Why doesn't national health insurance pay for maternity care?

Japan’s two national health insurance programs are predicated on coverage for sick people. Anything that falls outside of that very simple and general guideline does not apply. That’s why your national health insurance does not pay for annual checkups, though most local governments offer cancer screenings and other preventive health measures for free, or mostly free. In terms of dentistry, orthodontia — considered cosmetic in Japan while in the West it is a health concern since crooked teeth are likely to cause dental problems later in life — is not covered by insurance. Neither is teeth-cleaning, strictly speaking, though many dentists, including my own, have found a way to get around it.

Having a baby is also not covered by Japanese national insurance, though it is in most Western countries that have state-funded medical insurance plans. Unless the expectant mother has a complication that requires medical attention, she has to pay for all pre-natal, delivery-related and post-natal care out of her own pocket. However, the government does have a system of reimbursement called shussan ichijikin, which means “one-time payment for giving birth.” Traditionally, a woman who gives birth pays her obstetrics bill, which usually includes a hospital stay in addition to doctors’ fees, and then applies for the payment to the National Health Insurance Union (Kokumin Kenko Hoken Kumiai), which administers payouts. Several months later she receives a standard ¥420,000 payment, regardless of how much money she spent.

Last October, the health ministry started a new system on a test basis. Under this new system, the shussan ichijikin is paid directly to the hospital, not to the woman who gave birth. The idea is that the woman is not burdened with a large fee when she leaves the hospital. At the moment the system is optional for hospitals, and according to a recent article in the Asahi Shimbun many who did opt for the system say they are not happy with it. Because they have to wait up to three or four months to be reimbursed, it plays havoc with their cash flow. As a result, the future of the system, which was originally planned to be instituted fully at the end of March, is in doubt.

The system was proposed several years ago by former health minister Yoichi Masuzoe at the urging of Rengo, the Japan Trade Union Federation, which advocates insurance coverage for maternity care and a nationwide fixed fee for delivery. The revised shussan ichijikin idea is a compromise, and one of Rengo’s requirements is a detailed breakdown of costs related to a woman’s care. As it currently stands, hospitals and obstetricians can set their own fees with no interference from the government, but once the insurance union starts giving out money to medical institutions under the new system, it basically has the potential to ask these institutions about the fees they are charging and set limits, and the Asahi article implies that this is something doctors want to avoid at all costs. Thus, their stated reason that the new system is a strain on their financial situations may be a smokescreen.

Hospitals in rural areas, where property values are low, charge much less for maternity care than do hospitals in big cities, and public hospitals are more expensive than private ones. The Japan Obstetricians Association surveyed its members and found that the average cost of having a baby in Japan is ¥424,000, almost exactly the amount of the shussan ichijikin, but that the cost varies from a low of ¥218,000 to a high of ¥810,000. What doctors are afraid of is that everything they charge may be scrutinized by the insurance union, and so, they say, they will not be free to provide the best care available. On the other hand, consumers could be concerned that doctors may simply be gouging patients when they don’t have an outside organization observing what they do.

Interestingly, the fact that maternal care is not paid for by national insurance may explain why C-sections, or caesareans, are not as common in Japan (around 20 percent) as they are in, say, the U.S. (around 30 percent). Though many people claim that Japanese people frown upon C-sections because it is believed vaginal birth is something that a mother has to go through in order to be a mother, the rate of C-sections in Japan has tripled in the past two decades. But the rate could be even higher if maternal care was covered by insurance. Because hospitals can charge whatever they want now, they can afford to wait for nature to run its course. Labor can take a long time, and in America it’s believed that the high percentage of C-sections is due to the notion that obstetricians are impatient and don’t want to wait around for the baby to make its move.

If the insurance union paid a fixed reimbursement for maternal care in Japan, doctors might be pressured to keep costs to a minimum and thus would be more likely to opt for C-sections, which are covered by insurance since, in principle, they are only carried out when there is a medical problem.

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