Trump’s Assault On Health Care, Seen From a Country That Does Health Care BetterJapan is a showcase for universal health care, and what we’re losing in GOP attacks on the Affordable Care Act.
Tokyo, Japan Yes, an accident of timing meant that I spent several days this past month traveling in Japan, learning about their health care system right as lawmakers were voting on what to do with ours. But the setting and the conversations turned out to be an ideal way to get some perspective on what has been unfolding in Washington not just this past week but this past year—and why the ongoing debate over key pieces of the Affordable Care Act is even more important and revealing than the headlines convey. Japan’s health care system guarantees comprehensive insurance for everyone, which means people don’t routinely ration their own care or go into financial distress because of medical bills. And changing that very basic arrangement is simply not part of the Japanese political conversation, Ikegami told me. “There are no politicians, even among the ultraconservatives, who call for doing away with universal health care,” he said, seeming a little bewildered by the possibility when I raised it to him. It wasn’t the first time I’ve heard things like that. Universal health care exists in just about every other economically advanced nation, and over the years I’ve gotten the chance to study several of these arrangements up close.¹ They differ in their particulars, but not in their basic functions or in the feelings they generate among their citizens. Everybody with financial resources pays into these systems, generally without objection, with the expectation that coverage will be there for them when they need it. And although political parties argue over how to fund, manage, and deliver the guarantee of health care, they do not argue over whether to provide it. That is decidedly not the case in the United States, where we have spent the better part of a century arguing whether universal health care is even worth trying. The Affordable Care Act was a big step in that direction—the biggest since the creation of Medicare and Medicaid back in the 1960s. But this year Donald Trump and the Republicans have pushed back hard, first by cutting a trillion dollars out of Medicaid this past summer and now by refusing—at least for the moment—to extend those Obamacare subsidies. Something like 14 million people stand to become uninsured as a result of these changes, with many more of the remaining insured facing higher prices. It’s virtually certain many will struggle with medical bills, suffering financial or physical hardship or both. And if Trump or the Republicans are losing sleep over this possibility, they haven’t shown it. Many—including Trump himself—have called to roll back government insurance programs even further. The enthusiasts for this position will talk about the virtues of “empowering consumers” or “unleashing markets,” or of making shopping for insurance more like Costco. But implicit in their view is an argument that’s come up anytime a big expansion like the Affordable Care Act has been up for debate: that government-managed, universal health care systems are a disaster, and that creating that kind of “socialism” in the United States would destroy all that is good about ours. If they came to Japan like I did, they’d see how wrongheaded that argument is. Japanese health care has its pluses and minuses, as all systems do. But it performs quite well by any reasonable standard, and has some features I suspect most Americans wish they had. Stick with me as I explain why. . . . LET’S START BY GOING BACK IN TIME, to the early twentieth century. It was the era when most countries were first grappling with the cost of health care following life-saving but expensive scientific breakthroughs and the professionalization of medicine. In Japan, it was also a moment when the national government was trying to supercharge industrialization. The result was the Health Insurance Act of 1922, which paid for the health care of welders in the Yokohama shipyards, weavers in Osaka’s textile mills, and the rest of Japan’s industrial workforce. The government expanded coverage to most of the rest of the workforce and dependents in the 1930s, and then to the rest of the population in the 1950s shortly after the end of America’s postwar occupation. That’s when it became truly “universal.” Each step in that expansion took a different form. The initial provision for factory workers relied on companies to cover their employees through plans they would manage, while the subsequent expansions involved creating new government programs. That’s why today the majority of Japanese get insurance through private plans that employers still operate on their own, albeit under tight national rules, with the rest getting coverage through public plans that municipal governments manage for their residents. This is frequently the way health care systems develop—in stages, and by building upon whatever pieces are already in place. It’s also why universal coverage takes more forms than commonly understood or discussed in American politics. There are countries like Canada and Sweden where everybody gets insurance through the same government plans—what we all call “single-payer” programs. There are countries like the Netherlands and Switzerland where everybody gets coverage through private carriers. And then there are countries like Japan, whose system is more of a mishmash. But what matters most is what these systems have in common: the basic guarantee to all citizens not just of insurance, but of comprehensive, relatively generous insurance. That’s certainly true in Japan, where the insurance covers everything from routine care to surgery, and prescription drugs to rehabilitation. The system also caps what any individual has to pay out of their own pocket in a given month or year. The elderly, people with low incomes, and those with rare medical conditions pay even less. That’s not the same as making health care free. Enrollment is mandatory and includes premiums that vary based on income. And even with the cap on out-of-pocket expenses, Ikegami told me, people with expensive-to-treat conditions like cancer can struggle financially if they make a little too much money to qualify for low-income assistance. But “there’s no comparison to the U.S.” said Ikegami, who did some of his post-graduate training in Philadelphia before returning to practice in Tokyo. “The U.S. is a total outlier in how much people suffer.” UNIVERSAL HEALTH SYSTEMS have another common element, one that tends to get less attention in the media even though it’s essential to their functioning: The national governments manage spending closely, typically by setting some kind of overall annual budget and then regulating payments—not just to pharmaceutical companies for their drugs, but also to doctors, hospitals, and pretty much every other provider of medical services or goods. It’s how things work in Japan, and you can see the effects clearly by looking at how much they spend on health care relative to us: about 11 percent of their gross domestic product in recent years, versus 16 to 17 percent for the United States. That’s a big deal! But regulation of spending is also the feature of universal health care that most easily animates American critics of universal systems—because, they note, it can lead to rationing of services. Usually their arguments include stories about long waits for specialty services in Canada, or denial of coverage for cancer drugs in the United Kingdom, both of which really do happen and really can cause hardship. But rationing is a reality of every country’s health care system, including ours, which is obvious to anybody who has ever battled insurance companies for approvals of treatments or consultations—or simply waited many months to see a specialist. And that’s on top of all the people delaying or skipping care in the United States because they have no insurance or can’t pay their out-of-pocket expenses. This brings us to the part of Japanese health care that most surprises visitors—or anybody who assumes that “universal coverage” translates to “waiting to get medical care.” Access to care in Japan is notoriously quick, at least by international standards. People who are sick or injured can just show up at clinics or hospitals, which typically can see most patients within an hour or two. The hospital scenes from the 2003 film Lost in Translation give a sense of what the experience still looks and feels like today.  And while the most popular, prestigious doctors may have long waiting lists, simply because they are in so much demand, specialty care in general doesn’t take long to get. “I would say the waiting lists are quite a bit shorter in Japan than in the U.S,” Hideki Hashimoto, a professor of public health at the University of Tokyo, told me. He would know. In addition to being an expert on health systems, Hashimoto is also a cardiologist who spent several years at Harvard, where he watched how they do things at that university’s world-famous teaching hospitals. Hashimoto said that he has enormous respect for the work they do in Cambridge and elsewhere in the United States, especially when it comes to treatment of rare conditions and highly specialized procedures that few places offer. But overall, he says, “the quality of care is somewhat similar between the U.S and Japan.” And in those instances when U.S. institutions truly have no peers abroad, he says, that’s at least partly a function of the United States supporting university-level medical research so generously through the National Institutes of Health—yes, the same universities and same NIH that have been dealing with huge cuts from the Trump administration. Hashimoto’s judgment is a subjective one, obviously. But one way to measure the quality of high-end care is to consider the availability of health care resources. And if there’s one thing the Japanese system has, it is resources, as a recent analysis by the American researcher Jared Maeda noted:
Just to be clear, these potential strengths of Japanese health care—the plentiful supply of high-tech gear, the unfettered access to physicians—can also be weaknesses. Japanese officials worry a lot about over-utilization—that is, people getting too much care—because of its potential to run up higher costs or put extra strains on doctors and hospitals. They also worry that too few people have primary care doctors coordinating treatment for complex and chronic conditions. But these are problems in the United States, too. And the baseline in Japan is a quality of care that looks awfully good by international standards. You can see it in the calculations of “treatable” deaths, which researchers use to measure how well a country’s health care system helps people dealing with injuries and sickness. In 2018, the latest year for which there is comparable data, the United States had 94 treatable deaths for every 100,000 people. Japan had just 51. These sorts of calculations are hardly perfect, but they are consistent with Japan’s reputation as the kind of system that does right by its patients.² AS I SAT IN THAT CAFÉ IN TOKYO, across the globe, members of Congress were engaging in a series of debates over whether or not to extend Affordable Care Act subsidies, for how long and with what tinkers. The end result was . . . nothing. No deal was reached between the two parties. With both houses adjourning for the year, that means those extended subsidies will now lapse on December 31, with only faint hope of some kind of retroactive fix in the future. Health care politics in Japan can be divisive as well, with ongoing fights over whether to increase some prescription copays or finance the training of more physicians. But those debates are nothing like ours, in which insurance for so many millions is at stake as Republicans go after Medicaid and Obamacare. How could these two advanced countries be engaged in such wildly different conversations? Part of the answer lies in culture and demographics, including the fact that Japan is a lot less diverse than the United States. Researchers since the early 1990s have talked about the importance of “welfare chauvinism”—the idea that, crudely speaking, voters in democracy are more likely to support government programs when they perceive the beneficiaries will be people who look like they do. Trump and the Republicans have tried to appeal to this thinking repeatedly this year, by arguing that their cuts to Medicaid and the ACA were merely efforts to cut off support for non-citizens. Another likely factor is the sheer difficulty of dislodging a system that has existed for so long. The United States didn’t embrace universal coverage after World War II like Japan did, more or less entrenching the system we have today. Any serious attempt at altering it is bound to anger industry groups who make money off the way things are, and to spook Americans who—however unhappy with the general state of health care—are going to be wary of giving up what they have. The Affordable Care Act was a nod to these and other political realities—an attempt to expand coverage and impose some cost control where possible in the hopes of moving gradually toward a universal coverage system. Its architects recognized that they could only take steps that didn’t raise the spectre of large-scale disruption that had killed previous, more ambitious reform efforts. Even then, they had to compromise on their vision, which is why—after the law’s enactment—they sought to make the program more generous, eventually getting their chance with those enhanced subsidies that became law in 2021. Usually, when an expansion of health care coverage makes its way into law, voters get accustomed to the additional benefits and lawmakers recoil at the prospect of taking them away. But that has not been the case this year. Those subsidies are now set to expire. And even if Republicans come around to endorsing an extension, it would almost surely be a partial one—which, combined with the summer’s Medicaid cuts, would mean far fewer people insured than when Trump took office. The result will be more hardship—the kind rarely seen in places like Japan where universal health care is a reality and not a suddenly more distant dream. 1 Among the countries I’ve visited are Canada, France, the Netherlands, and the United Kingdom. Before going to Japan, my most recent visit was to Taiwan, which also offers some fascinating lessons for the United States. You can read about that here. 2 Even the best researchers have a hard time disaggregating the influence of the health care system itself and factors like the underlying health of the population. Case in point: Obesity rates in Japan are about one-tenth of what they are in the United States. You’re a free subscriber to The Bulwark—the largest pro-democracy news and analysis bundle on Substack. For unfettered access to all our newsletters and to access ad-free and member-only shows, become a paying subscriber.We’re going to send you a lot of content—newsletters and alerts for shows so you can read and watch on your schedule. Don’t care for so much email? You can update your personal email preferences as often as you like. To update the list of newsletter or alerts you received from The Bulwark, click here. Having trouble with something related to your account? Check out our constantly-updated FAQ, which likely has an answer for you.
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