for Japanese men surpassed 80
years in 2013. Japan’s infant mortality
rate, reported as 2.1 per 1000
live births in 2013, is the lowest
in the world. But a continuing decline
in birth rate means that the
country’s population is shrinking,
even as it ages more rapidly
than in other societies. The proportion
of people older than 65
years increased from around 12%
in 1990 to 25% in 2013, and the
proportion of older people has
exceeded the proportion of young
people (0 to 14 years of age) since
1997. This demographic transition
has created huge fiscal and
health care challenges.
In addition to improving health
outcomes, Japan’s social insurance
system has made incremental
improvements in equity through
cross-subsidies and tax transfers,
which contributed to income redistribution
in addition to risk
pooling. As many countries have
done, Japan expanded health coverage
population group by population
group, through policies designed
for different groups with
differing levels of coverage (both
in terms of benefits and funding)
— thereby creating disparities
and problems of fairness. Government
action and new social policy
were required in order to reduce
these inequities. Japan’s single
reimbursement fee schedule (for
all physicians and patients) and
single benefit package for all social
insurance programs created
a foundation for equity in access.
The government then increased
equity by changing the copayment
policies for the various insurance
programs, reducing benefits for
employees of private companies
(by increasing their copayment
rates), and increasing benefits for
the elderly and non–employmentbased
insurance plans (by reducing
their copayment rates). Policymakers
thus made the overall
health system more equitable over
time, reflecting the value that
Japanese society places on egalitarianism.
Those achievements in equity
are now at risk. Japan still has
about 3500 insurance plans, with