Frank
Hello, this is Frank.
Today, I want to discuss the “unfairness of Japan’s National Health Insurance (NHI).” Have you ever felt frustrated paying high NHI premiums, even when you are healthy, rarely visit the doctor, or run a business at a loss?
1. Differences Between National Health Insurance and Social Insurance
Japan’s healthcare system is based on the “universal health coverage” principle, where everyone must enroll in some form of public health insurance. Company employees and government workers join “social insurance” (employee health insurance or association health insurance), while freelancers, self-employed, and unemployed individuals must join National Health Insurance (NHI).
The biggest difference lies in the payment method. Employees have premiums automatically deducted from their salary, and their employer covers half. NHI members bear the full cost themselves, creating a significant gap even if annual income is the same.
2. Why You Pay NHI Even if Your Income Tax is Zero
You may wonder, “Why do I pay NHI even when my income tax is zero?” This is because NHI calculations differ from income tax. Income tax is levied on income after deductions, but NHI premiums are based on total income from the previous year.
Even if tax law considers you exempt, the system assumes you can pay, which is why premiums are charged—one of the reasons it feels unfair to many people.
3. Why You Must Pay Even if You Rarely Visit Hospitals
“I barely visit hospitals—why do I pay so much?” Many ask. NHI operates on mutual assistance: healthy individuals subsidize those who are sick. While the purpose is understandable, those who rarely use medical services often feel they are losing out.
4. Why Self-Employed People Pay High NHI Even When Running at a Loss
Self-employed individuals face an even tougher situation: you may pay high NHI premiums even if your business is in the red. Taxes might be zero during a loss year, but NHI uses previous year’s income as the basis, sometimes billing tens of thousands of dollars even with low revenue.
Simply put, “you pay for last year’s income even if you didn’t earn this year,” which is a heavy burden for unstable businesses.
5. Could It Be a Usage-Based System?
The main complaint is “paying even if unused.” Could a “beneficiary pays” model work? Fully usage-based insurance may be impractical, but a “minimum premium plus additional charge based on usage” could reduce the sense of unfairness.
In summary, NHI supports Japan’s healthcare system, but healthy individuals and self-employed people often perceive it as unfair. Without flexible designs considering “ability to pay,” “usage,” and “fairness,” dissatisfaction grows, risking trust in the system.
The real issue is political inaction. The long-dominant LDP has left imbalances unchecked, and even highly educated elites in administrative positions often lack practical implementation and citizen awareness. Opposition parties have also struggled to present realistic reforms.
For a healthcare system that citizens can trust, bold reforms and decisive actions are necessary. Healthcare reform should take precedence over formal leadership contests or political performances.
References
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国民健康保険料が高すぎる！ 保険料を下げる10のこと (中公新書ラクレ) 新品価格 |
Disclaimer
This article provides general information and the author’s opinions on Japan’s National Health Insurance. Systems and calculations vary by municipality. Always verify actual premiums and details with your local government or professional advisors.
Check out the Spanish version of this article here.
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