There are reasons why I, an American, have decided to live the rest of my life in Japan, and though one of them is the current state of political discourse in my native country, that factor entered into the decision late in the game. Certainly, the most pertinent economic advantage of living in Japan as opposed to living in the U.S. is health insurance. I really don’t see the point of the private insurance system in the States, which, besides being expensive, is arbitrary with regard to the kind of treatment that’s available depending on your plan. Japan’s isn’t necessarily cheap, but it is pegged to income, which makes it fair, and everything, including dental care and all major surgery, is covered. There’s just no comparison.

For some years now, Japan’s national health insurance system has become a serious burden on the government, the main reason being the rapidly aging population that demands more care. But another reason is the basic cost of care, which is increasing almost exponentially as new treatments are developed. The reason these increased costs are such a concern was covered in a September 7 Asahi Shimbun article, which considered whether Japan’s medical care system can be maintained at such a high standard into the future. Part of the reason, according to the journalist who wrote the piece, Makoto Hara, has to do with Japanese attitudes, which hold that every single life is precious and thus the best medical care must be available to everyone regardless of social station and income. Hara thinks this attitude is the reason why Japanese lifespans are the highest in the world. Some people may disagree with this assessment, but in practice it seems to be the fundamental philosophy behind the health care system. At the same time that Japanese people live longer than others, Japan’s national debt is also higher than other countries’, owing mainly to its medical insurance system. But there are other countries in the world with universal health care and they don’t have the same level of debt. What’s the difference?

Hara says that it’s the way Japanese doctors are encouraged to utilize the most cutting edge treatments as soon as they are available. At first glance, that statement seems self-justifying. After all, one of the sticking points of America’s health insurance situation is that, depending on your plan, many treatments, especially new ones, may not be available to you, and such limitations could have a serious effect on your level of care. In Japan, there are no such limitations as long as the treatment—be it a drug or a procedure—has been approved by the health ministry. And as Hara reports, there’s a kind of taboo against criticizing the use of such treatments, since anyone should be able to access them. But an increasing number of doctors, especially those who treat cancer, are wondering if the pressure to use state-of-the-art treatments isn’t bankrupting the system at this pace. Many of these doctors believe that not enough research has gone into determining how effective these new treatments are compared to older treatments, which often cost a fraction of what new treatments cost. 

A group of 30 doctors broke this taboo by carrying out a survey of 15,000 cancer patients being treated at 300 medical institutions over a one-year period. What they found was that the “medical structure” led to a “cost bubble” wherein expensive drugs were being used even in cases where they weren’t necessary. In the past ten years, they discovered, the cost of treating cancer patients has increased by between 10 and 50 times, depending on the type of cancer. In terms of extending life spans, they deemed that effectiveness of treatment was the same for lower cost drugs than they were for the new expensive drugs, but in more than half the cases doctors chose to use the more expensive drugs simply because they could. 

The reason they chose the more expensive drugs isn’t difficult to figure out. Something that’s new, especially in a constantly developing field like medicine, is always thought to be better than something that came before it. A more significant point is that hospitals and clinics can charge the insurance system more for expensive drugs and thus increase their profits. Patients, of course, are not adversely affected because they pay only 30 percent out of pocket for treatment, and only up to a certain ceiling, at which point the government steps in and reimburses the patient for any costs incurred above that ceiling, which is low. In addition, many people are now taking out supplemental private insurance, which gives doctors more of an incentive to use the more expensive treatments. And because hospitals are used by pharmaceutical companies to carry out clinical trials of new drugs—which benefit the hospitals financially—medical institutions never question whether drug companies may be gouging the system, so there is no general discussion within the medical profession about how to reduce costs for treatments. The only solutions are to increase premiums and spend more tax money on medical care. 

One doctor interviewed for the story moonlights as a writer who takes on what he calls “corruption” in the medical field. He says that other countries, including the U.S., have developed systems that check the overuse of expensive treatments by studying relative efficacies, and essentially advise against the use of expensive medications when it is deemed a cheaper form is just as effective. He wonders why Japan doesn’t have a similar system and chalks it up to politics, the power of physician associations, and even a sense of ethics that deems it improper to question what doctors do. But he maintains that the problem is getting worse and must be addressed, especially as more medical institutions go out of business due to insolvency or lack of qualified personnel. 

Another Asahi report chronicled these increases. According to the health ministry, between 2021 and 2023 (¥47 trillion paid to doctors and medical institutions), the amount of money spent on health care increased by almost 3 percent each year, which may have been a reaction to the pandemic, during which hospital visits dropped precipitously. In any case, the rate of increase itself seems to be going up. Last June, NHK reported on the cancer survey cited above. One part of the survey looked at 700 men with stage 4 prostate cancer being treated at 38 hospitals. Use of the newest anti-cancer drug, which came out in 2015, cost between ¥272,000 and ¥424,000 a month, while the previously used anti-cancer drug cost only ¥16,000 a month. Of the patients surveyed, 14 percent used the old drug and 56 percent the new one. According to NHK research, in the U.S. and Europe, between 30 and 40 percent of stage 4 prostate cancer patients use the new drug, though NHK doesn’t elaborate on the difference. The doctors group who did the survey will release a report covering 17 types of cancer by the end of the year.

One of the doctors who carried out the prostate cancer survey told NHK that, naturally, patients should benefit from progress in treatments, but in Japan doctors never seriously consider the cost of the treatments they use because they don’t have to. As already mentioned, when the cost of treatment in Japan reaches a certain level, depending on the patient’s income, the Kogaku Iryo Seido (High Medical Cost System) kicks in, and government subsidies are used to cover the rest of the treatment. In practice, this means that the patient covers the 30% copay in full and is then refunded the excess above the ceiling by the government several months later. For patients with more limited income who require special care, a certification can be issued that allows them to factor in the refund at the time of payment. So for a person less than 69 years old whose income is “average” (¥3.7 to ¥7.7 million), if the bill comes to more than ¥1 million for a given month, the patient in the end only pays ¥87,430, regardless of how much above ¥1 million the bill amounts to. Theoretically, that means a person can get a heart transplant for that amount of money. 

There are other issues with the insurance system that Asahi and NHK didn’t mention, especially with regard to cancer treatment. One has to do with diagnosis. Since second opinions are not yet a common practice in Japan, doctors and medical institutions have an incentive to suggest the most cost-intensive care, meaning intrusive surgery and a regimen of medication that may not be entirely necessary. Prostate cancer, in fact, is fairly easy to over-diagnose, since it might take many years for a patient who tests positive to actually develop a tumor. Of course, the standard protocol in cancer treatment is to catch the illness early and nip it in the bud, but if any level of treatment is available, sometimes the doctor or hospital will go the most expensive route because it is the most profitable. This partly explains, for instance, why radical mastectomies in Japan were standard operating procedure following breast cancer detection long after less invasive and destructive treatments were developed in other countries. It’s also why Japan has one of the highest rates of dialysis in the world: The bar for kidney dysfunction wherein dialysis is recommended is set lower. 

It’s better being safe than sorry, so these concerns will not be central to most people’s thinking if and when they are faced with a dangerous illness or medical condition. They will trust their doctor to do what’s best, but that’s why some Japanese doctors are calling for a more robust system of choosing treatment options. Mostly it’s about the money, but it’s also about quality of life, since cancer treatment can sometimes be as harmful as the disease itself. There’s no reason why the system can’t be more discerning as long as the people who use it are honest.