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Foreign Workers and Health Insurance in Japan: The Case of Japanese Brazilians. Hiroshi Kojima. Abstract. This is a preliminary analysis of a 2004 survey of ...

The Japanese Journal of Population, Vol.4, No.1 (March 2006)

Foreign Workers and Health Insurance in Japan: The Case of Japanese Brazilians Hiroshi Kojima

Abstract This is a preliminary analysis of a 2004 survey of Japanese Brazilians conducted by Iwata City in Shizuoka Prefecture.

According to the survey results, only 28.3% of Japanese Brazilians are

covered by any health insurance.

Among them a little more than 30% are covered by the

Employer’s (Health) Insurance (Shakai Hoken) while only a little more than 40% by the National Health Insurance (Kokumin Kenko Hoken) and a little more than 20% by other types of health insurance.

This analysis has revealed that the coverage and type of health insurance affect medical

care (health-seeking) behaviors of Japanese Brazilians when they get sick or injured.

It has also

found that the ability to collect information and to communicate, including fluency in Japanese language, and the necessity for health and medical services (particularly among those with infants and young children) also affect health insurance coverage and medical care behaviors.

As previous

studies found, this analysis has found that the type of employment (direct or indirect) affects the coverage and type of health insurance, and that the characteristics related to the employment type, including monthly income, housing, work hours, number of job changes, may also affect the ability to collect information and to communicate, and the necessity for health and medical services. Japan’s social integration policy for international migrants, including health insurance, medical care and language-teaching programs, should strengthen the linkage between international migration policy and social security policy. Key Words: Japanese Brazilians, international migrants, health insurance, medical care

returning home is only up to three years’

Introduction

contribution.

In Japan, many foreign workers are not

Foreign workers who expect to

Most

stay in Japan for more than 3 years are likely to

undocumented foreign workers are not covered

lose additional returns on their contribution

by the Japanese health insurance program due to

unless they come back to stay and contribute for

their

25 years in total.

covered

by

health

residence

status.

insurance.

Even

documented

foreign workers are not necessarily covered

Thus, many foreign workers have an

partly because their contribution is collected

incentive to avoid the contribution to the

together with the contribution to the Japanese

Japanese old-age insurance program. In doing so,

old-age insurance program, which requires at

they must unwillingly avoid the contribution to

least a 25-year payment for entitlement to receive

the Japanese health insurance program.

pension.

of

foreign workers are not covered by health

reimbursement when they opt out at the time of

insurance also because their Japanese employers

The

maximum

amount

78

Many

The Japanese Journal of Population, Vol.4, No.1 (March 2006) naturally have an incentive to avoid making a

shift

matching contribution for their workers in order

subcontracting/outsourcing companies (wherein

to cut labor costs.

the subcontracting company manages its workers

They can also avoid the

some

factory

workers

from

of

at the factory) to dispatching companies (wherein

employment is for less than two months, which

the factory manages the workers) and which may

has increased the number of Japanese and foreign

also increase the number of workers on a

workers on a short-term contract of less than two

short-term contract.

months.

foreign workers is not clear because language

matching

contribution

if

the

contract

Among foreign workers, Japanese

However, its effect on

Brazilians are often working on a short-term

and other skills are required to manage them.

contract because they are often employed

any case, there may be no change to the tendency

indirectly

of employers to avoid the matching contribution

by

subcontracting/outsourcing

In

to the Employer’s Insurance Program.

companies which subcontract workers for work done at a factory on a weekly or monthly basis,

Private medical insurance in Japan only

instead of being employed directly by the factory

supplements the parts not covered by the

or the company owning it.

patient’s Japanese health insurance programs and

Consequently, many

Japanese Brazilians cannot join the Employer’s

cannot be used as an alternative.

Some

Insurance (Shakai Hoken) Program.

short-term foreign workers are enrolled in a

Some subcontracting companies encourage

travel insurance policy at home or in Japan, but

their workers to join the National Health

many of them end up being uninsured, putting

Insurance (Kokumin Kenko Hoken) Program.

them at greater health risk.

However, the National Health Insurance Program,

with the travel insurance is that it does not cover

which is a municipality-based program and

the whole family and the children can be exposed

primarily

to an even greater health risk.

for

the

self-employed

and

the

Another problem

non-employed, also requires those covered to pay

However, it is not easy to make special

contributions to the National Pension (Kokumin

legal arrangements for foreign workers under the

Nenkin) Program.

principle of equality among nationalities.

In addition, the contributions

are usually higher than for the Employer’s

Japanese

Insurance Program because there is no matching

contributions from foreign workers and their

contribution from the employers even though it is

employers, it may increase underground work

subsidized by tax revenue.

even

Due to the

Government

by

documented

tries

to

If the

foreign

enforce

workers,

Program’s deficits, some local municipalities do

particularly Japanese Brazilians who have a

not

subcontracting

special residence status to stay and work in Japan

companies (often Japanese Brazilians among

without any qualification requirements or time

foreign workers) to join the Program because

limit since the 1989 revision of the immigration

they are virtually employed continuously for

control law.

more than two months by the same company and

control law, but the labor law should also be

are supposed to join the Employer’s Insurance

coordinated with the social security law to

Program.

increase the coverage of foreign workers by the

permit

employees

of

health insurance and possibly the old-age and

A new law to allow the dispatch of non-specialized

workers

(including

Thus, not only the immigration

labor accident insurances.

factory

According to the results of a survey

workers) was implemented in 2004, which may

79

The Japanese Journal of Population, Vol.4, No.1 (March 2006) conducted by Iwata City in 2004, only 28.3% of

Literature Review

Japanese Brazilians are covered by any health

There

insurance.

empirical

Among them a little more than 30%

are

not

studies

on

too the

many

Japanese

health

insurance

(Health)

coverage of foreigners and on health behaviors,

Insurance while only a little more than 40% by

while there is an increasing number of studies on

the National Health Insurance and a little more

these topics in the US and Europe (e.g., LeClere

than 20% by other types of health insurance.

et al. 1994, Ku and Matani 2001, Yu et al. 2004,

Major problems regarding the medical care of

Prentice et al. 2005, Migrations: Études 2002,

foreigners are broken down into the following

2004) due to their policy-oriented interests.

two by Ikegami (2002): 1) burden of medical

relative lack of Japanese empirical studies is

care costs due to non-coverage by health

partly due to the limited availability of both

insurance; and 2) communication gap at medical

micro-

care facilities due to lack of Japanese language

collected for administrative purposes in Japan,

fluency.

and partly due to the limited interests of Japanese

are

covered

by

the

Employer’s

and

scholars

This study examines the determinants of

macro-data,

studying

particularly

international

The

those

migrants.

care

Fukawa (1997) may be the only study showing

medical care

macro-data for the health insurance coverage of

facilities, drawing on micro-data from the 2004

Japanese Brazilians at the prefecture level, which

survey of Japanese Brazilians in Iwata City.

It

showed a relatively low coverage by the National

tries to derive implications for possible measures

Health Insurance and the variation among local

to help foreign workers get Japanese health

municipalities.

insurance coverage and maintain a healthy life,

first survey-based work on the health and

with a focus on Japanese Brazilians.

health-related behaviors of Japanese South

health

insurance

coverage,

behaviors and troubles with

medical

It also

Hochi et al. (1992) may be the

seeks to explore the ways to modify and

Americans including Brazilians.

coordinate immigration control, labor and social

Ikegami (1998) drew policy implications from

security laws without distorting the equality

the results of a survey of participants in a

among workers of different nationalities and

medical

without endangering the health of foreign

Unfortunately, these Japanese surveys tend to be

workers staying in Japan.

too small in scale or tend to use samples too

This is particularly

NGO’s

free

health

Hayashi and

examination.

important for Japanese Brazilians because many

selected for statistical analysis.

of them are likely to stay in Japan more or less

2004 Iwata survey had about 500 usable cases,

permanently.

which

Kojima

preliminary

The present author has been interested in

(2005a)

analysis

on

has

However, the conducted

health

a

insurance

the social integration of international migrants

coverage, medical care behaviors and attitudes,

and has conducted both theoretical research (e.g.,

while Chitose (2005) and Takenoshita (2005a,

Kojima 1993) and empirical research (e.g.,

2005b, 2006) analyzed them from a different

Kojima 2003, 2005b).

focus (children and income).

This is an extension of

Kojima (2005a), which shares with Kojima

No hypotheses are constructed in advance

(2005b) the author’s interest in the relationship

due to the lack of past empirical studies in Japan.

between migration and health.

However, this study will broadly draw on the analytical frameworks presented by the (U.S.)

80

The Japanese Journal of Population, Vol.4, No.1 (March 2006) Institute of Medicine (2001: Fig. A.1, 2.2; 2003:

report (Iwata City 2005), the aim of the survey

Fig. 1.1, 1.2) for the interpretation of the results.

was

This is still a preliminary study in this sense.

improvement of measures for foreign citizens

to

collect

basic

information

for

the

and to promote multicultural cohesion in its policy planning.

Data and Method

Americans

Iwata City is located near the western end

The subjects were South

(mostly

Brazilians

of

Japanese

of Shizuoka Prefecture (near the center of the

descent) aged 18 and above living in the city

main island along the Pacific coast), next to the

(with usable questionnaires for 497 respondents).

major industrial center of Hamamatsu City and

The

not too far from Toyota City in the eastern part of

distributed, and the self-enumerated ones were

Aichi Prefecture (capital city: Nagoya).

Iwata

collected between August and October 2004.

is also an industrial city itself with manufacturers

The items questioned included demographics,

of

to

work, housing, health insurance and medical care,

a

living conditions and attitudes, language learning,

machinery

automobiles

including

and

those

motorcycles.

related It

has

questionnaires

in

Portuguese

were

children’s education and future plans.

population of almost 170,000, of which almost 5% are registered foreigners after the integration

This analysis has applied, to the 2004

of the city with surrounding towns on April 1,

Iwata survey data, the binomial logit model with

2005.

The percentage of foreigners was about

stepwise selection of independent variables

6% at the time the survey was conducted between

constructed from answers to related questions as

August and October 2004 even though the total

well as demographic, socioeconomic and cultural

population was nearly one half the current

characteristics.

population.

procedure.

More than three quarters of

It has used the SAS/LOGISTIC The frequency distribution of

registered foreigners are Brazilians (mostly those

dependent variables is presented in Appendix 1

of Japanese descent and their family members).

and that of independent variables in Appendix 2.

In terms of absolute number, Iwata City had 6,597 registered Brazilians as of June 30,

Results

2005.

1. Health Insurance Coverage

But the city proper had 3,713 as of

Table 1 shows the results of the logit

March 31, 2004, which is one year before the The

model with stepwise selection for determinants

number of Brazilians in 2004 has almost doubled

of health insurance coverage, type of insurance

from 1997 (1,875) and has grown by 50% from

and reason for non-coverage.

2001 (2,566).

based on the response to Question 21 which is as

integration

with

surrounding towns.

The proportion of foreigners to

The analysis is

follows:

the entire population has grown steadily from 0.9% in 1991, 2.0% in 1994, 3.6% in 2000 to 5.3% in 2004.

Q21. Are you covered by any type of

It has declined a little to 4.9% in

2005 after the integration.

health insurance?

In terms of

1) Covered (Circle one that is applicable)

percentages among households, however, those

A.

headed by foreigners represent 8.2% in 2005.

Health

Insurance

(Kokumin Kenko Hoken)

This study draws on micro-data from the B.

sample survey of Japanese Brazilians conducted by Iwata City in 2004.

National Employer’s Hoken)

According to the survey

81

Insurance

(Shakai

The Japanese Journal of Population, Vol.4, No.1 (March 2006) of each.

C. Travel Insurance D. Others (

The first column in the upper panel

shows the determinants selected for health

)

insurance

2) Not covered (Circle all that are

coverage.

Among

Japanese

Brazilians, those aged 25-29 or 45+, those with

applicable) (M.A.) A. The employer refuses to cover.

two children, those who first arrived in 1991-92,

B. It is too costly.

those who first arrived to visit relatives, those

C. It is difficult to understand the

fluent in Japanese and those wishing to study Japanese are more likely to be covered by health

Japanese insurance system. D. I plan to return home soon.

insurance.

E. Others (

who never changed jobs or changed jobs once,

)

But those employed indirectly, those

those living in housing contracted by the The last two types of insurance (travel

employer and those uncertain about obtaining

insurance and others) are collapsed into one

Japanese nationality are less likely to be covered

category, “others” because of the low frequency

by health insurance.

Table 1

Determinants of Coverage, Type of Insurance (if covered) and Reason for Non-Coverage (if

not covered) Significant Independent Variables Positive Effects

Q21: Coverage Covered by Any Health Insurance Age: 25-29 Age: 45+ # of Kids: 2 First Arrival: 1991-92 Purpose of 1st Visit: Relatives Speak Japanese: Yes Wish to Study Japanese: Yes

Negative Effects

Type of Employment: Indirect Marital Status: Single Type of Employment: Indirect Contact with Japanese: # of Job Change: 0 # of Job Change: 1 Consulting Housing: Company Contract Apt Plan for Japanese Nationality: Undecided

Significant Independent Variables Positive Effects

Q21 (if not covered) Reason for Non-Coverage (M.A.): Refusal by Employer Too High Cost

Negative Effects

Marital Status: Single

(Source)

Q21(if covered): Insurance Type National Health Insurance Employers' Insurance Marital Status: Single First Arrival: 2003-04 Housing: Private Apt Housing: Public Japanese-Speaking Kid: Yes

First Arrival: 2001-02 Type of Employment: Indirect First Arrival: 1995-96 Daily Work Hours: 9-10 Kid's Schooling: Brazilian C Care Contact with Japanese: Consulting Contact with Japanese: None Info Source: Brazilian Paper Kid's Schooling: Brazilian Sch

Kid's Age: 0-2 Years in Iwata: 3 Type of Employment: Direct Community Assoc: Member Speak Japanese: Yes

Difficulty to Understand Insurance System Kid's Age: 15-17

Others Kid's Age: 15-17 Kid's Age: 18+ First Arrival: 1991-92 Daily Work Hours: 11+ Housing: Company Dorm/Apt

Living with: Kids

Plan to Return Soon Age: 40-44 Age at 1st Arrival: 15-19 Years in Iwata: 1 # of Job Change: 0 Info Source: Brazilian Paper Kid's Schooling: Brazilian Sch

Wish to Study Japanese: Yes Housing: Public Living with: Kids Speak Japanese: Yes Plan for Japanese Nationality: No

Microdata from the Iwata City Survey of Brazilians (2004).

82

The Japanese Journal of Population, Vol.4, No.1 (March 2006) The

As mentioned qualitatively in previous

fourth

column

presents

the

studies, indirect employment has a negative

determinants selected for coverage by other types

effect on health insurance coverage.

of

Japanese

insurance,

including

travel

insurance.

Brazilians who speak Japanese fluently seem to

Japanese Brazilians with children aged 15+,

be in a better position to negotiate with the

those who first arrived in 1991-92, those working

employer for coverage.

Those with two

for 11 hours or more per day, and those living in

children should have greater needs for health

company dormitory or apartment are more likely

insurance coverage to insure their children,

to be covered, while those living with children

particularly when they are small.

are less likely.

This seems to imply that older

When we look more closely at the factors

Japanese Brazilians who came to Japan alone are

affecting whether the respondent is covered by

more likely to be covered by other types of

each kind of health insurance in the following

insurance. The lower panel of Table 1 shows the

three columns in the upper panel, the following As for the determinants

results for reasons of non-coverage among

selected for coverage by the National Health

Japanese Brazilians who are not covered by any

Insurance (Kokumin Kenko Hoken) in the second

type of health insurance.

column, single Japanese Brazilians, those who

presents the determinants selected for refusal by

first arrived in 2003-2004, those living in a

the employer as a reason for non-coverage.

private apartment or public housing, and those

Japanese Brazilians employed indirectly, those

with Japanese-speaking children are more likely

working for 9-10 hours per day, and those

to be covered.

Those employed indirectly are

sending their children to a Brazilian childcare

less likely to be covered, which may be less

center are more likely to be not covered by health

readily understandable than if covered by the

insurance due to the refusal by the employer,

Employer’s Insurance (Shakai Hoken).

possibly because they have less negotiation

points become clearer.

Perhaps

The first column

it implies that those directly employed are more

power.

likely to be covered by the National Health

likely to be not covered for this reason, probably

Insurance even if they could not be covered by

because they are more likely to be covered by the

the Employer’s Insurance.

National Health Insurance as shown by the second column in the upper panel.

The third column shows the determinants selected

Employer’s

The second column in the lower panel

Japanese Brazilians with children

shows the determinants selected for high cost as

for

Insurance.

Single Japanese Brazilians are less

coverage

by

the

aged 0-2, those living in Iwata for 3 years, those

a reason for non-coverage.

employed

the

who first arrived in 1995-96 or 2001-2002, those

community association (Chonai-kai), and those

contacting Japanese for consultation or those

fluent in Japanese are more likely to be covered,

who have never contacted them, those for whom

while single Japanese Brazilians and those

Brazilian papers are their information source, and

contacting Japanese for consultation are less

those sending their children to a Brazilian school

likely.

As expected, those employed directly,

are more likely to be not covered by health

those fluent in Japanese and those with greater

insurance due to the high cost, possibly because

needs are more likely to be covered by the

they are more interested in saving money for

Employer’s Insurance.

their life in Brazil.

directly,

those

who

joined

83

Japanese Brazilians

Japanese Brazilians wishing

The Japanese Journal of Population, Vol.4, No.1 (March 2006) upper panel.

to study Japanese are less likely to be not covered for the cost reason, probably because

The last column presents the determinants

they are more likely to be covered by whatever

selected for plan to return soon as a reason for

health insurance as shown by the first column in

non-coverage.

the upper panel.

those who first arrived at ages 15-19, those living

Japanese Brazilians aged 40-44,

The third column presents the determinants

in Iwata for one year, those without job changes,

selected for difficulty to understand the Japanese

those for whom Brazilian papers are their

insurance system as a reason for non-coverage.

information source, and those sending their

Japanese Brazilians with children aged 15-17 are

children to a Brazilian school are more likely to

more likely to be not covered for this reason

be not covered for this reason possibly because

possibly because their children who have not

many of them are new-comers migrating to Japan

received Japanese education cannot help their

just to work for a short period.

parents

Japanese

Brazilians living with children are less likely to

Brazilians living in public housing, those fluent

be not covered for this reason possibly because

in Japanese, and those not planning to obtain

they are covered by the National Health

Japanese nationality are less likely to be not

Insurance or the Employer’s Insurance or they

covered for this reason probably because the first

are not covered for other reasons as shown by the

two groups are more likely to be covered by one

rest of Table 1.

understand

the

system.

Japanese

of the two major insurances as shown in the Table 2

Determinants of Medical Care Behaviors

Significant Independent Variables Positive Effects

Negative Effects

(Source)

Q22: Behavior in Case of Desease or Injury Go to Doctor Buy Medicine

Others

Age: 45+ Housing: Public

Years in Iwata: 0 Monthly Income:

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