Household survey analysis of financial hardship due to health spending and unmet care needs of older people in Japan with implications for the Kansai region

Protection against financial hardship due to direct payments made for health care is an important element of universal health coverage (UHC). The causes, magnitude and consequences of health spending that exceeds specified thresholds needs to be well understood for designing better policies to prevent impoverishment and improve access to health care in the context of population ageing. Even in countries such as Japan that have achieved some of the highest standards of population health and health system development, population ageing presents a significant challenge to sustain progress toward UHC. Relatively little is known about the extent to which financial hardship due to health care utilization and financial barriers to health care access is a problem for the rapidly growing number of older people in Japan. Much less is understood about subnational/regional variations in this phenomenon. Experiences from Japan could yield helpful lessons for progressing towards UHC to meet the needs of older people.

To understand the current situation regarding both financial hardship due to out-of-pocket health spending that exceeds 10% of total household consumption and unmet care needs of older people in Japan with specific implications for the Kansai region.

1. Secondary analysis of the Japan Household Panel Survey (2004-2020) and the National Survey of the Japanese Elderly (2002-2021) to assess levels of financial hardship due to out-of-pocket health spending greater than 10% of total household consumption and unmet care needs among older people.
2. Consultation with relevant experts and key stakeholders in the Kansai region and analysis of publicly available health statistics to contextualize the research findings.

Based on the analysis of data from the Japan Household Panel Survey:

• In the total sample, during 2004–2020, the incidence of out-of-pocket health spending greater than 10% of total household consumption remained relatively stable, mostly ranging between 8.0%–10.0%, and peaking in 2007 at 12.4%. The incidence was higher among households with older person(s), ≥65 years old (range from 10.9% to 22.9%), than among households with only younger people, ≤64 years old (range from 5.2% to 9.9%). However, during the same period, the incidence of self-reported unmet need due to foregone care remained consistently higher among younger people (range from 6.2% to15.5%) than among those who were older (range from 1.8% to 8.6%).
• The financial consequences of health spending greater than 10% of total household consumption varied by household age structure. Statistical models of the impact of such high health spending in one year on other types of spending in the following year showed that households with older members reduced spending on food and social activities in the year following the high health spending more so than did households with only younger members, which tended to reduce spending on education instead. The results also showed that households with only younger members experienced an income decline in the year following the occurrence of the high health expenditure, while this effect was not found among households with older members.
• A U-shaped relationship was observed between age and the probability of experiencing unmet health care need where the probability was lowest for 55–60-year-olds and got progressively higher at younger and older ages.

From the pooled analysis of data from Wave 6 (2002) to Wave 10 (2021) of the National Survey of the Japanese Elderly, 60 years old and over:

• Among those reporting limitations in activities of daily living, 15.5% reported a lack of informal and formal care or support, and 62.5% had not yet been certified eligible to receive long-term care (LTC) services.
• Inequity in public LTC use by education level was observed particularly among women and those 80 years old and above. Those with higher education were more likely to use public LTC services, even after accounting for levels of need based on demographics, health, and functional status.

Based on the sub-analysis for the Kansai region and Hyogo Prefecture:

• The incidence rate of out-of-pocket health spending greater than 10% of total household consumption in the Kansai region was 7% among all households, lower than in other regions. The rates for both households with and without older members were lower than other regions as well (about 11% and 5%, respectively).
• The prevalence of self-reported unmet health care needs among adults of all ages was about 4%, which ranked in the middle compared to other regions. The rate among people ≤64 was lower (about 5%) but higher among those ≥65 (about 2%) compared to other regions.
• Based on publicly reported data on mortality and disability, the overall population health status of Hyogo prefecture has improved in the past 30 years but the noncommunicable disease burden has increased due to population ageing.

The interpretation and analysis of levels of out-of-pocket health spending as an indicator of financial protection coverage should consider differences by household age structure. Our study suggests that health spending greater than 10% of total household consumption may be more common among households with older persons, but the financial consequence may be greater for younger households that rely on employment-based income. Conversely, households with older people may be more resilient to such levels of health spending because their source of income (e.g., pension benefits) is not affected by their health status and they tend to have more savings. Moreover, it is important to assess the extent of unmet health care needs in addition to levels of out-of-pocket health spending, as health spending only results from health service use. Our study found that people both younger and older than those in the 55-60-year-old group have higher unmet health care needs, potentially due to different reasons. Younger people may forgo care because of their milder symptoms or opportunity costs of seeking care while older people may do so due to the high costs of care for multiple chronic conditions or physical barriers to access care. Thus, age-disaggregated data about unmet needs for health care along with the reasons why they forgo care is essential to more accurately understand and respond to their different needs.

Although Hyogo prefecture compares favourably to many other prefectures in terms of their population health metrics and levels of out-of-pocket health spending and unmet health care need, available health statistics show that the noncommunicable disease burden is increasing with the trend in population ageing. Continued efforts are needed to reduce behavioural risks, such as smoking, unhealthy diet, and insufficient exercise, as well as metabolic risks, such as hypertension, hyperglycaemia, and hypercholesterolemia in the population. Monitoring of household health spending, their impact on household finances, and unmet health care needs will also be important.

• Okamoto S, Yamada A, Kobayashi E, Liang J. Socioeconomic inequity in access to medical and long-term care among older people. International Journal for Equity in Health 24, 28 (2025). https://doi.org/10.1186/s12939-024-02345-7
• Preliminary results were described in the Global Monitoring Report on Financial Protection in Health 2021 (Box 5, p21). https://www.who.int/publications/i/item/9789240040953
• Okamoto S, Komamura K. Towards universal health coverage in the context of population ageing: a narrative review on the implications from the long-term care system in Japan. Arch Public Health. 2022;80:210. https://doi.org/10.1186/s13690-022-00970-8
• Sano J, Hirazawa Y, Komamura K, Okamoto S. An overview of systems for providing integrated and comprehensive care for older people in Japan. Arch Public Health. 2023;81:81. https://doi.org/10.1186/s13690-023-01076-5
• Okamoto S, Sata M, Rosenberg M, Nakagoshi N, Kamimura K, Komamura K, Kobayashi E, Sano J, Hirazawa Y, Okamura T, Iso H. Universal health coverage in the context of population ageing: Catastrophic health expenditure and unmet need for healthcare. Health Economics Review 14, 8 (2024) https://doi.org/10.1186/s13561-023-00475-2

A report and presentation on the findings for the Kansai region (in Japanese only) are available as downloadable PDF files on the Japanese page.