3. Growth of Economy and Accomplishment of Universal Medical Insurance and Pension Programs: 1955-1964

(1) Overall Situation

Growing Economy and Improving the Standard of Living

• Our country's economy grew rapidly through a large-scale business boom chiefly led by capital investment, which started in 1955. In this process, the emphasis of the nation's industrial structure changed from one based on light industry to the heavy and chemical industries. This change of the industrial structure prompted people to migrate from farming villages to cities on a massive scale, and advanced in the nuclear family phenomenon.
  Then, during this economic growth period, people's standards of living improved substantially.

From Public Assistance Programs to Social Insurance Programs

• As people's living standards improved, in addition to relief measures for the needy, measures to prevent ordinary people from getting into poverty because of sickness or aging became more important. Therefore, a medical insurance and pension systems to cover all the citizens was introduced. This prompted a shift from a period of public assistance programs financed by public funds to a period of social insurance programs in which participants pay insurance premiums and prepare themselves for such risks as sickness and old age.

Achieving Universal Insurance

• Our medical insurance system was on the verge of collapse right after World War II because sufficient insurance benefits could not be provided. After that, the rebuilding of the system was underway, but about 30 million people were still not participating in this system in 1956. Under these circumstances, the Four-Year Plan was created to expand the application of the National Health Insurance, a community-based insurance program. Later in 1961, those, such as the self-employed and farmers, who were not covered by the Employees' Health Insurance were enrolled in the National Health Insurance on a compulsory basis, thus achieving universal medical insurance coverage for the entire nation.

• Along with the achievement of universal medical insurance, aid measures were implemented for developing medical care facilities to meet increasing demand for medical care. Along with financial assistance to public medical care facilities such as national and public hospitals, loans for the welfare of insured persons were provided, using the pension reserve funds as a financial source. In addition, the Medical Finance Corporation was founded in 1960 for the exclusive purpose of providing long-term low-interest financing for facilities and equipment of private medical institutions, and this resulted in a rapid development in medical facilities.

Measures Against Tuberculosis and Other Illness

• During this period there was a remarkable improvement in the fight against tuberculosis, which had been called a "national disease" since prewar days. Beginning in 1950, domestically manufacturedstreptomycin and PAS (p-aminosalicylic acid) were covered by medical insurance and became generally available, resulting in a dramatic improvement in the mortality rate. Beginning in 1951, a wide range of public health measures began to be implemented. Schools and companies started giving regular screening, BCG vaccinations were administered, and a patient registration system and home-visit guidance by public health nurses were initiated. It is believed that BCG vaccinations resulted in a sharp drop in the morbidity of tuberculosis. Further progress in the fight against tuberculosis occurred in 1955, when regular screening was expanded to include all Japanese citizens, and beginning in 1957 all tuberculosis screening, tuberculin tests and BCG vaccinations were administered at public expense, resulting in the firm establishment of the tuberculosis control measures. A private national organization called the Japan Anti-Tuberculosis Association also played an important role in surveys/research, public education and treatment, and prevention at the community level in close cooperation with a community organization called the Women's Anti-Tuberculosis Association (most of whose members were housewives) which was active throughout the country.

• A law on Hansen's disease was enacted immediately after the war under the policy of isolating patients in specialized hospitals and livelihood security measures were established. However, in 1963 a resolution was passed at the International Leprosy Society meeting, requesting that this illness should be handled in the same manner as other communicable diseases. Upon passage of this resolution, efforts were made for public education on this illness by such means as establishing a "Week to Properly Understand Leprosy." However, the isolation policy itself remained unchangedresulting in a delay in the patients' social rehabilitation until the ultimate abolishment of the Leprosy Prevention Law in 1996.

Promoting Maternal and Child Health

• Once the postwar chaos was over and the problems of food supply and communicable diseases had subsided, there was a movement away from a one-sided emphasis on measures for social defense,towards an emphasis on improving the health level of citizens. In the field of health, lowering the infant and child mortality rates is a major policy issue, and maternal and child health measures were energetically promoted. Although the Pregnant and Lactating Women's Health Handbook had been issued since the war time, it was revised to become the Maternal and Child Health Handbook. This has been used for keeping health records concerning pregnancy, childbirth and child care. Health examinations and guidance for mothers and children were actively conducted.
  Moreover, comprehensive health examinations have been carried out for all three-year-olds since 1961, and in 1965, the enactment of the Maternal and Child Health Law provided an opportunity for providing examinations for pregnant women at medical institutions among other measures. In particular, "community-wide activities" in all areas of the country were unique feature of maternal and child health activities during this period. Measures were promoted involving government and citizens working together, including the activities of local members (mostly housewives) of the Boshi Aiiku-kai (Imperial Gift Foundation), a private national organization which had existed since prewar days, in providing health examinations and health guidance as intermediaries between community residents and health centers.
  As one health maintenance measure aimed at school children, students, etc., the School Health Law was enacted in 1958 to enable health examinations and efforts to maintain and improve a hygienic environment in schools.

• The spread of family planning should also be mentioned in the context of motherhood protection.During the period of rapid population growth after the war, there was a rash of artificial abortions which were conducted illegally or by amateurs, and the high mortality rate among pregnant and nursing mothers was a threat to maternal health. In order to remedy this situation, the Eugenic Protection Law was enacted in 1948, and after several revisions, artificial abortion was virtually legalized. At the same time, in order to deal with the rise in the number of artificial abortions after legislation, the idea of "family planning" has been promoted since 1952, with the aim of allowing parents to have only as many children as they wanted, when they wanted. As a means to this end, conception control guidance was offered at health centers and other facilities. Since 1955, practical measures have been introduced including the sale of contraceptive drugs and devices by instructors for conception control (public health nurses, midwives and nurses all of whom were with specialized training). At the same time, deliveries at medical institutions sharply rose. As a result, the maternal mortality rate fell by more than half, from 178.8 in 1955 to 87.6 in 1965. In addition, the total fertility rate, a statistic showing the total number of children that a woman bears in her lifetime, sharply fell from 4.3 in 1949 to 2.0 in 1957.

Realization of a Universal Pension

• The pension system plays an important role in preventing a reduction in income accompanying the transition to old age, disability or the death of the main income earner. Our country's pension system was initially developed for employees, but, having experienced the period of confusion following the war, from the second half of the 1950's on, there were increased demands for old age income security for the self-employed and farmers as well. Therefore, in 1961, the National Pension was inaugurated with the coverage for these types of people and a universal national pension was realized.

• Under this system, self-employed people and farmers started paying into the National Pension program at age 20, and could begin receiving fixed old-age pension benefits at age 65. Fatherless families and people with disabilities also are eligible for pension benefits. In addition, welfare pensions all of which were borne by the National Treasury were paid to those who were already elderly and therefore could not receive contributory pensions, and to fatherless families and people with disabilities both of whom had low incomes.

Welfare for People With Mental Retardation, Elderly People and Mothers With Dependent Children

• In the field of social welfare, in addition to child welfare and welfare for people with physical disabilities which had already been promoted in earlier periods, policy issues were also raised with the aim of improving the lives of people with mental retardation, elderly people, and fatherless households. Laws were established to this end, and a) welfare measures were implemented to establish residential facilities for adults with mental retardation over the age of 18; b) a system of nursing homes for the elderly was established for elderly people needing care; and c) maternal and child welfare loan funds and welfare facilities for fatherless families were established to provide for fatherless families. Through these efforts, the above-mentioned system of the three welfare laws became the "six welfare laws" system by adding the Law for the Welfare of People With Mental Retardation, the Law for the Welfare of the Elderly and the Maternal and Child Welfare Law.

Discussion of Social Security Policies

(1) Universal Medical Insurance and Pension Programs

• The establishment of the universal medical insurance and pension programs opened the door to the age of social insurance. There is a great significance in establishing a core system to maintain national health and to secure post-retirement life in our country through these efforts.

1. Background for Achievement
   
   

   a.

   A background for achievement was provided as the Japanese economy and society began to recover from the postwar chaos, when the Japanese people called strongly for the establishment of a social security system which would include all citizens. About 30 million people were not covered by the medical insurance system, including employees of very small companies, the self-employed and farmers. This became a serious social problem because once these people became sick or injured, they often needed public assistance because of diminished income and increasing medical bills. Also, the feudalistic family and inheritance systems were reformed after the war, and this caused very different attitudes towards the support for families. Under such circumstances, farmers, self-employed people and others who did not receive pensions for employees were deeply worried about planning for old age, and they called strongly for improvements of the pension system. Thus, although the country was in a very serious situation of economy and finances, expansion of the social security system had become a vital political issue.

   
   

   b.

   Various ideas were adopted in order to facilitate the process of achieving universal medical insurance and pension programs. In terms of the medical insurance system, the National Health Insurance which was a community-based insurance program was expanded to cover the previously-uninsured, and workers at companies with less than five employees were included so as not to increase the burden on extremely small employers. In order to strengthen the National Treasury's support for the National Health Insurance, the insurers of which are the municipalities, the proportional burden (the National Treasury's fixed proportion of insurance financing) was supplemented by a financial adjustment system (by which the National Treasury's support was increased preferentially to financially weak municipalities). When this system was first implemented, the benefit ratio was limited to 50% in order to control the insurance premium burden as much as possible. Although the National Pension was based on contributions, a supplementary and provisional system with non-contributory pensions (welfare pensions) was adopted out of consideration for fatherless households, people with disabilities, and those who had already reached a certain age and did not have sufficient time to contribute. Moreover, in order to stabilize the contributory pension system and ensure that premiums would not be wasted, a lump-sum death benefit was instituted in cases of early death, and those who wished were allowed to start drawing a pension at age 60, without reaching the pensionable age of 65.

   
   
   
2. Significance
   
   By means of the universal medical insurance and pension programs, Japan's social security systems moved away from a system of " ex post facto relief" for the needy and towards "poverty prevention." In medicine, a universal medical insurance system meant that all citizens were covered by public medical insurance, and access to medical care was secured from an economic standpoint. In addition, it must be noted that the universal medical insurance system resulted in a switch from uninsured medical practice to insured one on the part of medical institutions partly because of the need to ensure a stable income. Thus, under the medical insurance system, medical standards across the country became more uniform, but medical fee revisions meant that the issue of medical costs often tended to become a political issue because they were resolved through deliberation between representatives of insurers and medical institutions at the central level.
   
   
3. Issues
   
   As a practical measure, the universal medical insurance and pension programs preserved a system which was segregated depending on the participant's trade or profession, resulting in a dual structure of workplace-based insurance for employees and the National Health Insurance/National Pension programs which embraced those who were not covered by workplace-based insurance for employees.
   For this reason, a differential or imbalance of benefits and payments between the two systems has continued to be an issue. In particular, as the population aging and workers moving away from primary industries into secondary and tertiary industries, those insured under the National Health Insurance grew gradually older, and there was less of an increase in farmers and other participants in the National Pension, so that the financial strength of both systems was affected.

• Maternal and child health measures were highly successful during this period. Through health guidance using the Maternal and Child Health Handbook and health checkups for three-year-olds, Japan's infant and child mortality rates were lowered to one of the lowest in the world.
  This was due to comprehensive guidance and health education targeted to the mass. It should also be mentioned that a dramatic improvement in health standards was achieved through means such as mass screening and group vaccination aimed not only at mothers and children, but at most Japanese citizens through public health efforts in schools and workplaces to combat tuberculosis, which is a "national disease" and other illnesses. A famous example is the nationwide administration of oral live polio vaccines in 1966, which lead to successful prevention of the polio epidemic. Such nationwide health measures were possible because there were no extreme differences among citizens in living standards, knowledge and educational level, so they were able to understand and accept the guidance of public health nurses without any particular resistance.

• In addition, "community-wide" activities enlisting the cooperation of private community organizations (such as the local branches of the Boshi Aiiku-kai, the Women's Anti- Tuberculosis Association and dietary life improvement promoters) must not be discounted, and these activities by local organizations were aided by subsidies from the national government.