health status compared to their higher
income counterparts as shown in Table 1. Despite unfavorable health status, low income elderly did
not have health check-ups in the past and were more likely to postpone or stop receiving the healthcare. Although diabetes is more prevalent among the low socioeconomic groups in developed highincome nations, we did not find significant differences among our population. One such reason isunder-diagnosis of the illness. Since responses about illnesses were elicited by self-report, people who
did not get medical care might not know that they had diabetes even they actually did. As for lifestylesuch as smoking or heavy drinking, no remarkable difference by income group was observed. One
reason might be survival effect. Unhealthy individuals might not live long enough to become older.
Another is that unhealthy elderly might already have stopped smoking or heavy drinking.

Int. J. Environ. Res. Public Health 2010, 71338

As for reasons for not getting the care, most significant ones among the low income elderly were
cost and the distance/transportation. The data of this study, collected from semi-rural areas where
medical facilities are sparsely distributed, indicates that 15.8% of low income elderly subjects reported
distance as a reason compared to only 9.2% of higher income counterparts and 13.9% of low income
elderly subjects also stated the issue as being transportation relative to 6.9% and 7.2% of middle andhigher income elderly. Distance and transportation are major concerns, especially in rural areas where
medical facilities are sparse. The elderly of those regions often travel hours to get to a hospital. Studies
in the UK and US demonstrated that accessibility to public health services is a vital determinant for thehealth of population [22,23]. These results are congruent with a study in Nigeria by Onwujekwe, whodemonstrated that geographical proximity of services is an important factor that affected the utilizationof health services [24]. This is often the case in rural areas both in developing and developed nations.
As Babazono et al. reported, after the increase in coinsurance from 20% to 30% in Japan there wasa decrease in outpatient visits among diabetic patients with no complications [12]. This is of great
concern, since studies indicate that increases in cost sharing reduced physician visits but increased
hospitalizations [12,13]. The agency for Health Care Research and Quality in the US states that lower
socioeconomic individuals are less likely to receive recommended diabetic services and more likely tobe hospitalized for diabetes or its complications [25]. Since hypertension and diabetes often have mild
symptoms or no symptoms at all, in the first stage of illness, people tend to stop seeking the care theyneed when out of pocket expenses increase. Delayed care might lead to severe situations andconsequences that require more medical treatment such as cardiovascular illnesses, functional
impairments, or even dialysis, unless they are treated while their symptoms are mild.
The results of this study confirm that access to health care is not assured equally to the elderly
despite a universal health care system in Japan. Under the pressure of curtailing rising health care cost,
the Ministry of Health, Labor and Welfare of Japan decided to reconstruct the current health caresystem and intend to raise co-insurance. However, this might pose additional barriers to care for theold. Among our sample, when stratified by age group, 35.8% of those aged 65−69 reported cost as
reasons for not getting the care compared to 20.1% of those over 70. This is important since they werein different payment scheme at the time of the survey. Those aged 65−69 paid 30% as co-insurance
while those over 70 paid only 10%. Such difference in co-insurance might pose higher financial
burden among the 65−69 old people. For the implementation of health care reform, evaluating theimpact of increases in co-insurance or premiums, especially on low income people, might
be necessary.
Finally, we need to touch upon some limitations. We used data on older people. This might lead toan underestimation of the association between income and delayed care. Since most of our samples
already live on pensions, the quality of health care they receive might be quite similar since they are
under the same insurance system. To truly assess the impact of socioeconomic status on health careseeking behaviors, we may need younger generations since we expect such inequalities in health mighteven greater among younger generations. In addition, dislike of doctors or condition not serious
enough also emerged as reasons for not getting health care, irrespective of their income level. Financial
burden might not be the sole reason for the delayed care. It is imperative to investigate possible
barriers to health care not only from behavioral but from societal perspective as well.

Int. J. Environ. Res. Public Health 2010, 71339

5. Conclusion
Even in Japan, with its universal health care system, low income elderly were more likely topostpone or stop seeking health care in the past year, indicating a health disparity acrosssocioeconomic status. Most reasons reported by the low income elderly were the burden of health carecosts and distance. As causes of differential health-care access, there is a lack of available services andeconomic barriers to care [5]. The WHO urged for action by stating that “National governments ensure
public sector leadership in health-care systems financing, focusing on tax-/insurance-based funding,ensuring universal coverage of health care regardless of ability to pay, and minimizing out of-pocket
health spending” [5]. Providing financially accessible services for everyone irrespective of theirincome as well as creating basic health care facilities in remote areas might be important since delayed
health care may lead to worse health consequences.
A change of regime occurred in Japan in August 2009, and the new government is facing challengesof reviewing the health care system for the elderly. Further study requires investigating theconsequences of delayed care by using follow-up data for better health care policies.
Acknowledgements
This study was supported by funding from the Ministry of Education, Culture, Sports, Science andTechnology of Japan and used data from the Aichi Gerontological Evaluation Study (AGES) which
was conducted by the Nihon Fukushi University Center for Well-being and Society as one of theirresearch projects. We also greatly acknowledge the research support provided by the Japan Society for
Promotion of Science (#19530490 and #21530585) and the Research Council of Rutgers University,
the State University of New Jersey, U.S.A. (#202361 and #202100). Any credits, analyses,interpretations, conclusions, and views expressed in this paper are those of the authors, and do notnecessarily reflect those of the institutions.
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