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Gaijin health coverage: an appeal for choice

by Ronald Kessler

Unless you’ve just made it to this corner of the world in the last couple of weeks, you’re probably well aware of the new visa guideline that’s scheduled to go into effect in April 2010. Because of this guideline, foreigners who wish to renew their visa and who are required to be enrolled in social health insurance will be asked to present their social health insurance cards to Immigration officials.

Now, many foreigners have jumped to the “inevitable” conclusion that not having said insurance will equate to ultimately having no visa either. But, like so many other things in Japan that tend to be a bit obscure, the new guideline fits into a very “gray” category.

It should be clarified, however, that this guideline is not a law, nor was it created in the Diet as were the new immigration laws. Indeed, this is a completely separate issue that was not spawned by Immigration. It was created on June 22, 2007, by the Cabinet Office’s Council for the Promotion of Regulatory Reform, under the Shinzo Abe Cabinet. In actuality, it is merely a guideline mentioned in a report. Laws are created in the Diet by way of a majority vote. Therefore, any revision of this guideline would not require a vote in the Diet. The guideline in question is actually one of a list of eight. Immigration is merely following the guidelines contained in the report — well, somewhat.

Ahead of Japan’s recent election, the Free Choice Foundation, a grassroots foreigners’ rights organization (chaired by yours truly), contacted 300 lawmakers by e-mail to inquire about the guideline. Now we knew that putting a question like that to a politician on the stump is eerily similar to trying to feed a lion at the zoo while carrying only a microphone and wearing a lamb-chop necklace. Nevertheless, we did get some sincere replies from several Democratic Party of Japan lawmakers, along with a rather insincere one from a Liberal Democratic Party legislator.

Perhaps the most encouraging response was a two-page letter from the secretary of a DPJ lawmaker who took enough interest to call the Immigration Bureau and investigate the issue. He was also kind enough to offer to act as a diplomatic channel between Free Choice and Immigration. According to the information he was able to gather over the phone, foreigners applying for visa renewal without social health insurance enrollment will not necessarily be denied that renewal automatically.

You may ask (and understandably so), “What’s the point of the guideline, then?” Well, think of it like this: If you are applying for a job and all of your credentials are great except for one, it doesn’t automatically mean that there’s no chance you’ll be hired.

Plainly speaking, it’s easy to see that this new guideline has not been thought out very well. One politician actually remarked that the Cabinet Office report is so poorly worded it would flunk the Education Ministry’s kanji proficiency test. In fact, every Immigration official you ask about it will probably give you a different answer, because they themselves don’t seem to fully understand it — which is why we feel the guideline stands a fair chance of evaporating.

The DPJ lawmaker’s letter also (interestingly) points out that employers are ultimately the ones responsible for workers’ social insurance enrollment. Now, if this is the case, why should Immigration pick on the poor little guy at the bottom of the ladder? Shouldn’t the onus instead be upon the Social Insurance Agency to get employers to comply with already established laws? Immigration does not logically fit anywhere into the equation, which begs the further question, “Why are they really doing it?”

Indeed, there are many foreigners who want to be a part of the social insurance program but are locked out of it because their employers cannot or simply choose not to enroll them. But, let’s also not overlook the fact that the number of foreigners not enrolled in the system is dwarfed by the count of Japanese citizens who are also not enrolled. Millions of Japanese are denied access to the social system for the very same reason that foreigners are: The economy has been going downhill ever since the bubble era, and the notion of a lifetime employment system is now just a fading memory. Many small- to medium-size companies are already on the rocks, and to force them onto the plan at this stage would likely mean economic failure for a large percentage of them.

Again, let’s be crystal clear about something: For some foreigners, having public insurance is indeed a marvelous thing. For instance, if you move here, marry a Japanese, raise children and put down roots, acquire a family cemetery plot and firmly intend to remain in Japan until the day you die, then social insurance could very well be ideal for you.

Unfortunately, for someone who does not fit that description, mandatory social insurance could simply be a disaster waiting to happen. Many people living outside of their home country prefer to buy an expatriate health insurance policy for very specific reasons; that is, because of the special benefits they offer that directly address a number of issues expatriates typically consider to be vital, such as:

Communication: Many foreigners do not communicate well with Japanese doctors, and in extreme cases they have even been misdiagnosed. They often prefer to visit foreign doctors practicing in Japan who have had more experience treating fellow foreigners, and who have a better feel for which drugs to prescribe and the dosages that work best for them. Most of these doctors don’t accept public insurance, because if they did they would never be able to give their patients the level of personal attention they do now.

Level of service: Japanese hospitals are not exactly a favorite among most foreigners. To compensate for this fact, many expatriate insurance companies offer benefits for medical evacuation and will repatriate a patient to another country if it is in his or her best interest.

Repatriation of remains: Often overlooked, this is one of the most important benefits of a comprehensive expat insurance plan. Determining your final resting place is one of the most important decisions you’ll ever make. When a person dies in Japan having no family here, his or her embassy will usually have the body embalmed and returned to the home country. Now, this expense can easily run one to ¥2 million. Some embassies may pay for it upfront, but will then bill the family for the cost. Needless to say, this could mean financial disaster for the deceased’s family, or a significant burden on the embassy should the family default. Because of this, many embassies will not even consider shipping the deceased’s remains without at least a sizable deposit — or even payment in full — being made first.

These important benefits are not covered by Japan’s social insurance. And, to be fair, there’s absolutely no reason why they should be. Japan’s social insurance was designed with the citizens of Japan in mind, and rightly so. But, that being said, we don’t think that Immigration has the mandate or the expertise to play doctor for us foreigners. They do not understand the health care needs of the foreign population, and merely enforcing compliance to an arbitrary rule without an accurate comprehension of those needs is a certain prescription for bad medicine. It also shows that they really have no particular concern for our health care — or our health.

So, how do other nations deal with the issue of foreigners and health insurance? Well, Europe’s 25-member Schengen Zone mandates that visa applicants show proof of enrollment in an expatriate health insurance plan before they’ll even consider issuing a visa. Other countries have similar provisos. Japan’s overseas embassies, however, do not require visa applicants to have expatriate coverage before entering the country. However, if a foreigner meets with a serious injury or illness while here and is financially unable to pay for medical care, it’s he or she who’ll shoulder all the blame for it.

Foreigners here are trapped between the proverbial rock and a hard place, and that’s why Free Choice endeavors to bring attention to these issues as well as build a groundswell of support through our online petition drive (you can visit the Web site at www.freechoice.jp ).

Foreign teachers here, for example, often work on a part-time basis at two or three different schools, which means that their employers are not required by law to enroll them in social health insurance. The new guideline does not state whether foreigners in those situations would be forced to apply for National Health Insurance (another form of public insurance, designed for the self-employed and the elderly). However, if that were the case, they’d be required to pay up to two years (more in some cities) of back premiums, calculated from the time they first registered in Japan to the present. It’s reasonable to assume that many foreigners would not be able to afford such a payment and would be forced to leave Japan, or be compelled to become illegal aliens living “underground.” And isn’t that precisely the opposite of the intended effect of the newly passed immigration laws, which seek to curtail foreigners from overstaying their visas?

But, oddly enough, the guideline stops short of actually mentioning NHI. Is that a simple oversight, or could it be that the government knows (and even expects) the problems that such premium back payments would have? If they truly wanted to enforce this thing, wouldn’t it be easier and more above board to create an actual law and say, “Either enroll or you’re out”? Again we must ask, “What are their true motives?” It’s a distinct possibility that this is nothing more than the Immigration Bureau’s attempt to gain an “ace in the hole” to be used as added leverage when they simply want to kick someone out.

The guidelines stated on the Ministry of Justice Web site do not include certain statements contained in the council’s original report — “details” that foreigners would undoubtedly be interested in, such as:

• “The guideline is only intended as a format and the decision to renew a visa shall be left entirely to the discretion of the Ministry of Justice (read “the individual immigration official”).

• The original guideline states that “care should also be taken to use the listed items as a format, because of individual cases such as those who have a grace of payment, etc.” And this gem: “while taking into consideration the human rights, cultural and social backgrounds of non-Japanese and their families.”

What does all this mean? We can only speculate. It’s painfully clear that neither Immigration nor the Abe Cabinet have given this matter the long and careful consideration it deserves. For the moment, health care is a hot topic for everyone, and as we approach April 2010, it’s a good bet things will get even hotter.

Ronald Kessler is an IT consultant specializing in health care solutions. Send comments on this issue to community@japantimes.co.jp