Effectiveness of Universal Health Insurance in Asian Countries

20-22 March 2018, Yogyakarta, Indonesia

Session 4: Handling the strain of the aging population
on universal health insurance

Reforms corresponding to the

population ageing
The case of Japan

Reiko Hayashi, Ph.D.

hayashi-reiko@ipss.go.jp
National Institute of Population and Social Security Research (IPSS)
Tokyo, Japan
The views expressed in this presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank Institute (ADBI), the Asian Development Bank
(ADB), its Board of Directors, or the governments they represent. ADBI does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequences of their use. 1
Terminology used may not necessarily be consistent with ADB official terms.
 Population by broad age group
and aging rate, 1920-2065 (in million)
2010 2015
140 128.057 45%
127.095
40%
120
24 23 22 21 19
29 26 18 35%
93 32 17
35 16
100 36 16 88
0-19 years old 35 15 30%
in million

14

Proportion 65+
34 13
80 36 12
25%
37
56 38
75 71 68 66 64 60 55
38 78 52 49 20%
60 36 79 46 44
34 79 42
76
30 74 20-64 years old 15%
26 71
40 68
63
56 10%
46 51
41
20 35 39
27 31
29 34 36 37 37 38 39 39 38 37 35 34 5%
18 22 26
11 12 15 65 years and older
0 3 3 3 4 4 5 5 6 7 9 0%
1920

1930

1940
1947
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
Year Projection
Source : 1920 to 2015 by Population Census, Statistics Bureau, Ministry of Internal Affairs and Communications. 2020 to 2065 by Population2
Projections for Japan, medium-fertility and medium-mortality assumption (2017) National Institute of Population and Social Security Research
 Proportion 65+ stable around 5%
140 45%

40%
120
24 23 22 21 19
29 26 18 35%
32 17
35 16
100 36 16
35 15 30%
in million

14

Proportion 65+
34 13
80 36 12
25%
37
38
75 71 68 66 64 60 55
38 78 52 49 20%
60 36 79 46 44
34 79 42
76
30 74 15%
26 71
40 68
63
56 10%
46 51
41
20 35 39
27 31
29 34 36 37 37 38 39 39 38 37 35 34 5%
18 22 26
11 12 15
0 3 3 3 4 4 5 5 6 7 9 0%
1920

1930

1940
1947
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
Year
Source : 1920 to 2015 by Population Census, Statistics Bureau, Ministry of Internal Affairs and Communications. 2020 to 2065 by Population3
Projections for Japan, medium-fertility and medium-mortality assumption (2017) National Institute of Population and Social Security Research
 Protection of the vulnerable elderly
7,000 • Relief Regulations (1872)
- For the elderly who were very poor and single
Number of elderly
Number of elderly relieved (person)

6,000 received the relief aged 70 years or over who was in the same time
stipulated by the very sick or frail.
5,000 Relief Regulations - They were entitled to receive the rice of 1 koku
8 to, equivalent of 325 litter yearly.
4,000 - Family registry (started in 1872) played a role.
• Relief Law (1929)
3,000 - Aid to the frail elderly aged 65 and over who
are unable to live normally due to poverty.
2,000 - Elderly homes were institutionalized which
were established by the municipality
1,000 governments or social work organizations upon
the approval of the prefectural governor.
0 • Public Assistance Act (1946, 1950)
1880 1890 1900 1910 1920 1930 1940
Year
-Cash allowance for the elderly in poverty as well
as free medical care
Source : Cabinet Bureau of Statistics “Statistical Yearbook of the
Empire of Japan”, reproduced in “Historical statistics of Japan” -Elderly facilities started to receive central
(1988) Statistics Bureau and Japan Statistical Association government subsidy
4
 Proportion 65+ reaching 7%
and demographic dividend
140 45%

40%
120
24 23 22 21 19
29 26 18 35%
32 17
35 16
100 36 16
35 15 30%
in million

14

Proportion 65+
34 13
80 36 12
25%
37
38
75 71 68 66 64 60 55
38 78 52 49 20%
60 36 79 46 44
34 79 42
76
30 74 15%
26 71
40 68
63
56 10%
46 51
41
20 35 39
27 31
29 34 36 37 37 38 39 39 38 37 35 34 5%
18 22 26
11 12 15
0 3 3 3 4 4 5 5 6 7 9 0%
1920

1930

1940
1947
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
Year
Source : 1920 to 2015 by Population Census, Statistics Bureau, Ministry of Internal Affairs and Communications. 2020 to 2065 by Population5
Projections for Japan, medium-fertility and medium-mortality assumption (2017) National Institute of Population and Social Security Research
 Health care insurance
Universal Health Coverage in 1961
Medical Care
System for Elderly
in the Latter Stage
100 of Life
Mutual Aid Association
(Civil servant) Seamens'
Insurance

80

National Health Insurance Mutual Aid

Association
(Farmer, informal sector)
Coverage %

60
National Health
Insurance

Health Insurance
40 Health Insurance
Managed by Government for Day Labourers
(Small company)

Health Insurance -
20 Managed by
Health Insurance Government

Managed by Association
(Large company) Health Insurance -
Managed by
0 Association
1926
1928
1930
1932
1934
1936
1938
1940
1942
1944
1946
1948
1950
1952
1954
1956
1958
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
6
Sources : Ministry of Health and Welfare (1976) 、Historical Statistics of Japan (Statistics Bureau), Social Security Statistics of Japan (IPSS), Takagi (1994)
 Health insurance system

Sources : Ikegami et al. (2011) “Japanese universal health coverage: evolution, achievements, and challenges”, Lancet 2011; 378: 1106–15
7
Japan: Universal Health Care at 50 Years http://www.thelancet.com/series/japan
 The Act on Social Welfare for the Elderly
(1963)
• The Universal Coverage on health and pension
achieved in 1961 stimulated the public opinion for the
betterment of the welfare of elderly both in social
welfare and health perspectives
• The first of its kind in the world
• It came much later than the Child Welfare Act of 1947
or Act for the Welfare of Persons with Physical
Disabilities of 1949
• Stipulated the measures such as elderly health
checkup, utilization of welfare facility, dispatch of
home helper
• Creation of Intensive Care Home for the Elderly
(Tokuyou) > The focus of elderly care shifted from
poverty to disability 8
 Co-payment according to the type
of health insurance
and category of insured in Japan

Health insurance Category 1961 1964 1968 1973 1984 1997 2003

Employer- Employee 0% 0% 0% 0% 10% 20% 30%

provided plans
(for employee in Dependent 50% 50% 50% 30% 30% 30% 30%
private
companies, civil
servants, etc.)
CHI Houshold 50% 30% 30% 30% 30% 30% 30%
(for farmers, self- head
employed, Other 50% 50% 30% 30% 30% 30% 30%
unemployed, member
etc.)

9
 400
Tuberculosis

350
Cause specific Malignant neoplasms

death rate Diabetes mellitus

300 Hypertensive diseases

Heart diseases
250
Cerebrovascular
Deaths per 100,000 population

diseases
Pneumonia
200
Chronic bronchitis and
emphysema
150 Asthma

Gastric ulcer and

100 duodenal ulcer
Diseases of liver

Renal failure
50
Senility

0 Accidents
1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020
Year Suicide

10
Source : Vital Statistics, Ministry of Health, Labour and Welfare, Japan
Free medical care for the elderly 70+ since 1973
25

Age specific
20
medical access
ratio Age 0
1-4
15 5-14
15-24
25-34
%
10 35-44
45-54
55-64

5 65-74
75+

0
1940 1950 1960 1970 1980 1990 2000 2010 2020
Year
Note : Number of patient is the sum of out-patient and in-patient during one day of the survey
Source : Patient Survey, Ministry of Health, Labour and Welfare 11
 The location of death in in Japan
(1951-2013)
90%

80%

70%

60%

50%
Medicalization
40%
of Death
30%

20%

10%

0%
1950 1960 1970 1980 1990 2000 2010
Hospital Facility Home Other
12
Source : Vital statistics, Ministry of Health, Labour and Welfare
 Proportion 65+ reaching 14%
increasing fiscal burden which paved way to the restructuring
140 45%

40%
120
24 23 22 21 19
29 26 18 35%
32 17
35 16
100 36 16
35 15 30%
in million

14

Proportion 65+
34 13
80 36 12
25%
37
38
75 71 68 66 64 60 55
38 78 52 49 20%
60 36 79 46 44
34 79 42
76
30 74 15%
26 71
40 68
63
56 10%
46 51
41
20 35 39
27 31
29 34 36 37 37 38 39 39 38 37 35 34 5%
18 22 26
11 12 15
0 3 3 3 4 4 5 5 6 7 9 0%
1920

1930

1940
1947
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
Year
13
Source : 1920 to 2015 by Population Census, Statistics Bureau, Ministry of Internal Affairs and Communications. 2020 to 2065 by Population
Projections for Japan, medium-fertility and medium-mortality assumption (2017) National Institute of Population and Social Security Research
Health and Medical Services Act for the Aged in 1983
Financing of elderly medical expenses
before and after the Elderly Health System
Owed by Insurers Government
82% 18%

National Govt.
Employer-based Health Insurance

Local Govt.
Government
18%
Before
National Health Insurance

Owed by Insurers Government

70% 30%
Employer-based

National Govt.

Local Govt.
Health Insurance Employer-based
After Health Insurance
National Health
Insurance National Health
Insurance

By the number of insured Adjusted by the national

elderly average rate of elderly
50% 50%

Source : Health and Welfare Statistics Association (1985) “Journal of Health and Welfare Statistics” 14
 Restructuring medical and welfare expenditure
to medical and long-term care expenditure
900

Medical, welfare and long-

3
800

3
3
term care expenditure per

2
Thousand yen per person aged 65 and over

2
6
3

2
2
8
8
person aged 65 and over

8
700

263
256
145 8

249
238
178

227
221
224

224
219
208
195
65
600

67
64
61
60
52
48
46
42
39
36
500

33
32
34
29
29

400
28
28
26
24

300

572
22

558
558
558

546
544
544
542
541
541

537
532

526
525

520
518
518

517
515

513
513
510
21

500
489
471
465
444
19

422
394

200
374
360
335
310
283
252
219

100

0
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Medical expenditure Long-term care expenditure Welfare expenditure
Year
Note : To obtain the identical time series from 1977, the medical care expenditure is that of medical treatment (excluding dental treatment, food and living care during
admission, pharmacy dispensing medical expenditure, judo therapist and acupuncturist treatment) which ranges from 90.0% in 1977 to 72.1% in 2011 of total medical care
expenditure. Welfare expenditure after the 2000 is mostly included in the long-term care expenditure but there is no data for the welfare expenditure not included in the
long-term care expenditure. Long-term care expenditure is that of the primary insured (aged 65 years or older).
Sources : Medical expenditure by “Estimates of National Medical Care Expenditure” and long-term care expenditure by “Report on Long-term Care Insurance Services” 15 of
Ministry of Health, Labour and Welfare. Welfare expenditure by “Financial Statistics of Social Security” of National Institute of Population and Social Security Research.
 Proportion 65+ reaching 21% and entering
population decline phase
140 45%

40%
120
24 23 22 21 19
29 26 18 35%
32 17
35 16
100 36 16
35 15 30%
in million

14

Proportion 65+
34 13
80 36 12
25%
37
38
75 71 68 66 64 60 55
38 78 52 49 20%
60 36 79 46 44
34 79 42
76
30 74 15%
26 71
40 68
63
56 10%
46 51
41
20 35 39
27 31
29 34 36 37 37 38 39 39 38 37 35 34 5%
18 22 26
11 12 15
0 3 3 3 4 4 5 5 6 7 9 0%
1920

1930

1940
1947
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
Year
16
Source : 1920 to 2015 by Population Census, Statistics Bureau, Ministry of Internal Affairs and Communications. 2020 to 2065 by Population
Projections for Japan, medium-fertility and medium-mortality assumption (2017) National Institute of Population and Social Security Research
Long-Term Care Insurance started in 2000
7,000
6331
6215
6077
Care5
6,000 5859 601
5643 602
604
5330 605
5076 612 768 Care4
747
5,000 4870 609 730
4690 711
4548 593
4348 4408 564 696 Care3
813 836
4108 515 670 793
500
3874 465 489 641 769
4,000 630 747
465 590
Care2
In 1,000

3484 579 724

455 525 547 1,106
497 713
700 1,062 1,083
3029 414 479 738 1,029
3,000 561 652 711 993
2582 381 424 527 952 Care1
492 901
394 431 651 823 854
2180 341 614 756 806 1,176 1,224 1,263
595 1,115
2,000 290 365 394 1,052 Transitional
641 970
339 358 852 910
571 769 788
317 1,387 876
490 1,332 839 858 867 Support2
1,252 1 771 806
1,000 394 1,070 40 669 712
891 629 662 654
522
551 709
655
601 674
527 552 575 604 662 692
773 825 874 888 890 Support1
291 320 398 505
45
0 59
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Source : Monthly Report on the Status of Long-term Care Insurance, Ministry of Health, Labour and Welfare
Note : From 2000 to 2005, Support level had only one level. Number of person is that of April each year. 17
Long-term care insurance system in Japan
Premium Subsidy
Source of financing

Co-
Primary Secondary payment
insured insured National Prefectural Municipal
Aged 65+ Aged 40-64

Insurer and Operator

Municipalities (Shi-Ku-Cho-Son)

Care-needs assessment and Care-Plan elaboration by Care-

manager
Operation

Community
Nursing -based
Community
In-home Facility care nursing
-based care
services services prevention care
services
services prevention
services
18
 Integrated Community Care system
Healthcare Long-term care

Commuting to medical
facilities/care facilities

Home-visit care
Own home/elderly housing • Nursing care
with long-term care
Integrated community
care support center/ Housing
care manager

Provides consultation
and coordinating
services
Old people’s club, residents’ association, long-term care
prevention, living support, etc.
Living support Prevention
19
 Cost control by setting medical fee through
Central Social Insurance Medical Council
Annual Change of Medical Expenditures Annual Change of Medical Expenditures Per Capita
7 by Age Groups (%) 7 by Age Groups (%)
6 6
5 5
4 4
3 3
2 2
1 1 0.19
0.19 0.00 0.10
0 0
0.00 0.10
-1 -1
-1.00 -0.82 -1.00 -0.82 -0.84
20% of out of pocket 20% of out of pocket
-2 payment introduced -2 payment introduced
for the elderly 70-74 for the elderly 70-74
-3 -3
-3.16 -3.16
-4 -4
2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016
2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

medical fee
改定率(%) Elderly
高齢者 Non Elderly
非高齢者 medical fee
改定率(%) Elderly
高齢者 Non Elderly
非高齢者
change(%) change(%)
Note : Elderly : over 70 years old from 2004 to 2011, over 75 years old after 2012. 2016 figures are for April to July. Calculated using MEDIAS
Source : Hisao Endo “A Current Situation and Challenges of Health Care Reform in Japan as a Super-Ageing
Society ” Presentation made at “IPSS and KIHASA Second Annual Joint Seminar- Population and social security
20
through life-course -” on 23rd Feb.2018
Compact health system along with population decline
Regional Medical Plan and setting the target to reduce the number of hospital bed
2.0

1.8 Clinic beds

1.6

1.4 Psychiatric beds

Number of beds in million

1.2

1.0

0.8 General beds

0.6

0.4

0.2
Long-term care beds
0.0
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Hospital: Long-term care beds Hospital: General beds Hospital: Transitional
Hospital: Psychiatric beds Hospital: Infectious disease beds Hospital: Tuberculosis beds
Hospital: Hansen's disease beds Clinic beds 21
Source : Survey of Medical Institutions, Ministry of Health, Labour and Welfare
 The Third Demographic Dividend?
Care burden or promotor of new industry?
6

Increasing number of
5 health, social welfare and
Number of employed in million

long-term care workforce 1.6

4
1.3
0.7
0.5
3 0.4 0.3 0.3 0.3
0.1 0.2 0.3
0.2
0.2
2 0.2
0.1
2.6 2.6 2.8
2.2 2.4
1 1.8
1.6

0
1985 1990 1995 2000 2005 2010 2015
Health care specialist Health care worker
Other social welfare specialist Social welfare specialized personnel
Long-term care worker Home helper
Other family life support service worker Long-term care personnel
Other household service worker
22
Source : Population census, Statistics Bureau