Trump’s Assault On Health Care, Seen From a Country That Does Health Care Better

Tokyo, Japan
IT WAS ALMOST TWO WEEKS AGO that Republican senators voted to block renewal of the enhanced Affordable Care Act subsidies set to expire at year’s end. But I wasn’t in Washington on that day to see the vote, even though it was big news on my beat. I wasn’t even in the country. I was at a café in the center of Tokyo, talking with Naoki Ikegami, a physician and professor emeritus at Keio University who is one of his country’s leading experts on health policy.

Yes, an accident of timing meant that I spent several days this past month traveling in Japan, learning about their health care system right as lawmakers were voting on what to do with ours. But the setting and the conversations turned out to be an ideal way to get some perspective on what has been unfolding in Washington not just this past week but this past year—and why the ongoing debate over key pieces of the Affordable Care Act is even more important and revealing than the headlines convey.

Japan’s health care system guarantees comprehensive insurance for everyone, which means people don’t routinely ration their own care or go into financial distress because of medical bills. And changing that very basic arrangement is simply not part of the Japanese political conversation, Ikegami told me.

“There are no politicians, even among the ultraconservatives, who call for doing away with universal health care,” he said, seeming a little bewildered by the possibility when I raised it to him.

It wasn’t the first time I’ve heard things like that. Universal health care exists in just about every other economically advanced nation, and over the years I’ve gotten the chance to study several of these arrangements up close.¹ They differ in their particulars, but not in their basic functions or in the feelings they generate among their citizens.

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Everybody with financial resources pays into these systems, generally without objection, with the expectation that coverage will be there for them when they need it. And although political parties argue over how to fund, manage, and deliver the guarantee of health care, they do not argue over whether to provide it.

That is decidedly not the case in the United States, where we have spent the better part of a century arguing whether universal health care is even worth trying. The Affordable Care Act was a big step in that direction—the biggest since the creation of Medicare and Medicaid back in the 1960s. But this year Donald Trump and the Republicans have pushed back hard, first by cutting a trillion dollars out of Medicaid this past summer and now by refusing—at least for the moment—to extend those Obamacare subsidies.

Something like 14 million people stand to become uninsured as a result of these changes, with many more of the remaining insured facing higher prices. It’s virtually certain many will struggle with medical bills, suffering financial or physical hardship or both. And if Trump or the Republicans are losing sleep over this possibility, they haven’t shown it. Many—including Trump himself—have called to roll back government insurance programs even further.

The enthusiasts for this position will talk about the virtues of “empowering consumers” or “unleashing markets,” or of making shopping for insurance more like Costco. But implicit in their view is an argument that’s come up anytime a big expansion like the Affordable Care Act has been up for debate: that government-managed, universal health care systems are a disaster, and that creating that kind of “socialism” in the United States would destroy all that is good about ours.

If they came to Japan like I did, they’d see how wrongheaded that argument is. Japanese health care has its pluses and minuses, as all systems do. But it performs quite well by any reasonable standard, and has some features I suspect most Americans wish they had.

Stick with me as I explain why. . . .

LET’S START BY GOING BACK IN TIME, to the early twentieth century. It was the era when most countries were first grappling with the cost of health care following life-saving but expensive scientific breakthroughs and the professionalization of medicine. In Japan, it was also a moment when the national government was trying to supercharge industrialization.

The result was the Health Insurance Act of 1922, which paid for the health care of welders in the Yokohama shipyards, weavers in Osaka’s textile mills, and the rest of Japan’s industrial workforce. The government expanded coverage to most of the rest of the workforce and dependents in the 1930s, and then to the rest of the population in the 1950s shortly after the end of America’s postwar occupation. That’s when it became truly “universal.”

Each step in that expansion took a different form. The initial provision for factory workers relied on companies to cover their employees through plans they would manage, while the subsequent expansions involved creating new government programs. That’s why today the majority of Japanese get insurance through private plans that employers still operate on their own, albeit under tight national rules, with the rest getting coverage through public plans that municipal governments manage for their residents.

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This is frequently the way health care systems develop—in stages, and by building upon whatever pieces are already in place. It’s also why universal coverage takes more forms than commonly understood or discussed in American politics.

There are countries like Canada and Sweden where everybody gets insurance through the same government plans—what we all call “single-payer” programs. There are countries like the Netherlands and Switzerland where everybody gets coverage through private carriers. And then there are countries like Japan, whose system is more of a mishmash.

But what matters most is what these systems have in common: the basic guarantee to all citizens not just of