(As a worker in a Japanese hospital for almost 20 years) I can't speak for the government on why there is a penalty for latecomers to the national health insurance program, but the penalty is the same for Japanese citizens as well. Those failing to contribute, or who return from living abroad and do not contribute, are assessed a late penalty to re-enroll. By law, back payments can be involuntarily withdrawn from one's salary. According to my source, the back payment to enroll after failing to do so is up to two years — not five years.

If one is a regular employee, enrollment in national health insurance is mandatory and virtually no one escapes deduction from pay. If one is part time — fewer than 30 hours a week — self-employed, contracted, unemployed or with a small company that does not follow the rules, not enrolling in the kokumin kenko hoken program for these groups is risky.

I regret making the "Go home" remark in my Oct. 11 letter (directed at foreigners who find their circumstances in Japan unacceptable) but with a caveat: I think there is an attitude that the world should speak English and that's naive. For one not to look into national or municipal health insurance options upon choosing to work in Japan is also naive.

Not all patients go to major medical facilities, and to think that each hospital or clinic in Japan should have fully staffed English-speaking insurance and billing experts is ethnocentric arrogance. Foreign insurance processing is a nightmare for hospitals in Japan. Exceptions, denials, length-of-stay limits, pre-existing conditions, co-payments and deductions, and the requirement to provide detailed records and itemized billing in English is simply not possible for most.

Getting a check in U.S. dollars or euros from an insurer — after processing fees, currency conversions and long delays — that ends up less than the billed amount is similarly an accounting nightmare. Paying up front in cash is the perfect option, but unfortunately there are many who can't do that regardless of whether they have private insurance that will reimburse them. The answer is to enroll in one of the readily available national health insurance programs.

name withheld