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Chronology: The History of Medical Care/Welfare Systems in Japan

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Ÿ1948 (July): Post-war medical care reforms are begun by GHQ, various laws are passed including the Medical Care Act, the Medical Practitioners Act, and the Act on Public Health Nurses, Midwives and Nurses

Ÿ1958 (December): The National Health Insurance Act is passed

Ÿ1961 Universal health insurance coverage is realized
Health insurance: Individual patients have almost no burden of payment (close to 100% coverage)/families have a 50% burden of payment, National health insurance: individual patients/families have a 50% burden of payment (50% coverage)

* Kitaba, Tsutomu 2000 Sengoshakaihosho no keisei: Shakaifukushikisokozo no seiritsu o megutte [Formation of post-war social security: on the completion of basic social welfare structures] Chuo Hoki
"In 1961 the Kyushu Social Welfare Council, Democratic Socialist Party (DSP), and Liberal Democratic Party (LDP) each presented proposed legislation or overviews of proposed legislation governing social welfare for elderly people, and plans for legislation were quickly made concrete when the LDP included social welfare for the elderly in their platform during the July 1962 House of Councilors election" (Kitaba [2000:66]).
In 1963 legislation was proposed and enacted during the 43rd session of the Diet.

Ÿ1963 Act on Social Welfare Service for Elderly
National health insurance: Burden of payment 30% for the insured person, 50% for dependents

Ÿ1968 Amended National Health Insurance Act: Burden of payment 30% for the insured person/dependents

Ÿ1972 Amended Act on Social Welfare Service for Elderly (beginning in the following year (1973) medical care fees were eliminated for people over the age of 70)

Ÿ1973 Medical care fees are eliminated for the elderly
Amended Health Insurance Act: a 30% burden of payment for dependents/high cost treatment system is established, and the rate of state aid is fixed for government administered health insurance

Ÿ1975 National Health Insurance: full implementation of the high cost treatment system

Ÿ1978 Implementation of a "Short stay service" system
The term "short stay service" means to have the persons with disabilities, or others who need short-time placement in support facilities for persons with disabilities or the other facilities prescribed Ordinance of the Ministry of Health, Labour and Welfare due to sickness of their caretakers who conduct nursing care at their home or other reasons to enter such facilities for short time to provide care for bath, elimination, or meal, and the other benefit prescribed in Ordinance of the Ministry of Health, Labour and Welfare.

Ÿ1979 (October) "Report on fundamental aspects of government administration of medical care" (Edited by office of statistical reporting, Ministry of Health, Labour and Welfare) - the Ministry of Health and Welfare began to develop a statistical understanding of "bedridden elderly people"
Implementation of a "Day service" system (a welfare facility designed to care for disabled aged persons who live at their own homes, is called aged person's day service center)
Revision of the fee collection system for residential facilities for the elderly (A system is introduced in which usage amounts are collected from persons obligated to provide care in cases where the amount of user expenses received does not meet the amount to be paid for costs of measures taken (240,000 yen/month)).

Ÿ1980s The Nakasone cabinet was in power during this period and made military expansion its main focus. These policies were pursued against a backdrop of economic growth threatened by the two "oilshocks" during the 1970s and America losing the war in Vietnam.

Ÿ1980 (June) The Ministry of Health and Welfare established a "Department to take charge of issues concerning medical care for the elderly" and began planning proposed legislation for an elderly person medical care act to be integrated into the state budget for fiscal 1981.

Ÿ1980 (September 4th) First proposal¨public opposition¨legislation proposed in May 1981¨public opposition¨public opposition/failure to pass through three Diet sessions over a period of 15 months after being proposed in the legislature¨with an agreement to "slightly lower personal burdens of payment," the Act on Assurance of Medical Care for Elderly People was passed in August 1982 with the approval of the Liberal Democratic Party, the Social Democratic Party, and Komeito (the law came into effect in February 1983), and elderly people can no longer receive medical care free of charge.

Ÿ1981 (July 10th) The Second Provisional Council on Administrative and Fiscal Reform releases its first findings¨reducing medical costs is positioned as one of the main national policy goals.

Ÿ1981 Health insurance: 20% burden of payment for dependents hospitalization

œ1982 (March) Misato Central Hospital Incident ? the extent of "excessive testing" and "excessive prescription of medication" becomes clear.

Ÿ1982 (July 23rd)
*NIKI Ryu 1994 gSekaiichih no iryouhi yokusei seisaku wo minaosu jiki [A time to reexamine the gworldfs besth medical care cost control policies], Keiso Shobo, pp.47-48
"A proposal entitled "On a vision for the future of social security" is submitted to the Minister of Health and Welfare by the "the Ministry of Health and Welfare Social Security Long-term Vision Round-table Conference" and clearly asserts that "regarding the scope of future national medical care costs, the aim must be to keep them within the growth rate of national income, taking into account the fact that the population is aging.""(1)

"At the time this proposal is seen as something "cooked up by the Ministry of Health and Welfare to compete with the provisional commissions for administrative reform," and "an attack on the campaign to curtail the growth of social security burdens being waged by the financial/business community and the provisional commissions.""(2)p.47

"cHowever, this was ignored in "My thoughts on the circumstances surrounding medical care costs and how to deal with them," an essay by Social Insurance Commissioner Yoshimura published in Shakai Hoken Junpou [Social insurance bulletin] in March 1983, and the idea of "growth [in costs] in line with the national income growth rate" was abruptly put forward as a "framework for controlling medical care costs.""(3)p.48

(1) "Shakaihoshou no shorai tenbou nitsuite[Concerning a vision for the future of social security]", Shakai hoken junpou[Social insurance bulletin] No.1403, July 23rd, 1982, pp. 28-32
(2) (Current discussion) "Chokikon no teigen[Long term round-tablerecommendation]" Shakai hoken junpou No.1403, July 23rd, 1982, p.3
(3) Yoshimura, Hitoshi, 1983, Iryouhiwomegurujyousei to taiounikansuruwatashi no kangaekata [My thoughts on the circumstances surrounding medical care costs and how to deal with them], Shakaihokenjunpou No.1424, pp.12-14

Ÿ1982 (August 17th )Enactment of the Act on Assurance of Medical Care for Elderly People
"Overview of management of dispatching operations" revision (target for the dispatching of "home helpers" expanded from households on social security/households not paying income tax to households that pay income tax. A fee system was introduced for households that pay income tax).

Ÿ1983 (February) Implementation of the Act on Assurance of Medical Care for Elderly People (abolition of the free medical care for elderly people system)
A new system is introduced in place of the extant health insurance system for people over the age of 70. Under this framework revenue is contributed by each health insurance system, with 50% of the total costs after co-payments are deducted being paid with public funds (2/3 by the national government, 1/6 by the prefectural government and 1/6 by the municipal government) and 50% contributed by each health insurance system.
Introduction of co-payments for elderly people: 400 yen/month for regular outpatient treatment, 300 yen/day for hospitalization (two month limit)
With the aim of having proper care at hospitals for the elderly, medical care facilities with more than 60% of their patients over the age of 70 are designated as extra-special variance hospitals for the elderly and distinguished from special variance hospitals and general hospitals.
¨New decisions are also made regarding the existence of differences in medical repayment scoring and standards for provision of staff (number of doctors, nurses, caregivers, etc.)
-"Designated patient institutionalization management fees" are established for special variance hospitals for the elderly.
-Special hospitals for the elderly "designated patient institutionalization management fees" and "elderly person treatment fees" are integrated.
-"Integrated assessment for hospitalization treatment (treatment, tests, injections)" is established for extra-variance hospitals.

Ÿ1984 (October 10th) Revision of the Health Insurance Act
‡@A burden of payment of 20% (initially 10%, 20% from 1997 onwards) for the insured person
‡ALegalization of collection of remaining balances through the introduction of a special medical care expenditure system and the expansion of "medical treatment at patients' own expense" (a form of medical treatment fee provision system)
‡BDrastic cuts in government funding of the national health insurance
‡CEstablishment of a new retiree medical care system with no government funding

"Special medical expenditure system": A system in which, when a patient has received medical care including specially designated high grade medical treatments and special services (amenities), insurance covers the portion of the total fees incurred that overlaps with standard care (special medical treatment expenditures) and the patient must pay for the portion incurred by special services.

There are two kinds of special services, ghigh grade cutting edge medical treatments,h which are performed only at specially approved medical care facilities such as university hospitals, and "provision of special hospital rooms according to the desires of the patient and other medical treatments designated by the Minister of Health and Welfare," which can be provided by all medical care facilities (NIKI [1994:112-113]).

Reason for the establishment of the "retiree medical care system": Improvements were sought because elderly retirees such as "salarymen" saw their level of benefits drop when they entered the national health insurance after retirement (until the reforms of 1984, they received 100% coverage while working but only 70% coverage after retiring and entering the national insurance).
¨Retirees are put into a special "retiree medical care system" framework in which 80% coverage is guaranteed. The government's financial burden is expected to be reduced, however, as funding for this system is covered by payments from various sources such as health insurance funds and "mutual aid" funds.

Ÿ1985 First revision of the Medical Care Act
EPlanning of regulations for the guidance and supervision of local medical care programs/medical care organizations (on-site inspections, intervention in human resource management, 20% self-owned capital)
ECreation of a single doctor medical care organization system
Rate of the government's financial burden for fees of welfare such as social security fees and fees for welfare of the elderly is reduced from 80% to 70%.

*NIKI Ryu 1984 "Sekaiichi" no iryouhi yokusei seisaku wo minaosu jiki [A time to reexamine the gworldfs besth medical care cost control policies], Keisoshobo
Ministry of Health and Welfare (Eds.) 1985 Kousei hakusho shouwa rokujyuunendoban-choujyu shakai he mukatte sentakusuru [Ministry of Health and Welfare white paper fiscal 1985 making choices with a view towards a long lifespan society], Health and Welfare Statistics Association
"To keep growth in national medical care costs within growth in national incomes going forward" (NIKI [1994:43])

Ÿ1986 The round-table conference on basic frameworks for social welfare proposed a "basic framework for the improvement of social welfare".
Reforms to the Act on Assurance of Medical Care for Elderly People: Partial increase in individual burden of payment (outpatient care 800 yen per month, hospitalization 400 yen per day), Raise of subscriber proportional ratio

Establishment ofmedical care facilities for elderly people: transitional facilities between hospitals and homecare, period of hospitalization to be under three months as a rule, medicine, testing, and rehabilitation to be included in the daily payment amount - as a result of difficulties in meeting facility standards (room size, etc.), these institutions rarely functioned as transitional facilities.
There were also "usage fees" of around 50,000 yen per month to cover food and other expenses.

Ÿ1987 Revision of the Act on Assurance of Medical Care for Elderly People: confiscation of health insurance cards from people who do not pay their insurance premiums.

Ÿ1988
Shouwa 63 nendo kouseikagakukenkyuujigyouEnetakiriroujin no genjyoubunsekinarabinishogaikoku to no hikakunikansurukenkyuuEkenkyuuhougokusho [Fiscal year 1988 Ministry of Health and Welfare scientific research special research projectEresearch/research report on an analysis of the current state of bedridden elderly people in Japan in comparison with several foreign countries] (Health and Welfare Minister's secretariat, elderly people health and welfare department, elderly people health division)

Ÿ1989 Beginning of the "Heisei" era

Ÿ1989 (March) Opinion paper is released by the three council meeting on social welfare (Central Social Welfare Council/Physical Disability Welfare Council/Central Child Welfare Council) "Kongo no shakaifukushi no arikata ni tsuite" [Concerning the future of social welfare]

Ÿ1989 (April 1st) Consumption tax introduced (3%)
A "Ten year plan to improve health and welfare services for elderly people," the so-called "Gold plan," is formulated (the securing of 100,000 "helpers" [nursing care providers] is proposed). For-profit corporations are accepted as autonomous sub-contractors for home-helper services for 75% of state payments for welfare benefits such as livelihood assistance and 50% of welfare measure expenditures.

Ÿ1990 (March 31st)
Netakiri zero wo mezashite-netakiri roujin no genjyoubunseki narabini shogaikoku tono hikaku nikansuru kenkyuu [Aiming for zero bedridden - An analysis of the current state of bedridden elderly people in Japan in comparison with several foreign countries] (Health and Welfare Minister's secretariat, elderly people health and welfare department, elderly people health division)
"In order to avoid creating bedridden elderly people, as a starting point each elderly person must have a "desire for life" regarding independence, and in addition society as a whole must support this desire. Regarding concrete preventative measures, to begin with it is important to use various proactive measures to "keep them moving" in order to prevent illnesses that cause people to become "bedridden" from arising, prevent their causing disabilities when they do arise, and prevent disabilities from worsening once they exist. There are many such measures, and they are intricately intertwined with one another through a wide range of labels and categories. In order to make this proposal clear, we will employ two perspectives without worrying about overlap; one perspective takes the point of view of individual elderly people, arranging various measures individuals need in accordance with their chronological progression from a healthy elderly person to the point when disabilities arise, while the other perspective focuses on those who provide support/implementation, arranging services in accordance with, for example, the people or organizations that provide support/implementation. In addition, in order to establishthe local care structures need to facilitate these two strategies, in what follows we also summarize the measures that must be taken by the national government, local governments, and other bodies." (p.23)
Promotion of the "Zero bedridden initiative"

Ÿ1990 (April) Medical fee revision
Introduction of a flat-rate system (diminishing returns method) into designated hospital for the elderly-one or more care worker(s) for six patients
"Act revising parts of the Act on Social Welfare Service for Elderly" (Revision of eight acts related to welfare). Rate of payment for policyholders in the medical care insurance for the elderly system is increased to 100% and control over admittance to facilities such as special care homes for the elderly is transferred to municipal governments. Authority over measures is unified in municipalities. Legal positioning of in-home services: there is now an obligation to formulate a "health and welfare for the elderly plan" for each prefecture/municipality.

Ÿ1991 Revision of the Act on Assurance of Medical Care for Elderly People: Establishment of home visit nursing care, increase in public payment rate with a focus on nursing care (from 30% to 50%).
Individual burden of payment becomes 1,000 yen per month for outpatient care (increased from 800 yen) and 800 yen per day for hospitalization (increased from 400 yen).
Introduction of a sliding system of charges are added to the total individual burden of payment at a fixed rate corresponding to increases in the cost of medical treatment for the elderly, partial removal of payment obligation for people with low income remains at 300 yen per day (two months).

Ÿ1991 (April 1st) Kouseihakusho (heisei 2 nenban) - shin no yutakasa ni mukatte no shakaishisutemu no saikouchiku yutakasa no cosuto - haikibutsu mondai wo kangaeru [Ministry of Health and Welfare Whitepaper (fiscal 1991 edition) - Restructuring the social system to achieve true prosperity The cost of prosperity - considering the problem of waste] (Ministry of Health and Welfare ed.,Health and Welfare Issues Research Association).

Ÿ1991 (November 18th) "Shogai roujin no nichijyouseikatsu jiritsudo (netakirido) hanteikijun" no katsuyounitsuite [Concerning the practical application of "standards for determining the degree of independence in daily life (degree to which the person in question is bedridden) of elderly people with disabilities"] (a report by the head of the elderly people health and welfare department within the Minister of Health and Welfare's Secretariat) A single set of "standards for determining the degree of independence in daily life (degree to which the person in question is bedridden) of elderly people with disabilities" to be used throughout Japan.

Ÿ1992
Second revision of the Medical Care Act
EConsolidation of conceptual guidelines regarding the provision of medical care, rendering of these guidelines into lawESystematization of the function of medical care facilities (systematization of special function hospitals and long-term care beds)Erelaxation of regulations on advertising, obligations concerning the posting of notices within hospitalsEMedical care facility administration: establishment of criteria for permission to be given to subcontractorsEconsolidation of regulations concerning medical care organizations (legislate names of specialties to be used in publicity.)
Establishment of "Home visit nursing stations for elderly people"

Ÿ1992 (January 22nd)
The research committee on clinical brain death and organ transplantation concludes that brain death is "human death" and that organ transplantation from brain dead patients should be accepted. A minority opinion opposing the acceptance of brain death is also noted.
*Wada, Masaru 1992 "21 seiki no iryou taisei to seido kaikaku [21st century medical care systems and systemic reforms] Shukan shakai hoshou 1716: 26-29
"Concerning the framework of today's health insurance system, while dealing with various difficulties we have used a wide range of techniques to assemble the resources needed for reforms. ...we have done many things, but at this point nothing further can be wrung from these techniques. In other words, the current situation is one in which we have devoured all eight legs of the octopus and have nothing left to eat." (Niki [1994:50])

Ÿ1993
The total fertility rate falls to 1.46, the lowest ever observed (reported in 1994).
A "Childcare service act" aiming to shift childcare center admittance from and administrative to a contract system is conceived.
¨fails to become law as a result of opposition¨shift in direction towards disassembling the elderly people welfare administrative system (towards the conception of long-term care insurance )

Establishment of "long-term care beds": Aimed at long-term care patients, improved nursing capabilitiesEdifferent staff assignment standards from regular hospitals, care fee areset according to the rate of elderly patients admitted and includes nursing care, testing, prescription of medication and medical treatment.

Ÿ1993 (Late September) According to the Ministry of Health and Welfare's "Byouin keiei kinkyuu jyokyo chousa [Study of urgent issues concerning hospital operation]", the operating conditions of hospitals worsened in fiscal year 1992: 30.7% of private hospitals were in the red, and 56.8% were performing worse than they had the previous year (Niki [1994:46])

Ÿ1994 Revision of the Health Insurance Act and other laws: abolition of attendant nursing/care (to be implemented by the end of 1995), clarification of in-home treatment, expansion of home visit nursing care, establishment of food treatment fees when patients are hospitalized, introduction of partial payment for food by patients, exemption from employee health insurance premiums during maternity leave, substantial relaxation of requirements for different-fee beds.

Expansion of different-fee beds: expanded to four people per room¨some hospital organizations/medical care organizations take the initiative in promoting this expansion.
Patients are now to pay for their own food while in hospital: In principle 800 yen per day, for two years 600 yen, sub-contracting to private companies¨opposition from hospitals.
Abolition of attendant nursing/care: prior to these reforms, when utilizing hospitals without standard nursing care patients would have an attendant accompany them with 50%-70% of the cost being repaid by their insurance (patients would not receive this reimbursement for 2-3 months and had to prepare funds to cover the entire fee at the time they received the service).

Ÿ1994 (March) "21 seiki gata fukushibijon - shoushi/kourei shakai ni mukete [21st century welfare vision - moving towards a society with a dwindling birthrate and an aging population]" (Personal advisory panel to the Minister of Health and Welfare "Aging society welfare vision round-table")

Ÿ1994 (April) A long-term care insurance act is passed in Germany

Ÿ1994 (September) Plans for a "long-term care insurance" appear in the second report by the Social Security Council Internal Committee on the Future of Social Security

Ÿ1994 (November 2nd) Passage of the Pension Reform Act (the age at which full benefits from the health and welfare pension begin to be paid is to be increased in stages to 65)

Ÿ1994 (December) "Aiming to create a new nursing care system for elderly people" (Elderly people nursing care/independent living support system research association)
"Drawing up a new gold plan" (New/ten-year strategy to promote the health and welfare of elderly people)

Ÿ1995 (July) Social Security System Council advocates the creation of a "long-term care insurance system" in their first recommendation in 33 years.
"On the establishment of a new long-term care insurance system for elderly people" (Council on Health and Welfare for the Elderly) - recommends a nursing care system for elderly people in the form of social insurance.

Ÿ1995 (August) Recommendation that "helper" working conditions be improved (from the Management and Coordination Agency's Administrative Inspection Bureau to the Ministry of Health and Welfare and the Ministry of Labour)

Ÿ1995 (December 16th) "Basic Act on Measures to Address the Aging of Society"

Ÿ1995 (December 26th) The November unemployment rate as reported by the Management Coordination Agency reaches 3.4%, the worst it has been since 1953
The "Family Care Leave Act" is passed (effective from April, 1999)

Ÿ1996 (April) "On the creation of a long-term care insurance system for elderly people" (Council on Health and Welfare for the Elderly)

Ÿ1996 (June) Revision of the Health Insurance Act
Introduction of personal payment for food during hospitalization
Creation of a basic proposal for a long-term care insurance system (Ministry of Health and Welfare)
"Aging society white paper" (Annual report) begins (Based on the Basic Act on Measures to Address the Aging of Society, the white paper is an annual report submitted to the Diet by the government every year beginning in 1996. It elucidates the state of the aging of Japanese society and countermeasures being implemented by the government as well as other policies it is striving to implement in consideration of the current circumstances regarding aging.

Ÿ1996 (October) Establishment of the "Terminal care welfare research association" at the Center for Longevity Social Development, an organization affiliated with the Ministry of Health, Labour and Welfare

Ÿ1997 Third revision of the Medical Care Act
EEstablishment of clinics with long-term care bedsEsystemization of "regional medical care support hospitals"Eexplanation to patients concerning care being providedEreevaluation of medical care planningEexpansion of the scope of activities engaged in by medical care organizationsEestablishment of a special medical care organization systemEincrease in what can be advertised

Ÿ1997 (April 1st) Consumption tax is increased from 3% to 5%
Revision of the Health Insurance Act: the burden of payment of the insured becomes 20%, partial individual payment is introduced for outpatient medication
Medical care for elderly people: Partial increase in individual burden of payment

Ÿ1997 (May) Long-Term Care Insurance Act is proposed, passes the House of Representatives

Ÿ1997 (June) Cabinet decision "on the promotion of fiscal structure reform"

Ÿ1997 (June 16th) Revisions of legislation such as the Health Insurance Act are passed (partial burden of payment for the insured enrolled in employee health insurance becomes 20%)

Ÿ1997 (December 9th) "Long-Term Care Insurance Act" is passed

Ÿ1998 (April) Implementation of the third revision of the Medical Care Act
Informed consent becomes obligatory, local medical care support hospitals are established
Fee for outpatient treatment for patients over the age of 70 becomes 500 yen per visit (for the first four visits per month; from the fifth visit the fee is waived)

Ÿ2000 (April 1st) Long-Term Care Insurance begins
"Gold plan 21" is drawn up. Through Gold plan 21, beginning in fiscal year 2000 the government engages in a "New zero bedridden initiative." As part of this initiative, "in order to prevent elderly people becoming bedridden, it is essential to provide, based on rehabilitation medical practice, appropriate rehabilitation treatment during emergency, recovery, and maintenance periods in accordance with the needs of each individual elderly person."

Ÿ2001 (March) Fourth revision of the Medical Care Act
EReorganization of categories of hospital beds (staff assignment standards for acute phase/chronic phase beds)Eformula for calculating the necessary number of bedsEchart disclosure becomes mandatoryErelaxation of advertising regulationsEclinical training becomes mandatory for doctors/dentists

Ÿ2002 (April) Revision of medical fees (-2.7%)
First negative revision to core fees for medical treatment (-1.3%)

Ÿ2002 (October) Revision of Health Insurance Act
Usage fees for patients over the age of 70: For outpatient care, introduction of a system in which medical care facilities can choose to charge 800 yen per visit (for the first four visits per month; from the fifth visit the fee is waived) or a 10% flat rate (up to a maximum of 3000 yen per month)
Hospitalization fees are based on a 10% flat rate (up to a maximum of 37,200 yen per month or 24,600 yen per month for low income patients)

Ÿ2003 (April) Implementation of revisions to the Health Insurance Act, user fees for patients under the age of 70 raised to 30%

Ÿ2004 New clinical training system for medical professionals begins
As a result of the manner of selecting training sites there is a flow of trainees towards municipal hospitals and staffing shortages worsen at university hospitals

Ÿ2005 Outline of medical care system reforms

Ÿ2006 (April) Revision of medical fees (-3.16%), largest negative revision in core medical fees (-1.36%)

Ÿ2006 (April 1st) Implementation of revised Long-Term Care Insurance Act

Ÿ2007 (April) Implementation of Cancer Control Act, first medical care system regulating participation in patient-side decision making

Ÿ2007 (April 9th) "Terminal care guidelines" are established by the Ministry of Health, Welfare and Labour's "Investigative commission on the state of decision-making processes regarding terminal care"

Ÿ2007 (October 15th) "Recommendation (guidelines) concerning terminal care in emergency medicine"

Ÿ2008 (April 1st) Implementation of Latter-Stage Elderly Healthcare System




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