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Uninsured foreigners in Japan face threats to life, ballooning medical costs

A bill issued to an uninsured Filipino man at a hospital affiliated with a university medical school is seen in this partially modified image. He was charged about 170,000 yen (about $1,480), or 300% of the usual amount, for tests and other medical services for skin cancer screening. The support group paid the bill, and he is said to have no prospect of treatment. (Photo courtesy of his supporters)

OSAKA -- The mismanaged medical system at Japan's immigration facilities became a major issue when a Sri Lankan woman died of illness at the Nagoya Regional Immigration Services Bureau in March. However, foreigners without residency status are in danger of death even outside detention centers.

    Since they are not allowed to join the country's health insurance system, in some cases they are unable to pay for the treatment of serious illnesses because they have to pay 100% of the medical expenses, which are very expensive. Support groups for foreign residents and medical professionals across Japan are raising their voices in protest.

    In the early morning hours of Jan. 23 this year, a Cameroonian woman named Relindis Mai Ekei passed away quietly at a hospital in Tokyo. The 42-year-old woman had breast cancer that had spread throughout her entire body.

    Mai came to Japan in 2004 on a short-term visa to escape her violent fiance and female genital mutilation. However, the security situation in Cameroon became unstable, and she was unable to return to her home country. Mai applied for refugee status, but it was not granted, and she was detained at immigration facilities twice. Since that time, she had been telling her supporters that she had chest pains, but she could not receive adequate treatment at the facilities.

    In 2018, Mai was given temporary release for a second time and then diagnosed with breast cancer. With no status of residence and no access to health insurance, her medical expenses were very high. In an effort to alleviate these costs, supporters and lawyers repeatedly asked the government to grant her resident status for the purpose of treatment, but the residence card (for a one-year period) did not arrive at the hospital until about three hours after Mai's death.

    In all, about 7 million yen (about $61,000) in medical bills for Mai's care remain unpaid to hospitals. Yoriyoshi Abe, 40, a pastor in the city of Ebina, Kanagawa Prefecture, who has been supporting her, said regretfully, "There were times when the hospital refused to treat her because she did not have health insurance. If she had insurance, treatment would have gone more smoothly."

    This provided photo shows the late Relindis Mai Ekei. (Photo courtesy of Mai's supporters)

    Meanwhile, there is a case where a foreigner's life was saved by being allowed coverage under the country's health insurance system. Burgos Fujii, 48, a Japanese-Peruvian man living in Nara Prefecture, was granted provisional release from an immigration facility in May 2020, but was later found to have pancreatic cancer, which progresses quickly and is fatal if left untreated. He had been hesitant to undergo surgery for fear of high medical costs.

    In mid-September of this year, he was finally granted residency status, so Fujii joined the health insurance system and was able to undergo surgery at the end of the month. The cost of the surgery was covered by donations from people all over the country.

    Japan has a universal health care insurance system as a general rule. Foreigners living in Japan are also covered, but if they do not have a status of residence or are only in the country for a short period (90 days or less), they are not allowed to be insured and must pay the full amount for medical expenses.

    In the case of serious illnesses such as cancer, it is not uncommon for the cost to go up to several million yen. Foreigners with no residency status are prohibited from working and cannot receive public assistance, so they have no income other than the support of those around them. Medical expenses are a huge burden for them.

    The north Kanto medical consultation association in Ota, Gunma Prefecture, which supports medical care for foreigners in the Tokyo metropolitan area, has helped many uninsured foreigners, including Mai. In 2020 alone, it helped 48 people with medical expenses, nine of whom were cancer patients (such as colon cancer and pancreatic cancer), and at least five of whom died after treatment. The total annual cost of support is 4.8 million yen (about $41,800), much of which is covered by donations.

    Masataka Nagasawa, 67, secretary-general of the association, said, "There are many cases where people refrain from seeing a doctor or receiving treatment for a long time due to a lack of money, and by the time we receive a consultation, it is already too late. Necessary medical care should be provided regardless of status of residence."

    For uninsured foreigners, paying 100% of medical expenses is a heavy burden. However, according to supporters, in recent years there has been an increase in the number of cases where 200% to 300% of actual medical costs are charged.

    Burgos Fujii, center, is seen with his residence card in his hand in front of the Osaka Regional Immigration Services Bureau in Suminoe Ward, Osaka, Sept. 13, 2021. (Mainichi/Ken Uzuka)

    According to the Ministry of Health, Labor and Welfare, the cost of medical care is calculated by adding up the cost of various medical procedures at 10 yen per point. But in the case of uninsured foreigners' medical treatment, hospitals can at their discretion set higher prices, such as 20 to 30 yen per point. This means that a visit to the doctor for a mere cold, which would only cost 3,000 yen (about $26) for an insured patient (who pays 30% of the total), would cost 20,000 to 30,000 yen (about $170 to 260).

    In recent years, the Japanese government has positioned "medical tourism" as one of its growth strategies, assuming that wealthy foreigners will visit the country for medical treatment. This has led to the setting of high medical fees for foreign visitors to Japan, but this has also had a negative impact on needy foreigners.

    According to a survey conducted by the health ministry in fiscal 2020, 24% of the 4,380 hospitals nationwide that responded to the survey set medical fees for foreigners at a unit price of more than 10 yen per point, and the figure rises to 66% when limited to the 86 hospitals that accept a large number of foreigners.

    The ministry's office for the promotion of international medical development said, "Medical fees for uninsured foreigners are set at the discretion of each hospital. We do not have the authority to instruct hospitals on prices, even if the patients are in need."

    While there has been a spate of high-cost billing of foreigners, there is also a mechanism to help them. The "free or low-cost medical service" provides medical care to the needy regardless of nationality. Certain hospitals designated by the social welfare law accept low-income and homeless people for free or at low cost. Although the hospitals incur losses, they have the advantage of having their property taxes reduced or exempted.

    However, the percentage of hospitals that have implemented this service is only 1% or less of all medical institutions in Japan. According to supporters, hospital finances are deteriorating due to the response to the coronavirus pandemic, and the number of those offering free or low-cost services that are willing to accept patients is decreasing.

    In reality, many uninsured foreigners receive treatment at hospitals that are not covered by this service, and sometimes the hospitals are left with unpaid medical bills. There is a system to compensate for such unpaid expenses by local governments, but only some municipalities, such as the Tokyo Metropolitan Government, have adopted this system.

    Supporters appeal for the need to improve the medical system in response to a series of high-cost medical bills for uninsured foreigners, at the Osaka Prefectural Government headquarters in Chuo Ward, Osaka, on Oct. 20, 2021. (Mainichi/Ken Uzuka)

    What makes the issue more serious is the increasing number of foreigners who are so impoverished by the coronavirus pandemic that they cannot pay their medical bills. Since last year, immigration authorities have placed many long-term foreign detainees on provisional release in order to prevent COVID-19 infection.

    In addition, there are those who came to Japan as foreign students or technical intern trainees. But their visa status has expired and they cannot return to their home country because they have lost their income due to the pandemic. If these foreigners become seriously ill without insurance, their lives will be in danger.

    In response to this severe situation, the Solidarity Network with Migrants Japan (SMJ), an NGO working to support foreign residents, is currently conducting a signature-collecting campaign until the end of December, calling on the government to improve the medical system, under the slogan "Don't take expensive medical fees from people who don't have money."

    In January this year, a foreigner supporters' group and medical professionals in west Japan's Kansai region launched a study group on medical care for foreigners without residency status. In late October, they submitted a letter of request with a similar aim to that of SMJ to prefectures and ordinance-designated cities in the region.

    In the meantime, there are many Japanese who are also suffering from the consequences of the pandemic, such as loss of jobs and reduced income, and this tends to lead to the argument, "Why help foreigners at a time like this?"

    Kaoru Hashimoto, 68, a member of the steering committee of SMJ, who is involved in supporting homeless people and foreigners mainly in Kobe, said, "The United Nations' Sustainable Development Goals include 'good health and well-being' for all. These foreigners cannot return home, cannot work, and cannot get welfare. So, how can they afford the high cost of medical care? It is clearly a human rights issue to abandon foreigners in life-threatening situations."

    (Japanese original by Ken Uzuka, Osaka Photo Department)

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