Japan’s health insurance system, praised globally for supporting one of the world’s longest-lived populaces, ensures medical care remains affordable for all residents through mechanisms such as capped out-of-pocket costs.
But the system is under serious strain from a shrinking workforce and surging elderly population, with its future now entangled in political maneuvering ahead of key elections, including the upcoming House of Councillors contest.
Analysts warn that turning the health insurance system into a political football could undermine its stability and erode public trust in government, emphasizing the need for a measured, long-term debate rather than rushed reforms driven by electoral pressures.
“How Japan maintains its lauded health care system under the pressure of an aging society is an issue of international interest,” said Yuri Ito, a professor at the Department of Medical Statistics at Osaka Medical and Pharmaceutical University.
Under Japan’s universal health care system, almost all citizens pay 30 percent of their medical costs at clinics and hospitals while making monthly insurance contributions, with a government program setting a cost ceiling for those facing particularly high bills.
Introduced in 1973, the high-cost medical expense benefit system, which has few parallels abroad, was designed to ensure economic equality in health care. Despite its obvious benefits, younger people, who contribute equally despite not requiring medical services as much as their older compatriots, are often skeptical of the framework.
Pledging to guarantee mutual social security support regardless of age, Prime Minister Shigeru Ishiba’s government is seeking to secure 3.6 trillion yen ($25.20 billion) for child-rearing steps, with around 1 trillion yen expected to come from medical system savings.
Even though the ruling bloc, led by Ishiba’s Liberal Democratic Party, does not hold a majority in the House of Representatives, the prime minister expressed eagerness in early 2025 to gradually increase the burden carried by about 12.5 million patients who incur high medical costs, starting in August.
Under the original plan by the Ministry of Health, Labor and Welfare, for example, the monthly out-of-pocket cap for those with an annual income of 3.7 to 7.7 million yen would have gone up by around 59,000 yen, reaching a maximum of about 139,000 yen.
The proposal sparked immediate backlash, with opposition lawmakers accusing the government of rushing changes without adequate consultation. Cancer sufferers voiced fears that higher costs could force them to forgo treatment or cut back on other crucial expenses.
File photo shows Japanese Prime Minister Shigeru Ishiba (2nd from R) meeting representatives of cancer patient advocacy groups at his office on March 7, 2025. (Kyodo) ==Kyodo
After encountering criticism even from within the LDP, Ishiba’s government ultimately froze all envisioned hikes following talks with patient advocates in March. The deadline for a new plan has now been pushed to after the upper house election.
Recently, Ishiba’s ruling coalition, which suffered heavy losses in the House of Representatives in October’s general election, has been compelled to make concessions to opposition parties from which it needs support. The minor parties have used their leverage to win policy changes that benefit the working-age voters they are courting.
The opposition Democratic Party for the People has been accused of taking a populist approach to win votes, leading Ishiba to apparently seek to keep the unpopular medical cost issue off the national election agenda, analysts said.
Ishiba seems to have believed that a full-throated debate on whether to increase the burden on sick people before the upper house election was “not politically advantageous,” said Tadashi Mori, a professor of politics at Aichi Gakuin University.
Mori, said Ishiba’s failure to stand behind his proposed changes to the high-cost medical expense benefit system has ironically hurt him as it has given the impression that he is prioritizing elderly voters who tend to make up the LDP’s support base.
As for the system itself, Michihito Ando, a professor in economics at Rikkyo University, said, “For people living longer thanks to improved health care, a limit on medical spending is valuable,” arguing that the current caps are “not low.”
“I would like to see the government abandon the idea of raising the caps,” Ando said, adding, “What I would propose is a long-term change of how Japan provides health care, such as by strengthening cost controls.”
Related coverage:
FOCUS: Japan’s role for ASEAN increasingly crucial amid U.S. tariff standoff
FOCUS: Japan makes major step toward revising controversial retrial system
Nearly 60% of Japanese believe election social media needs regulation
