Health Insurance Law Revised: Foster Understanding of Increased Out-of-Pocket Payments

Editorial

14:59 JST, May 30, 2026

With the aging population, medical expenses continue to rise and public spending is mounting. Reforms that increase patients’ out-of-pocket payments to a certain extent are inevitable.

Regarding so-called OTC-like drugs, which have ingredients and effects similar to over-the-counter drugs but require prescriptions, the revised Health Insurance Law and other related legislation have been enacted, with a key provision obliging patients to pay greater out-of-pocket payments for OTC-like drugs.

There are about 7,000 drugs classified as OTC-like drugs. With the enactment of the legislation, the government will raise patients’ out-of-pocket payments for about 1,100 drugs starting in March next year.

Specifically, public health insurance will cover just 75% of the amount covered under the existing system, and the remaining 25% will be added to a patient’s out-of-pocket payment. For example, if a patient has a health insurance plan that requires an out-of-pocket payment of 30% and is prescribed a 30-day supply of allergy medication, the out-of-pocket cost of the medicine will rise from the current ¥540 to ¥855.

Regarding OTC-like drugs, the Japan Innovation Party had demanded that all such drugs be removed from public health insurance coverage.

However, if that were to happen, people who believe their symptoms are mild might purchase over-the-counter medication at a pharmacy without visiting a medical institution, potentially leading to cases in which serious underlying illnesses are overlooked.

The government’s decision to increase out-of-pocket payments for certain medications while maintaining insurance coverage for all prescribed drugs can be considered reasonable for advancing medical cost reform.

During deliberations on the related legislation, the government presented its policy of not imposing any additional burden on certain people, such as hospitalized patients. Such consideration is also important.

The revised legislation also refers to the High-Cost Medical Care Expense Benefit system, which limits patients’ financial burden when the amount of out-of-pocket payments under the system is to be reviewed. It explicitly states that the impact on household finances will be taken into consideration for those who require long-term treatment.

Regarding this system, the previous Cabinet of then Prime Minister Shigeru Ishiba had drafted a plan that would have increased patients’ payments by up to 73% based on annual income, drawing strong opposition from patient organizations.

In light of such circumstances, the government revised its policy to set the range of increase at 4% to 38% based on annual income. The government should strive to dispel the distrust of patients.

Medical expenses for fiscal 2023 reached ¥48 trillion. The reforms related to OTC-like drugs and the High-Cost Medical Care Expense Benefit system are expected to reduce insurance premiums by ¥260 billion annually. However, these reforms alone are not sufficient.

The main point of contention during discussions on social security system reform is the review of out-of-pocket medical expenses. The JIP and the Democratic Party for the People argue that the proportion of out-of-pocket payments for the elderly should be raised.

Requiring those with sufficient income and the ability to pay to bear a fair share of the burden is an important issue to consider.

(From The Yomiuri Shimbun, May 30, 2026)