Charging patients for copayment of medical expenses has the following three main purposes.

1） To avoid the moral hazard of excessive use of medical resources

2） Cost shifting to shift the finances for medical expenses from public subsidy and insurance premiums to patients

3） To moderate the excessive orientation toward large hospitals and other inappropriate behavior of patients in selecting hospitals

Japan's public healthcare insurance system controls the medical expense copayments of patients through the official copayment rate and the high-cost medical care expenses system. The high-cost medical care expenses system places a cap on patient copayments, enables patients to receive high-cost medical care, and may be called a safety net for medical expenses payments.

While medical expenses continue to rise, the patient official copayment rate is being increased because medical insurance finances are worsening. As a result, the maximum copayment amount is being reached in a growing number of cases, and high-cost medical care expenses are rising. The percentage of high-cost medical care expenses in total medical expenses grew from 3.2％ in 2002 to 6.4％ in 2017.

Because of this increase in high-cost medical care expenses, even though the official copayment rate is on a rising trend, the effective copayment rate is declining. Specifically, the effective copayment rates were 22.7％ for patients age 74 or younger and 8.8％ for patients age 75 or older in 2003, and these declined to 19.7％ and 8.0％ , respectively, in 2017. Comparing the effective copayment rates between outpatient and inpatient treatment, the rates were 18.3％ for outpatient treatment and 6.6％ for inpatient treatment in 2017, with an extremely low effective copayment rate for inpatient treatment. This is because of the large expenditures paid as high-cost medical care expenses because of the high medical expenses for patients admitted to hospitals.

The official copayment rate for patients age 75 and older is set at 10％ in principle. The opinion has emerged that the health insurance premiums and copayment rates of the elderly are too low compared with those of the younger generation, and that therefore the copayment rates of the elderly should be increased. In contrast, others have noted that the elderly have low income and high medical expenses, and that their copayments constitute a higher percentage of their income than those of the younger generation, and argued that the copayment rates of the elderly should remain at 10％ to ensure their access to medical care. It took a long time to resolve this debate, but ultimately in 2020 the policy decision was reached that the copayment rate of seniors age 75 and older with annual incomes of at least ¥2 million will be increased to 20％.

There is no doubt that the pressures to increase patient copayment of medical expenses will intensify in the future as well. In that process, the key issues will likely be further increasing the official copayment rates of the elderly and revising the high-cost medical care expenses system.

Since its introduction, fixed amount out-of-pocket payment, whose main purpose is to optimize mild outpatients in large hospitals and to share functions with primary care doctors, has gradually expanded its scope of application. From the point of view of the purpose of the system, the fixed amount of out-of-pocket payment must be at a level sufficient to suppress the incentive to visit a large hospital, but on the other hand, it must not greatly hinder necessary consultations such as in severe cases.

How to accept the fixed amount out-of-pocket payment might be different for each individual, and how important fixed amount out-of-pocket payment in comparison with various other conditions has not investigated. We examined what factors and attributes affect the relative importance using conjoint analysis based on the data collected from the web survey.

As a result, it was suggested that the importance of the fixed amount of out-of-pocket payment when deciding to see a doctor is（1）there is a gender difference,（2） the relative importance of the elderly is low, and（3）the relative importance increases in the group with low annual household income.

This study compared out-of-pocket payment systems in Japan, Germany, France, and the United Kingdom. Points of comparison included age, income, disease and disability, high-cost medical treatment, pharmaceuticals, in-hospital and outpatient care, and hospital consultation. Compared to Germany and the United Kingdom, out- of-pocket payment systems are more complex in Japan and France, playing an important role in medical finance systems. The payment rate is lower for the elderly compared to other age groups in Japan and the United Kingdom, but the amount of out-of-pocket payments is small in the United Kingdom. Out-of-pocket fees and gatekeeping in medical delivery systems are not strongly related in Japan, unlike other countries. These differences among the four countries are attributable to differences in not only medical systems but also history and philosophy of social security.

Cost containment policy is regarded as pivotal in the face of threatened financial sustainability due to aging and low fertility, while the discussion on contribution fairness and protection against household' s catastrophic payment to healthcare service has been left behind. Using the microdata derived from the most recently available microdata of the National Survey of Family Income and Expenditure, we assessed the prevalence of catastrophic payment due to healthcare services expenditure, and contribution fairness according to the household' s ability to pay. Our estimation indicated that the current system effectively protect against catastrophic payment due to medical services covered by the public medical insurance scheme, though the non-ignorable portion of households, especially with low capacity pay and higher long-term care demands faced the catastrophic impact of wider healthcare service expenditures. Fairness in financial contribution was well reserved thanks to the recently improved progressivity in direct tax contribution, though the regressivity in out-of-pocket copayment and social insurance premium payment was strong. The results indicated that the policy discussion on the healthcare financing should consider the potential impact of selective copayment rate rising in older households and stagnated economy due to COVID-19.

Health policy making is very complex political process involving the interactions between multiple governmental agencies and pressure groups, requiring long time, and affected by socio-economical ups-and-downs and national elections. At the end of 2020, two policy issues reached conclusions under the COVID-19 calamity: the introductions of 20% patient burden into the Health Insurance System for the Late Elderly, and the increased outpatient burden without referral when visiting large hospitals. Why did these things happen?

To answer why, this study did three things: the historical and institutional considerations on the strengthening of the Cabinet, the development of the governance structure of actors and conference bodies, and the process tracking of the above two issues. Findings are (1) under the parliamentary cabinet system and the stable majority of the ruling party the reform of the political system in 1994, the repositioning of the governmental agencies and conference bodies in 2001, and the gradual strengthening of the cabinet functions in later years, helped the cabinet to have more efficient consensus making mechanisms than before, and (2) appropriate measures were wisely adopted, depending on the level of political difficulties, which in turn depends on the unique features of the issue (and their effects on national election) and the level of the resistance by the opposing pressure groups. Limitations of the study were also discussed.

The government decided to increase the co-payment for medical expenses for the elderly aged 75 and over. While this political decision is the first step toward increasing the financial sustainability of public medical insurance, the effect of the reform will be limited. In order to maintain the basic role of public medical insurance and increase the sustainability of medical finance, referring to the macroeconomic index slide introduced in the reform of public pension, it is worth considering the introduction of an automatic adjustment mechanism in the medical fee system for the elderly aged 75 or over.

・In Japan, with the declining birthrate and aging population, the existence of inter-generational burden disparities and severe financial constraints on medical insurance system will inevitably provoke discussion on heavier patients'financial burden.

・As the patients' out-of-pocket expenses increase, accountability for the medical fee points to the public and patients will be strongly required. It is then important to reform the medical fee system to make the system more understandable.

・It is necessary not only to discuss increase in patients' financial burden, but also to consider measures to reduce the increase, while maintaining or improving the quality of medical care, and it is also required to review incentives to patients to promote “choosing/saving wisely.”

・In order to enhance sustainability of the medical insurance system in Japan, “trinity reform” is important, under which “increase in patient's out-of-pocket expenses”must be combined with“improvement of understanding of the medical fee system from the patients' perspective” and “reduction of increase in patients' out-of-pocket expenses as incentives to promote “choosing/saving wisely.”

“Kenko keiei” or strategic management of worker’s health assets in worksite attracts increased attention in private and public sectors in Japan, while the concept has been treated and aimed at differently by a variety of stakeholders with distinctive interests. This paper took this heterogeneity in the conceptualization as given, and intended to map the sources of “Kenko keiei” concept and to match the measurement of construct of existing evaluation scale of the concept. Firstly, we identified that there are at least three different backgrounds that the concept of “Kenko keiei” originated from; namely, extension of occupational health management, visualization of human resource management to support external investor’s decision, and improved control of healthcare cost by the collaboration of public insurers with worksite management lines. According to the original background, different stakeholders in policy makers, private and public institutes were differently motivated to adopt the concept. Specifically, we discussed three main policy stakeholders; the Healthcare Industries Division, Ministry of Economy, Trade and Industry, the Health Insurance Bureau, Ministry of Health, Labour and Welfare, and the Labour Standards Bureau, Ministry of Health, Labour and Welfare. Finally, we analyzed existing evaluation scales and compared measurement constructs to match the different conceptualization of “Kenko keiei”. We conclude that the heterogeneity in the conceptualization successfully attracts a wider range of interests, though it may run the risk of miscommunication between the stakeholders that may hinder the implementation of the concept into practice. We argue that it is necessary for each practitioner of the concept to reflect its own organizational missions and to select, measure, and interpret evaluation measurement to effectively serve for their own strategies.