Putting it in Perspective: Comparing the U.S., Japanese, and Swiss Student Health Systems

By Veronica Pugin

Amid the health care debates in the U.S. Congress, the rising costs for health care, and the swine flu scare, it is natural that college students across the nation would be increasing their awareness of health issues. Comparatively, U.S. students bear the burden of health costs at a much higher level than students within most advance industrialized countries. Japan maintains a health care system for college students that provides a comprehensive set of benefits, ranging from prescription drugs to dental services, at a significantly lower premium than what U.S. public college students pay. Meanwhile, Swiss college students participate in a system that mixes some government control and private industry, which offers lower premiums while maintaining high quality, according to the WHO and the OECD. The key difference between the systems in the United States, Japan, and Switzerland systems is clearly the roles that public and private forces play. At a glance, it is easy to conclude that Japanese college students have the best deal, with low costs and a variety of benefits. However, when one considers the long-term effects of the Japanese system, its presumed superiority becomes questionable.

Without a nationwide system of government-owned medical facilities for the general public and the majority of states, the protocol for U.S. college students is to have the option of either demonstrating coverage from family plans, find an alternative plan on their own, or pursue a health insurance plan provided by their institution, such as the one at the Claremont Colleges. The plans provided by the colleges tend to provide students with a better deal than most publicly available plans, but they are still costly.
A prime example of health care options in the public university system is the University of California Los Angeles’s Student Health Care Insurance Program (SHIP), a system that does not directly bill insurance companies. UCLA generally mandates that all students enroll in this health insurance. Students have the option to opt out of SHIP if they prove eligibility. SHIP program includes basic medical benefits at a cost of $295 per quarter. This cost also covers any co-pays for campus physician visits.

Meanwhile, Japan maintains an egalitarian, state-controlled system in which insurers all offer the same services. An individual’s level of premiums and costs are based on their income level, and fees are relatively low. The Japanese then have the flexibility to choose their physicians and medical treatment providers. Also, as in Switzerland, the Japanese government subsidizes the costs for low-income individuals. Overall, the system is funded by a combination of taxes and income-based premiums. This system has worked with very few minor adjustments.

At the college level, Japanese public and private institutions are quite similar in their students’ health care practices. College students are enrolled in the Japanese National Health Insurance plan. The NHI is part of the universal health care insurance plan and is accepted by most Japanese hospitals. The public University of Tokyo has on-campus health services for students, faculty, and staff. The University encourages doctor visits and requires that all students visit the Health Service Center for an annual check-up. Like most universities, the University of Tokyo students are a part of the NHI plan, which covers 70 percent of their medical and hospital costs. As a college, non-income student, one’s annual insurance fee is $110.

Private university students also use the NHI plan. Sophia University in Tokyo, for example, provides a reimbursement service known as Mutual Union All, which reimburses 80 percent of a student’s medical expenses that were not covered by NHI. Mutual Union All will reimburse students up to $4,391 a year. This reimbursement plan is common among other Japanese universities as well.

The Japanese visit the doctor at an average of 14 times a year, which is far more often than Americans do, yet the Japanese also have significantly fewer surgical procedures done. The Japanese are almost always provided with a doctor visit on the day that they request and are all in all much healthier than Americans. An important factor in Japan’s healthier population is the large-scale availability of health services. The total expenditure on health as a percentage of GDP for Japan is only 7.9 percent, which is slightly more than half of the United States’ 15.3 percent.

But, despite these figures, Claremont McKenna Professor Myung-Koo Kang is less optimistic about Japan’s health care system. He explains, “I don’t think the Japanese [health care system] is substantially superior or efficient than that of other advanced countries.” He highlights the fact that the Japanese system’s structure is unsustainable. “First, Japan is placed in the worst situation in public debt among advanced economies… Second, Japan’s aging population if a serious challenge to the health care system.” The increasing aging population is a great concern for the Japanese government, for, as Kang emphasized, half of the population will be responsible for taking care of the elder half. Ultimately, this system will be hard pressed to sustain itself, as the government has already accumulated a high rate of public debt and will need to continue to do so to make up for the lacking taxable population. Kang concluded, “Consequently, the tax burden on the shrinking workforce will increase remarkably while social security spending needs to be expanded.”

In terms of health care for Japanese college students, Kang does express the fact that, “considering the situation here in the U.S., it must be a pretty lower burden to students in general than here in the U.S.” This is so because “at least all students can equally get benefits from the National Health Insurance.”

The high costs of the U.S. system and the unsustainability of the Japanese system suggest that a middle ground is needed. The Swiss national health care system uses a public-private approach for basic health care with no group insurance plans. All residents, including college students, are required to obtain basic health care by enrolling with private nonprofit insurers. These firms are placed under extensive government regulation. The Swiss government subsidizes the insurance costs for those who cannot afford it, and one-third of the Swiss population receives government-subsidized health care. The insurance covers medical treatment costs yet requires an out-of-pocket annual deductible, averaging to about $200 per person.

College students are offered an online list to compare different insurance companies, although for basic medical care, all companies have the same basic benefits; it is just the premiums that vary.

An aspect of the Swiss system that is appealing to U.S. reformers is the fact that while Switzerland’s government does take a more active role in the process, it does not provide a national state-run health care system and insurance plan. Given the Swiss government’s high involvement in the country’s health care, it is surprising to note that Switzerland’s government expenditure on health care as a percentage of total public spending is only 0.5 percent more than that of the United States. The adult mortality rate is also much lower in Switzerland than the United States, with 63 deaths per 1000 for Switzerland and 109 deaths per 1000 for the US.

Switzerland represents the middle ground between the U.S. and Japanese systems, and it could serve as a more manageable model of health care. Since it balances the competition needed for a system to be successful with the need to cover the entire population, this hybrid approach could provide a model that is agreeable to deficit hawks and those who want to provide health care to all.


Published with support from Generation Progress. genprogress.org

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