Japan’s universal health insurance system, widely regarded as a model for supporting one of the world’s longest-lived populations, is under increasing pressure. The system, which ensures that medical care remains affordable for all residents, is facing significant challenges due to Japan’s shrinking workforce and rapidly aging population. Now, as the country heads toward key elections, including the upcoming House of Councillors vote, the future of the health insurance system has become embroiled in political debate.
Experts caution that turning the health insurance system into a political issue could jeopardize its stability and undermine public trust in the government. They argue that any reforms should be based on careful, long-term planning rather than quick fixes driven by election-year pressures.
“How Japan sustains its renowned health care system in the face of an aging society is an issue of global significance,” said Yuri Ito, a professor at Osaka Medical and Pharmaceutical University’s Department of Medical Statistics.
Japan’s universal health care system, introduced in 1961, covers nearly all citizens. Under this system, people pay 30 percent of their medical costs at clinics and hospitals, while contributing to monthly insurance premiums. To safeguard against particularly high medical expenses, a government program sets an upper limit on out-of-pocket costs, with the high-cost medical expense benefit system—a pioneering policy introduced in 1973—ensuring that health care remains equitable.
Despite its successes, the system has faced growing criticism, particularly from younger people who contribute to the system but are less likely to require medical care than the elderly. This demographic has expressed concern about the financial burden they face.
In response to these concerns, Prime Minister Shigeru Ishiba’s government has pledged to secure 3.6 trillion yen ($25.20 billion) for child-rearing measures, with approximately 1 trillion yen expected to come from medical system savings. Despite not holding a majority in the House of Representatives, Ishiba has pushed for changes to the high-cost medical expense benefit system, with plans to gradually increase the financial burden on the 12.5 million patients who incur high medical costs, starting in August 2025.
The Ministry of Health, Labor, and Welfare initially proposed raising the monthly out-of-pocket cap for individuals with annual incomes between 3.7 million and 7.7 million yen by approximately 59,000 yen, bringing the maximum cap to about 139,000 yen. The proposal, however, faced strong backlash. Opposition lawmakers accused the government of rushing the changes without proper consultation, while cancer patients and other vulnerable groups voiced concerns that higher costs would force them to forgo treatment or make difficult financial sacrifices.
In response to the criticism, including from within his own Liberal Democratic Party (LDP), Ishiba froze the proposed hikes following discussions with patient advocates in March. The government has since postponed any new decisions until after the House of Councillors election.
Ishiba’s ruling coalition, which suffered significant losses in the House of Representatives in October’s general election, has been forced to make concessions to opposition parties. These minor parties, seeking to gain support from working-age voters, have used their leverage to push for policy changes that favor their constituencies.
The opposition Democratic Party for the People has been accused of adopting a populist stance to win votes, prompting Ishiba to avoid discussing the unpopular medical cost issue in the run-up to the national elections. Tadashi Mori, a professor of political science at Aichi Gakuin University, explained that Ishiba likely perceived a full debate on increasing the financial burden on sick individuals as politically disadvantageous ahead of the election.
Mori also noted that Ishiba’s failure to stand by his proposed reforms has inadvertently damaged his political standing, with critics suggesting that the prime minister is prioritizing elderly voters, who tend to form the LDP’s support base, over other segments of the population.
Economist Michihito Ando, a professor at Rikkyo University, emphasized the value of maintaining a cap on medical spending, arguing that the current limits are already quite high. “For people living longer thanks to improved healthcare, a limit on medical spending is crucial,” Ando said. He called on the government to abandon plans to raise the caps, advocating instead for long-term reforms that focus on strengthening cost controls within the healthcare system.
As Japan faces an aging population and strained resources, the future of its celebrated health insurance system hinges on finding a balanced approach that preserves its accessibility and fairness while addressing the needs of a changing society.
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