To our knowledge, this is the first study using rigorous methodology that demonstrates the pattern of health insurance coverage and the predictors of uninsurance among documented Latin American immigrants in Japan. We found that documented Latin American immigrants in Japan are uninsured at rates that are much higher than has been estimated in the general population (1.3%) [1
], we found that almost 20% of the documented Latin American immigrants over 18 years of age lacked health insurance.
Among the immigrants themselves, the most common reason for uninsurance was considering the premiums too expensive. For workers who had not paid into the NHI for many years, back payments of premiums for the time they had lived in Japan without enrolling (up to a maximum of 2 years) to join/rejoin the NHI was also considered to be prohibitively expensive by many of the respondents. Low perceived medical needs and the expectation of a short-term stay in Japan were also among major reasons; these may reflect financial trade-offs. Some of the correlates of uninsurance from multivariate analysis are supportive in this respect since factors related to lower perceived medical needs such as not having or having fewer children, and not having a chronic disease were all strong predictors of uninsurance. Unwillingness of some immigrants to enroll in medical insurance is clearly represented by the fact that only one third of uninsured reported that they will enroll in a health insurance plan in the next 6 months.
In addition, we found that the majority of insured full time employees are covered by the National Health Insurance (NHI) rather than the Employees' Health Insurance (EHI). According to Japan's Health Insurance Act, employers are obligated to enroll their employees and their dependants in the EHI (except those employed 2 months or less, who work less than three quarters of the hours that full time employees work, and those aged 75 years or older) [29
]. All those not eligible for EHI such as the self employed, unemployed, and retired younger than 75 years are covered by the NHI; and people aged 75 years and above are covered by the Late Elders' Health Insurance [30
]. Health insurance coverage patterns revealed in our participants clearly deviate from the pattern required by the law. This could be discussed from two point of views.
First, immigrants' financial trade-offs may be responsible for the disproportionately low EHI coverage among employed immigrants as workers may select the NHI rather than the EHI; the latter mandatorily includes a pension premium, a preference that has been reported by other authors [14
]. To receive a Japanese pension it is necessary to have paid into the system for 25 years and those who contributed fewer years than the stipulated, receive a maximum refund of only up to 3 years. Considering the fact that the majority of immigrants do not have intentions to stay permanently in Japan (in spite of the fact that most stay for many years), they may not have a strong incentive to enroll in the EHI.
Second, companies may be in part responsible for this inadequate and unusual coverage pattern. While the total employment period was about 3 years, the average contract period of full time workers was only 6 months. Furthermore, a high percentage of immigrants were working without a written contract. These mechanisms may allow the employer to avoid the obligation of providing EHI, and thus sparing half of the premium for the health insurance and the pension that is coupled with the EHI. Not providing EHI to full time employees who work longer than 2 months is illegal. This situation should be explored in further studies.
The high uninsurance rate among Latin American legal immigrants in Japan is troubling because it could have serious economic and health implications not only for workers themselves but also for their families. Immigrant workers have higher risks of occupational accidents and disability than native workers [34
]. In our study uninsured respondents were even more likely to have had a serious accident at work than those insured. Occupational accidents may have resulted in financial burden which in turn lead to the choice of uninsurance, or employers may have been responsible for both, not providing working safety and health insurance. Whichever the case, outreach programs to persuade the immigrant workers about the importance of health insurance could be promoted through multiple partnerships among peer workers, Japanese care providers, researchers, and community leaders to help them adapt to a new health culture, and increase awareness about health. Such outreach has been used successfully to increase access to healthcare and health information in a culturally sensitive way in other countries [35
]. Also, audit and legal enforcement on employers should be enhanced so that their employees are adequately insured.
To encourage immigrant employees to enroll in the EHI, policymakers in Japan should consider decoupling the pension premium from the health insurance premium. This would allow them to enroll in health insurance with a lower premium than the NHI. Alternatively, consideration could be given to promote a bilateral social security agreement between Japan and the country of origin of the immigrants to make the pension contributions effective in either country. Brazil is currently the only Latin American country to have recently signed an international social security agreement with Japan, though it is still awaiting implementation [38
]. Of course, strict enforcement of the law is necessary to not allow the companies, especially labor contract companies through which the majority of immigrant workers are employed, escape the responsibility to cover their employees by the EHI. Foreign immigrant workers are placed into an unfair situation where the companies that indirectly employ immigrant workers through labor contract companies place responsibility on the labor contract companies, while labor contract companies may try to evade their responsibility to provide health insurance for their employees.
Finally, it should be noted that we found that some labor contract companies provided to their employees private health insurance plans. These programs should be closely monitored as they may allow companies to avoid their share of the premiums for the EHI and pension. Furthermore, health insurance provided by labor contract companies are not connected to the public health insurance system, thus immigrants may face back payments of premiums when they change employer and wish to join public health insurance programs.
Our findings should be interpreted in the context of their limitations. First, we need to consider the non coverage error [39
] that may have arisen from the failure to include some immigrants from the selected clusters into the sampling framework during the mapping stage. Thus, the prevalence of uninsurance we found could in fact underestimate or overestimate the real value. Second, our findings may not be generalizable to other immigrant groups in Japan. However, we believe that our results shed light on the important fact that even in developed countries with universal health coverage, certain minority groups might be left out. Countries trying to achieve universal health coverage need to consider the vulnerability of these populations when planning and implementing reforms. Finally, as with any self reported data, the potential for reporting bias should be considered, as we were unable to verify their health insurance coverage or their legal status through other sources.