Containing Health Care Costs in Japan

27 Afterword: National Health Insurance, Cost Control, and Cross-National Lessons—Japan and the United States

CHAPTER 27 Afterword: National Health Insurance, Cost Control, and Cross-National Lessons-Japan and the United States Theodore R. Marmor Introduction The very title of this commentary suggests a cautionary theme. None of the widespread discussions of medical care practices abroad is useful for purposes of drawing lessons without some understanding of the benefits, costs, and limits of comparative policy research. Japan and the United States present an interesting picture of similarities and differences. Japan is outwardly very different from the United States: an island nation, with a significant language disparity and, until recently, strikingly different historical and cultural patterns. For purposes of direct comparisons of similar nation-states, Japan is not an obvious candidate for the United States. Yet, Japan's recent rise to be one ofthe world's major industrial nations and its striking move toward "Westernization" within its own cultural framework make it a fascinating object for other fonns of comparative inquiry. However fascinating, the language obstacle prevents easy transfer of Japanese infonnation. Geographical distance, too, contributes to this problem. The Theory of Comparative Policy Research Broadly speaking, there are two quite different reasons for comparing social policies across nations, each ofwhich requires a rather different research strategy. First, there is what I call policy learning (Klein 1983; Mannor, Bridges, and Hoffman 1978, 59-80). That is, one investigates the social policies of other countries in order to derive lessons or models that can be applied at home. This approach has a long history. Presidential bodies and European royal commissions regularly draw on the experience of other countries (see, for a telling instance, Committee on Economic Security 1935). Second, there is what one could tenn policy understanding. Here the emphasis is not so much on learning as on explanation. For example, if we are to achieve an understanding of the factors that shape the evolution of a social 286 CHAPTER 27 Afterword: National Health Insurance, Cost Control, and Cross-National lessons-Japan and the United States Theodore R. Marmor Introduction The very title of this commentary suggests a cautionary theme. None of the widespread discussions of medical care practices abroad is useful for purposes of drawing lessons without some understanding of the benefits, costs, and limits of comparative policy research. Japan and the United States present an interesting picture of similarities and differences. Japan is outwardly very different from the United States: an island nation, with a significant language disparity and, until recently, strikingly different historical and cultural patterns. For purposes of direct comparisons of similar nation-states, Japan is not an obvious candidate for the United States. Yet, Japan's recent rise to be one ofthe world's major industrial nations and its striking move toward "Westernization" within its own cultural framework make it a fascinating object for other forms of comparative inquiry. However fascinating, the language obstacle prevents easy transfer of Japanese information. Geographical distance, too, contributes to this problem. The Theory of Comparative Policy Research Broadly speaking, there are two quite different reasons for comparing social policies across nations, each ofwhich requires a rather different research strategy. First, there is what I call policy learning (Klein 1983; Marmor, Bridges, and Hoffman 1978, 59-80). That is, one investigates the social policies of other countries in order to derive lessons or models that can be applied at home. This approach has a long history. Presidential bodies and European royal commissions regularly draw on the experience of other countries (see, for a telling instance, Committee on Economic Security 1935). Second, there is what one could term policy understanding. Here the emphasis is not so much on learning as on explanation. For example, if we are to achieve an understanding of the factors that shape the evolution of a social 286 National Health Insurance, Cost Control, and Cross-National Lessons 287 security system, it is unlikely that we can do so by looking at one country in isolation, Are the key factors the level of industrialization and the political mobilization of workers? The history of Britain, examined in isolation, might suggest that they are, But comparative studies indicate otherwise (Wilensky 1975; Flora, Alber, and Kohl 1977; Carrier and Kendall 1977), Similarly, it has been argued that in Britain the power ofthe medical profession rests on its access to Whitehall (Eckstein 1960), while comparative studies show that the nature of that power is largely independent of the precise relationship between doctors and bureaucracy (Marmor and Thomas 1972), In short, comparative studies may be essential if misleading conclusions are...