WGU’s SAT Task 3: Healthcare Financing

A1. Country to Compare

Understanding different models of healthcare worldwide and examining the benefits or challenges can inform potential improvements in the US healthcare system. The United States is known to spend the most per capita income on healthcare than any other country yet gaps remain in establishing the most patient-centered healthcare system. Japan ranks one of the top-performing healthcare systems in the world by any meaningful measure. This discussion compares different aspects of healthcare between Japan and the United States to identify gaps and implications to nursing practice today.

A2. Access

Access to healthcare is critical to good health, yet many people face different barriers to receiving healthcare services. Access to healthcare means the timely use of personal health services to achieve the best health outcomes. To ensure accessibility, factors like timeliness of care, available healthcare workforce, services provided and coverage should be considered. The United States and Japan portray similarities and differences between healthcare access among children, unemployed, and the retired.

Children’s access to healthcare is important to the children themselves, their families, and society. In the United States, access to healthcare for children is mainly through insurance through a variety of programs. Medicaid and the Children’s Health Insurance Program (CHIP) are observed to be the main source of insurance for children in the US (Children’s Hospital Association, 2021). Medicaid is a jointly funded program that provides access to healthcare for families and children with special needs. Recent reports indicate that about 39% of all children are covered by Medicaid services while CHIP provides coverage to 9% of children and pregnant women who are not eligible for Medicaid (Children’s Hospital Association, 2021). Other sources of health insurance for children in the US include TRICARE, individual commercial health insurance sold through the Exchanges and employer-sponsored insurance (ESI), and private coverage through exchanges.

Unlike the US where children access healthcare through an array of insurances, Japan has a universal healthcare system that provides healthcare access across all populations. The National Health Insurance (NHI) and social health insurance are available to provide coverage to children seeking medical care in any healthcare facility. Japanese insurance pays for 70% of total medical costs and adults are required to pay the remaining 30% (Sakamoto et al., 2018). For children, one can apply for free medical care that will ensure the 30% is paid by the government. Additionally, a certificate for children is provided to ensure the child receives free medical care in any facility. Regarding vaccinations and baby checkups, NHI does not provide coverage but the ward or city office can provide coupons to cover the costs.

The second category of individuals that may exhibit challenges in healthcare access involves the unemployed. In the United States, Medicaid services only provide coverage to certain categories of unemployed individuals and this is dependent on the level of income. Because of these restrictions, most individuals get their plans through Marketplace application (Ruggles et al., 2019). Marketplace plans were set up by the Affordable Care Act (ACA) to make it easier for those with low income to access healthcare. The individual is able to see what plans are available in an area, compare them, and make a purchase according to their financial status. For unemployed individuals with children, CHIP provides coverage to children and in some states, it may extend to pregnant women. In Japan, healthcare access for the unemployed is made cheap through the Japanese NHI scheme. NHI provides cover for the unemployed, those working less than 30 hours per week, self-employed, and students (InterNations, 2021). The individual is only required to cover 30% of the healthcare costs as the government pays the rest.

The other category of individuals whom healthcare access is of great importance involves the retired. The average retirement age in the United States is 65 for men and 63 for women with the majority of the retirement benefits starting at the age of 66. Any individual that retires before the age of 65 has to enroll in private health insurance coverage. Medicare insurance provides coverage for most services upon retirement, but probably not all. It may force some individuals to purchase a private Medigap policy to cover all the other costs that Medicare does not. In other cases, the retired may fail to qualify for certain services if they choose to purchase other insurance plans. For instance, retirees who want to buy a Marketplace plan cease to get premium tax credits and other savings based on their income. In Japan, healthcare insurance coverage is available for all retired individuals below the age of 75 (InterNations, 2021). Those older than 75 usually enroll at the municipal and local levels to increase transparency and accountability aspects of care.

WGU’s SAT Task 3: Healthcare Financing

A2a. Coverage of Medications

Medications are an integral part of healthcare service delivery because they help patients live longer, healthier lives. The primary means of accessing medication in the US is through the Medicare drug coverage plan. This plan is optional and is offered to everyone with Medicare insurance. However, there are different plans that dictate the type of medications one can get and they are dependent on cost. Medicare drug plans are divided into part A and part B and individuals can join these plans to get access to certain medications. An alternative package called Medicare advantage Plan is also available for Medicare patients. Medicare plans only provide partial coverage of drugs and are more beneficial for those seeking inpatient services. Private insurance is also available to cover medications and is dependent on the company policies.

Health insurance is, in principle, mandatory for residents in Japan and is used to cover healthcare services and medications. Japanese healthcare system covers prescription medication and individuals are only required to pay 30% of the total fees. Prescriptions must be filed within four days to promote accountability (InterNations, 2021). Japanese doctors are free to prescribe any medication to patients because pricing is controlled and almost every pharmacy dispenses drugs at the same price. In some special circumstances, co-payment may be used to allow access to certain medications that are very expensive to be covered by NHI.

A2b. Referral to See a Specialist

As the first point of entry into the healthcare system, physicians are responsible for assessing and managing patients including timely referral for special care. Referral to see a specialist rests with the physician and the patient with important aspects like cost guiding the referral process. The Department of Human Services (DHS) indicates that referrals do not need to be made out to a certain specialist or consultant. The patient has a decision to whom they may like to be referred to (Ruggles et al., 2019). Before the referral, the physician should inform the patient of any out-of-pocket costs that may be incurred and may be required to speak with their insurance providers to confirm the services covered. The physician must undertake a professional attendance with the patient to determine the need for special care. The referral must be in writing addressing the medical specialist and should be sent earlier before the patient is seen. While most health maintenance organizations follow these guidelines, exceptions are available for specialists like psychiatrists and psychologists.

The Japanese healthcare system is quite unique when it comes to patient referrals for special care. Firstly, patients in Japan are free to visit any type of medical facility as they prefer. There are no referrals required to see a specialist and their location outpatient settings make it easy for self-referral. In some specialized hospitals, patients may be required to pay additional fees if they seek medical care with referral notes from other facilities. For example, the Health Insurance Law of japan requires individuals without a referral for special care to pay an extra ¥ 11,000 for medical and dental services (InterNations, 2021). The same amount also applies for return visits without referrals.

A2c. Coverage for Preexisting Conditions

Medicare defines a pre-existing condition as any health problem that you had prior to the coverage start date for a new insurance plan. The United States law dictates that companies cannot refuse to cover preexisting conditions both for adults and children (Ruggles et al., 2019). Individuals with an Original Medicare or Medicare Advantage plan are generally covered for all benefits. However, those with Medicare Supplement Insurance or with end-stage renal disease (ESRD) have some exceptions. All individuals must sign up during the Medigap open enrollment period to receive coverage for preexisting conditions. Sometimes the individual may be required to wait up to six months before providing full cover for preexisting conditions. For individuals with ESRD, it may be difficult to purchase Medigap policy until the age of 65. However, rules may vary according to the state one resides. Preexisting conditions coverage is not quite challenging in Japan compared to the United States. Health insurance in Japan is available through NHI and Social Health Insurance (SHI) and both cover preexisting conditions.

 A3. Financial Implications for Healthcare Delivery

Out-of-pocket spending. Out-of-pocket expenditure represents medical expenses that are not reimbursed by insurance. These fees include deductibles, coinsurance, and co-payments for certain conditions or medications. The complexity of the United States healthcare systems makes out-of-pocket spending high compared to Japan. For example, Medicare and other insurance plans do not cover certain prescription drugs leaving patients with an extra task of catering for their medications. Retirement before the age of 65 means that patients will have to seek other Marketplace plans for coverage before eligibility for Medicare is reached (Ruggles et al., 2019). In Japan, out-of-pocket costs are low because the Universal Healthcare System covers 70% of all costs. Individuals are only required to pay 30% with children receiving free medical care.

Specialty care services. There is a huge difference between seeking special care in the US and Japan. Individuals in the US will spend more time and money during referrals because of the insurance policies for special care. One has to confirm from their insurers if coverage is available for certain services and co-payment may be used during certain special care. In Japan, freedom is available to seek special care from any physician the patient chooses. The referral process is easy and having a letter from the physician during referral makes seeking special care even easier.

References

Children’s Hospital Association. (2021). Health care coverage sources for America’s children. https://www.childrenshospitals.org/issues-and-advocacy/general/fact-sheets/health-care-coverage-sources-for-americas-children

InterNations. (2021). Healthcare in Japan: Health insurance and the healthcare system of Japan explained. https://www.internations.org/go/moving-to-japan/healthcare

Ruggles, B. M., Xiong, A., & Kyle, B. (2019). Healthcare coverage in the US and Japan: A comparison. Nursing, 49(4), 56–60. https://doi.org/10.1097/01.NURSE.0000553277.03472.d8

Sakamoto, H., Rahman, M., Nomura, S., Okamoto, E., Koike, S., Yasunaga, H., … & Ghaznavi, C. (2018). Japan health system review. https://apps.who.int/iris/bitstream/handle/10665/259941/9789290226260-eng.pdf