Obamacare upheld! Now can I buy into the Japanese health system instead?

Doctors protest against the individual mandate in President Obama’s health care reform in front of U.S. Supreme Court this morning. (Photo from REUTERS/Yuri Gripas)

They do it better in Japan. They do it better in Costa Rica, in Andorra, and even in Slovenia.

No, I’m not talking about sex. I’m talking about living itself.

Americans just don’t live that long.

We come in a shabby 34th in global life expectancy rankings. The average Japanese citizen lives to 83.5 years old, five years longer than the average U.S. citizen, and yet the Japanese spend $5000 less per person per year on health care.

But we’re fixing our problems, right?

After all, the Supreme Court just issued a surprising ruling upholding the major pillars of the Patient Protection and Affordable Care Act (“Obamacare” or the PPACA, if you’re into the whole brevity thing).

Clocking in at a lumbering 907 pages, PPACA is a labyrinth of health care proposals (an economist friend takes a crack at explaining it thoroughly here). But basically, it’s meant to increase Americans access to insurance coverage, theoretically lengthening our lives and improving our overall health.

The Supreme Court ruled that the government can require people to be covered, meaning that most of  the 34 million formerly insurance-less Americans will get health insurance, one way or another, by 2020.

A nurse draws blood from a patient at a hospital in Brazil. Despite spending the most per-capita on health care, the US ranks 34th in life expectancy. (Photo by Carol Garcia via Flickr)

The pluses also include improvements for Medicare and Medicaid recipients, along with coverage for those with pre-existing conditions and required coverage for preventive services.

Insurance companies won’t be able to deny “problem patients,” more funding will be invested in drug development, Medicaid will be expanded, and coverage for prescribed drugs will increase.

But even after all these attempts at improvement, experts are still wrangling about whether or not Obamacare will actually improve our lifespans and our health. A clear downside will be cost management, with some physicians afraid a gap will still exist between having health insurance and having actual health care. Other experts think the act will actually hobble health care efficiency even more severely.

In the US, we spend much more money per person on average than our other Western counterparts, but our overall health is in much shoddier shape – greater disparities, more mistakes, and fewer providers. And it looks like this will continue even once all of Obamacare’s new provisions are in place.

Don’t think I’m complaining too much – PPACA, again, is a huge landmark, and a stab at balancing America’s complex private vs. public system of health care and health care insurance.

Without Obamacare, most Americans were struggling with health care in major ways. I’ll toss in a few personal anecdotes:

  • For the past three years I’ve been a PhD student, in public health, of all things, with only sporadic health care.
  • My father, a pharmacist of 30+ years with a degenerative disease, cannot afford to retire even two years early because of health care cost concerns.
  • A friend of mine works as an information tech contractor in Seattle. His (large, prestigious, Seattle-area) company drops their contractors right before the company would need to start paying for benefits, including health care, then hires them back again to start another uninsured cycle.

Those are just off the top of my head. The irony isn’t lost on me that, as a public health practitioner, I’m constantly encouraging others to prevent illness (“Don’t smoke! Get preventive health screenings! Go to wellness appointments!”), but that whenever I’ve had a “gap quarter” at school when I don’t end up on a project offering health insurance, I become a hypocrite, unable to afford following my own advice.

Prescription medications in Japan (Photo from Flickr by Evan Blaser)

Instead, I’ve adopted a “health insurance policy” along with dozens of my under-employed friends of ‘Just don’t get sick.’ Or, if I can swing it, I splurge on high-premium, short-term catastrophic insurance, ‘just in case.’

Forget prevention. Forget dental care and eye care. Forget properly taking care of colds, flus, and, frankly, anything less severe than near-death.

Forget it.

Forget the message the US has been sending us that we can’t afford better health care. The message that health care should be tied so firmly to (fulltime) employment. The message that my eventual sickness, decline, or death are my own personal shortcomings, and that I’m expected to be born with impeccable genetics, avoid all accidents, outmaneuver all diseases, stay mentally healthy, and side-step the dangers of cities and work habits built to encourage wolfing down calories without burning them off.

Obamacare attempts to address many of these problems, and in some ways I’m glad for it. As Nancy Pelosi has points out, it will help college students stay covered longer under their parents’ insurance, will help seniors pay for their prescriptions, and will (just maybe) make health insurances companies more accountable.

But is that enough?

While their systems are admittedly imperfect, countries like Japan, Switzerland, and Australia still arguably eke out better health for their citizens at a lower cost.

Let’s look at the two countries leading the list of long-lifers: Japan and Switzerland.

And the hospital food is better! (Photo from Flickr by TaylorandAyumi)

In Japan, where people smoke and drink a lot more, but are also much less obese, citizens have universal health care coverage through a mix of employer-offered insurance teamed up with neighborhood-specific insurance for those who aren’t insured through work.

The country’s coverage plans, remarkably, don’t vary much, and typically include mental health and dental (which are often omitted from U.S. plans.) Preventive services also get covered. Copays are high, but have a monthly ceiling and are moderated by the fact that Japanese doctors charge according to country-wide fees that are set yearly (so profit margins don’t vary much.)

Switzerland follows close on Japan’s heels in terms of average life expectancy, but grapples more with cost. The Swiss have chosen mandatory universal coverage, but citizens can still opt to purchase additional health coverage for preventive services not covered under their usual plan, or for services provided by non-professionals or by facilities out of their residential districts. Dental care gets left out, and long-term nursing care is not comprehensively covered.

Copayments hover around 10%, with a yearly cap. Only Norway and the U.S. spend more on health costs, and Switzerland is currently attempting to curb its costs.

A quick summary:

  Japan Switzerland U.S.
Avg. life expectancy 83.5 years 82.3 years 78.6 years
% GDP spent on health care 8.5% 11.4% 17.4%
$ per person spent on health care $2,878 $5,144 $7,960

I want to emphasize that neither Japan nor Switzerland have “perfect” systems of buying health and health care for their citizens. Japan is facing an increasingly elderly population whose health care costs are going to rocket, and Switzerland has expensive coverage that some of its citizens find cumbersome and problematic.

But Japan, for example, is doing a lot of health care tasks better than we are, and they’ve done it quickly, setting up universal coverage in 1961, putting all 3500 insurance plans on the same fee schedule, regulating what health providers can charge for services, and charging everyone the same co-pay rate (except that the elderly and children pay slightly less.) Plans cross-subsidize so that low-income citizens and the elderly aren’t left out in the cold.

The downside is smaller profits for health care providers and insurers, who no longer get to choose what they charge. (For a more in-depth summary of Japan’s health care, check out the Lancet series from 2011)

Obama makes a statement about the Supreme Court’s decision on his health care law. Most of the law was upheld, but there’s still a long ways to go to solving problems in the US health care system (Photo from REUTERS/Luke Sharrett)

We should take some lessons from Japan and the dozens of other countries who appear to get more health for less money.

Obamacare isn’t the perfect system. Neither was pre-Obamacare. But we need to quit grousing and realize that we don’t live in an action movie. No one will come riding in at the last minute, high-tech medical equipment blazing, to save us. We have to save ourselves.

It might mean cherry-picking successful health care approaches from other countries. It will definitely mean very painful compromises, including eating better, exercising more, preventing more illness, and taking responsibility for our future health by being willing to pay a price today for better living tomorrow. And, just maybe, it could also mean living longer and living better.


Cyan James is a PhD graduate student in the Institute for Public Health Genetics at the University of Washington, where she studies genetics, public health, and communications. She writes articles on health care, policy, and global health, and blogs at www.sensecyan.blogspot.com.


  1. Cyan, I’m wondering what you think about (what I perceive as) an over emphasis on individual responsibility for health (“None of this would be a problem if you didn’t eat, drink, smoke, watch TV so much.”) Seems to me that these other (healthier) countries accept government/nationally responsibility for quality of life/overall health where we do not. Am I wrong?

  2. Sarah, thanks for the great question. Do you mean that we in America have an over-emphasis on individual responsibility for health, as opposed to other countries’ take on what individuals do? From my perspective in public health, I’d say yes, American government puts a lot of emphasis on personal responsibility –it seems we’re willing to blame an individual for not being healthy, but government doesn’t always seem inclined to make it easy for an individual to get healthier. There are certainly ways we could structure our society to make it easier for us all to walk more, eat better, and develop stronger friendships (all of which would make us healthier.) I don’t have much of a first-hand feel for how other countries’ governments split the share of responsibility between individuals and government, but my anecdotal evidence is that, while how the share is split exactly may vary (like relatively high expectations for legal/government involvement, as in France, or lower expectations, but strong family and friendship bonds, as in Mexico), health care systems that emphasize prevention and shared individual/government investment seem to fare best.

  3. Hi Cyan,
    Interesting article especially in light of today’s Supreme Court announcement to uphold individual mandate (req all American’s to have health coverage). We (U.S.) have a rising elderly population (140 million with chronic dx) with 80% having 2 or more chronic diseases which places an enormous strain on our healthcare system. The American Telemedince Association (ATA) & mHealth will help improve access to care to many people but will also improve cost efficiency. I’m hoping that both political parties will move beyond their differences and start to work together towards Health IT solutions. You bring examples of countries that are doing it right and we should ‘cherry pick’ some solutions which might work for this country. We have to stop grousing and quickly start addressing these issues and as individuals we each need to be held accountable for our own (health) actions, whether that means walking more or wearing a pedometer everyday to get our 10,000 steps, or join Group Health’s Fitness Network: https://www.grouphealthfitnessnetwork.com/index.php/events/cycling-2#.T-0Jxo5oj24 we all need to make sacrifices and ‘healthy’ choices to improve our economy & our individual health. #NoMoreExcuses ;) #GroupHealthFitness as model #mhealth #Telemedicine

  4. I’ve noticed that it’s become more acceptable to openly/publicly judge people for eating/smoking/drinking/their size and wondered if this trend has something to do with the way we think about health care and government responsibility. I wonder if people in countries that have universal healthcare are more or less inclined to judge people for (perceived) unhealthiness/unhealthy behaviors. Thanks for writing an article that got me thinking about all of this from a totally new angle!

  5. And our big government in the USA approves HIgh Fructose Corn Syrup, GMO seeds, rBHST in our animals (which by the way, just may increase weight gain in humans the way it does in animals) and gives big parma companies money for research to give us more pills for more discoveries of diseases to treat. And have you seen the ads on tv for sugar coated cereals, if you depression is not getting better, try another medication–ask your doctor about—-yet the government wants to cut payment to medicare doctors by 30%–and the insurance companies can drop people for whatever…..Yep, I think “WE THE PEOPLE” need to take a pro-active stance on how our government and our own choices are affecting the health of this country.

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