Journal Logo



Courtesy, Pride, and Japanese Health Care

Walker, Graham MD

Author Information
doi: 10.1097/01.EEM.0000484520.79111.8b
    Japanese toilets have sinks built on top so that the water needed to fill the tank for flushing can first be used to wash hands.

    I'm writing this on a rainy day in Japan, on a bullet train from Kyoto to Osaka. It's been a whirlwind trip and a delight of foods, courtesy, and public transportation. I love international travel for its ability to expand your mind and challenge your assumptions about norms of human behavior, culture, and society.

    And, wow, America, we've got to get our act together.

    Don't get your patriotic panties in a bunch; we do many things well in the United States, many things other countries struggle with. And I can't wait to get back into my own bed, eat my own food, and enjoy bananas that are less than a dollar each. But I see we've got some catching up to do the more that I travel and the more I see the United States competing for jobs and dollars (and tourists, as more places become tourist-friendly).

    The American tech sector has done some amazing innovating internationally — Apple, Google, Facebook, Amazon, Uber, and Twitter are obviously all American creations — and our Kickstarter and Indiegogo campaigns are a great way to encourage and promote innovation, but I've come across so many interesting and smart Japanese creations that are so commonplace that I can tell they have clearly been around for decades.

    Hygiene and cleanliness are hugely valued in Japan, and it shows. From spotless, you-could-eat-off-the-floor food court bathrooms to wearing surgical masks to prevent upper respiratory infections, it's certain they value what's best for the group over individualism. (I can't even fathom what it would be like to grow up Japanese because my individualism seems so clearly tied to my sense of self, but it's fascinating to think about.)

    Here vs. There

    The Japanese also take such extreme pride in their work, and it's absolutely fascinating to watch. I find myself often jealous and wishing that was more common in America. I'm used to my food, purchases, or change in store being casually and hurriedly returned to me, but Japan has an in-the-moment Zen sense to everything (or they are really good at faking it). While waiting for my train to leave the station, I witnessed a young, Millennial-generation custodian notice a small paper receipt on the floor of our car. He entered, bowed, swept up the trash and then exited the car, bowing again. I'm not expecting that to happen tomorrow on the San Francisco subway, but when your city's escalator is shut down to clean the “sheer volume of human waste” found in its gears, you wonder if maybe we're doing something wrong.

    The Japanese are also incredibly polite, formal, and proper in a way that I'd probably be exhausted by, but it is really refreshing to see. I've seen co-workers bow to each other, and have now had two people stop what they were doing to provide me with directions. One shopkeeper left her cafe during lunch hours to walk me outside the shopping mall to show me where to go, and another walked into the rain, umbrella-less, to point me in the right direction.

    I'm not at all attempting to make political commentary; back at home, it's clear from the fervent support of Donald Trump and Bernie Sanders that a lot of people feel like our society and current political system aren't working for them. Whether it's health care or jobs, housing prices or taxes, a large portion of our society feels like our country isn't helping them enough. I know health care best, so I decided to take a look at how Japan's health care system operates. I found we have a lot of similarities, despite about double the cost in the United States.

    The 411

    Everyone in Japan is required by law to have coverage. Most people get their coverage through their jobs, but self-employed or unemployed people can participate in a national health insurance program. The patient typically pays some percentage of his total health bill.

    Japan doesn't seem to allow medical bills to bankrupt people, like we for some reason permit (about two million Americans will file for bankruptcy this year because of medical bills). (CNBC, June 25, 2013; Monthly cost ceilings are set for medical fees depending on income and age, and the government reimburses for fees above those ceilings.

    Japan also knows its doctors will try to upcode to game the system and make more money, so it re-assesses its reimbursement list every two years in response to demand. It slashed reimbursement for MRIs about 10 years ago when physicians started ordering tons of the test.

    Speaking of MRIs, the Japanese actually visit the doctor and use medical imaging way more than we do. They have four to six times as many MRI and CT scanners per capita than here, and the average Japanese person sees the doctor 13 times a year (but the average visit lasts seven minutes). This is in spite of Japan having a very low number of physicians per capita as well. (

    I head back home, dreaming of sushi, okonomiyaki, and tonkatsu, but still wondering how a capitalist, technology-embracing society like Japan uses so much health care, yet pays less than half of what we do, and ranks second in the world for life expectancy while we rank 43rd? (Infoplease;

    Share this article on Twitter and Facebook.

    Access the links in EMN by reading this on our website or in our free iPad app, both available at

    Comments? Write to us at

    Wolters Kluwer Health, Inc. All rights reserved.