Health Insurance Politics in Japan

Policy Development, Government, and the Japan Medical Association

Takakazu Yamagishi

• Publisher: ILR Press
• Year: 2022
• Print ISBN: 9781501763496, 9781501763496
• eBook ISBN: 9781501763502
• Topic: History
• Subtopic: Insurance
• Index: History

Japan is the fastest aging country, with the largest super-aged society in the world and growing larger by the day, yet its universal health care costs are relatively low. In Health Insurance Politics in Japan, Takakazu Yamagishi draws back the curtain for an international audience and investigates how Japan has been able to control health care costs through health insurance politics.

Covering the period from the Meiji Restoration to the Abe Administration, Yamagishi uses a historical institutionalist approach to examine the driving force behind the development of health insurance policies in Japan. Yamagishi pays special attention to the roles of government and medical professionals, the main actors of the policymaking and medical worlds, in this development. Health Insurance Politics in Japan pushes Japan into the spotlight of the international conversation about health care reform.

1 WESTERNIZING MEDICINE

Although it is controversial whether the Meiji Restoration was a “revolution” or not, it was an immense step for Japan toward becoming a modern nation. The Meiji Restoration was a reaction to external pressure brought by the Western nations. Commodore Matthew Perry came to Uraga with black ships powered by coal-fired steam engines and demanded that the Tokugawa shogunate open Japan’s major five ports to the United States, which meant that Japan would have to end its nearly two-hundred-year isolationist policy. The way the Tokugawa shogunate handled this demand and the following events ignited opposition from domains such as the Satsuma, Chōshū, and Mito. To ease the domestic tension, the Tokugawa shogunate decided to hand over governance authority to the emperor.

The Meiji government’s highest priority was to modernize—that is, westernize—the nation. The government implemented policies to abolish the feudal system, strengthen the economy, modernize and expand the military, change the political system, and become more like contemporary Western nations. The government needed to become stronger to rid itself of unequal treaties and prevent colonization by the Western nations. The Meiji government westernized Japan from the top down. It established the Imperial Diet in 1889, won the First Sino-Japanese War in 1895,¹ signed a treaty of military alliance with Britain, and won the Russo-Japanese War in 1905. A democratic movement gradually emerged, but party politics was not much developed, and the elite class—mostly founders of the Meiji government—controlled politics. By the time the Meiji Emperor died in 1912, Japan had become a modern nation and was recognized by many Western nations as an independent power in Asia.

Health care policy became part of the government’s westernization plan. The government took the lead in adopting Western medicine as the official standard. Meiji officials had almost a free hand to create a new Japanese health care system. Health care policy became a tool to prevent epidemic catastrophes, to strengthen the military, control social order, and be accountable to the people. The early Meiji period laid out the structural foundation of a Japanese health care system though health insurance did not come in to being yet. This chapter describes the six aspects of health care that the Meiji government took control of: medical education, medical licensing, hospitals and clinics, health care administration, medical associations, and the relationship with doctors and pharmacists. Development in these areas had a major impact on the later health care system, narrowing government options in public health insurance.

Medical Education

As described in the introductory chapter, the Tokugawa shogunate had begun to adopt Western medicine right before it collapsed. The School of Western Medical Science (Seiyō Igakusho) was established in 1860. It was renamed as the School of Medical Science (Igakusho) in 1863. After studying under J. L. C. Pompe van Meerdervoort, Kōan Ogata created seven courses of study: physics, chemistry, physiology, pathology, pharmaceutics, internal medicine, and surgery. Ryōjun Matsumoto set up the order of the curriculum. Doctors of Western medicine were trained in this school. Kenzō Ogawa, medical historian, contends that the 1863 reform was “very important because Western medicine was approved as the standard for Japanese medicine.”²

The period when the Tokugawa shogunate directly promoted Western medicine, however, was too brief for this standard to spread to the entire nation. The dominant majority among doctors were Kanpō doctors. They were not systematically trained because the shogunate had not intervened much in their practice. Primitive medical-training facilities, which were often connected with temples, existed for training in Kanpō medicine. But, overall, the medical training was limited.³ Many doctors began to practice after only a brief training under senior doctors without basic formal medical education. In 1873, soon after the end of the shogunate era, a newspaper article noted that four or five out of ten doctors, most of whom practiced Kanpō medicine, were illiterate.⁴

In 1868, Tsunenori Takashina, whose family had served as doctors in the Imperial Household in Kyoto, submitted a petition to the newly created government to make Western medicine the officially approved standard. In 1869, the Meiji government issued the Proclamation of Western Medicine (Seiyō Ijutsu Sashiyurushi) declaring that Japan adopted Western medicine as the national standard.⁵ Westernization of medicine was part of the government’s effort for “enriching the nation and building up national defenses” (fukoku kyōhei). From its civil war battles with the Tokugawa forces, the government realized that Kanpō was ineffective for curing injured soldiers. It became clear that Western surgical procedures were necessary for a strong military. Masujirō Ōmura, a military surgeon general, claimed that “Japanese medicine has to be westernized. Chinese medicine is useless in military hospitals.”⁶ Hiroshi Kosoto, medical historian, points out that Kanpō and Western medicine were qualitatively different. He writes, “While Kanpō emphasizes individual body conditions and symptoms, Western medicine is concerned with surgical procedures and public health. The military needed Western medicine to deal with large groups.”⁷ The elites in the new government were the main figures pressing for developing Western medical education.

Although the government began to actively engage in a policy of medical education to promote Western medicine and improve the quality of doctors, the government was not sure which Western country Japan should emulate. Many Japanese doctors had become familiar with Dutch medicine during the Tokugawa era. Britain, France, and the United States, however, were also possible models because of their contacts with Japan. In 1869, Jun Iwasa and Tomoyasu Sagara were appointed to direct medical education reform. They had full authority in medical affairs.⁸

British medicine initially gained attention because the United States, an English-speaking country, first opened diplomacy with Japan. English as a language was studied by Japanese elites, and it was natural that British medicine gained attention as a model for Japan.⁹ British medicine was familiar to many Japanese in the early Meiji era because of William Willis. Willis came to Japan as the British legation’s doctor in 1861 and later became a teacher of surgery in the medical faculty of a preceding institution of Tokyo Imperial University. He taught Kensai Ikeda, Tadanori Ishiguro, Tōyō Sasaki, and Jun Iwasa, who became leaders in adopting Western medicine. The British minister to Japan, Harry Smith Parks, also encouraged the Meiji government to adopt British-style medicine.¹⁰ Thus, it once appeared that British medicine would become the model for Japanese medical education.

Iwasa, however, supported adopting the German model. Having researched different types of medicine in major European countries, he concluded, “In Europe, there are no countries better than Germany in medicine.” To convince those who supported British medicine, Sagara also claimed, “Britain tends to despise the Japanese. The United States is too new of a country to have developed its medical education. Germany, as a national polity, is a similar country to Japan, although it is less known in Asia.”¹¹ Shungaku Matsudaira, former head of Echizen Domain, headed the administration of education at that time. Iwasa was also from Echizen Domain. This coincidence helped Iwasa persuade the others to accept his preference. The government thus decided that Japanese medicine would be based on the German model. This was not so new to the Japanese, because Dutch medicine was often based on translations of German medical texts.¹²

In 1874, as the first step in formally adopting Western medicine, the government issued the Medical Rules and Regulations (Isei), which importantly included medical education being based on Western medicine. The draft of the Medical Rules and Regulations, with its eighty-five articles, was prepared by Sagara, the first head of the Medical Bureau (Imu Kyoku) of the Ministry of Education (Monbu Shō). In 1874, Sensai Nagayo succeeded Sagara and continued Sagara’s work. Nagayo had intensively studied the European medical system. In 1871, he was dispatched as a member of what is known as the Iwakura mission to Europe and the United States. While the main purpose of the mission was to renegotiate the unequal treaties, the delegates also did research on politics, economy, society, and culture. Nagayo researched the legal systems and the administration of medicine. He was greatly inspired by the concept of “public health” or gesundheitspfege. He understood this to mean that the government needed to protect the population’s general health and that the administrative system needed to be based not only on medical science but also on other academic disciplines. Such concepts did not then exist in East Asia.¹³

The promulgation of the Medical Rules and Regulations was a top-down government policy to westernize medical education and produce doctors who could practice Western medicine. Akira Sugaya states, “The nature of the Medical Rules and Regulations was that Japanese medical traditions were totally neglected while the Western system was transplanted.”¹⁴ He also points out its impact: “The Medical Rules and Regulations created a trajectory of development of a private-practitioner system and suggested a clear transformation from the traditional Kanpō to Western medicine.”¹⁵

To take command of medical education, the Meiji government created Tokyo Imperial University’s medical faculty in 1877. The School of Medical Science, which the Meiji government inherited from the Tokugawa shogunate, was its predecessor.¹⁶ The new government continued to develop medical education based on Western medicine. In 1871, after Sagara and Iwasa’s decision to adopt German medicine, the government invited two German doctors, Benjamin Leopold Müller and Theodor Eduard Hoffmann, to reform Japan’s medical education. Meanwhile, the British doctor Willis was fired from his teaching position.¹⁷

After creating Tokyo Imperial University’s medical faculty to take the lead in medical education, the government also needed to create regional medical schools. Under the domain system there were some schools teaching Western medicine, though they were limited in number and quality. Kumamoto Seishunkan and Fukuoka Saiseikan, established in 1756 and 1868, respectively, were examples of these schools. Based on these foundations, the Meiji government attached medical technical schools to regional public hospitals.¹⁸ The number of public medical schools increased from nine in 1876 to forty-seven by 1880.¹⁹

In 1882, the government issued its Medical School Regulations (Igakkō Kisoku), which stipulated that “excellent” medical schools had to have at least three doctors of medicine (MDs) on their faculties. If they wanted to be considered “good,” they had to have at least one. At that time, only Tokyo Imperial University was able to turn out MD graduates. This regulation confirmed Tokyo Imperial University as the dominant power over regional medical schools, creating a clear hierarchy in the world of Japanese medicine—“the p...

Table of contents

• Acknowledgments
• List of Abbreviations
• Notes on the Text
• Introduction
• 1. Westernizing Medicine
• 2. Reacting to Deteriorating Health
• 3. Improving People’s Health for War
• 4. Reforming Health Care with the United States
• 5. Achieving Universal Health Insurance
• 6. Consolidating Universal Health Insurance
• 7. Making Universal Health Insurance Survive
• 8. Japanese Health Care in the Globalization Era
• Conclusion
• Appendix
• Notes
• Index