Topic: Health coverage: who's required to have it, and who actually pays
What does Japan require?
Everyday topic
Japan reached universal coverage on 1 April 1961, when the 1958 National Health Insurance Act required every municipality to run a kokuho scheme. The system runs on three tiers: employees' insurance (shakai hoken), municipal kokuho for the self-employed, and a separate system for age 75 and up. Patient co-payment scales by age under Article 74 of the Health Insurance Act — 30% for ages 6–69, generally 10% for 75 and older. Kyokai Kenpo's FY2026 national average premium rate is 9.9%, split evenly between employer and employee. A foreign national with residence status over three months must enroll in kokuho within 14 days of moving. The high-cost ceiling caps monthly out-of-pocket spending — roughly ¥80,100 plus 1% of costs above a threshold, for a mid-income household.
What is this topic?
Taiwan's National Health Insurance Act declares enrollment mandatory in its very first article, launched in March 1995, with premiums split employer 60%, insured person 30%, government 10%.
Japan closed the last gap in "universal coverage" only in 1961, after a 1958 law forced every municipality to run its own scheme; patient co-payments still scale by age, from 10% at 75-plus to 30% between 6 and 69.
Indonesia's 2004 SJSN Law states outright that "participation is compulsory," and a foreign worker becomes covered after six months on the job — almost the same threshold Taiwan uses.
Brazil's SUS is the direct product of Article 196 of its 1988 Constitution, "health is a right of all and a duty of the State," free to anyone within its borders.
China, by contrast, reports 95% nominal coverage, but its employee and resident schemes reimburse hospital stays at rates 18 points apart — 84.1% versus 66.0%.
India has no universal mandate at all: PM-JAY reaches only the poorest 40% of households, and out-of-pocket spending still runs 43.4% of the total.
The United States is the only one of the seven with no coverage guarantee whatsoever — its federal mandate has existed in name only since 2019, 8.0% of the population remained uninsured in 2024, and it spends more per person on healthcare than any other.
Sources and dates
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