Liberal and conservative philosophies combine to form Japan's welfare state.[9] The welfare state and working conditions are interconnected. As a result of declining working hours over the years, less stress was put on the welfare state.[1] In 2012 the average Japanese citizen visited a medical facility twelve times, which is three times more doctors' visits than the average United States citizen.[10] This is partly due to low-cost medical expenses and partly due to increased stress from working conditions.[11] Stress has a huge negative impact physiological and mental factors for individuals.[12] Work hours vary between firms and company size.