In Japan, the term 者の哀れ (mono no aware) – which translates to “the pathos of things” – highlights the awareness of the impermanence of living things. Ironically, Japan has the highest life expectancy and the oldest average population in the world. Due to lower fertility rates and low immigration flows, Japan’s population has been shrinking at an alarming rate. In what the International Monetary Fund refers to as “shrinkanomics,” the nation’s demographic change is putting pressure on a vanishing labor force. As a result, Japanese youths are forced to adapt to a reality that is focused on supporting their elderly.

Having attained universal health insurance coverage by 1961, Japan successfully equalized access to healthcare. It was a pivotal resource that diminished the influence of socioeconomic status on health outcomes. But Japan’s post-World War II success story has taken a troubling turn. The introduction of the Long-Term Care Insurance System in 2000, followed by the Medical Insurance System for the Latter-Stage Elderly in 2008, has created a disproportionate financial burden on the working generation who are employed and under 65 years old. While the elderly — major consumers of medical and nursing care — pay only 10 percent out-of-pocket for their care, the remaining 90 percent of the cost is borne by the working generation.

The resulting imbalance not only strains the economic stability of young adults; it also jeopardizes their ability to afford families and their children’s access to education. Around half of unmarried people under 30 do not want children, citing reasons like the high cost of living and anxiety about Japan’s future.

For Japan’s elderly population, medical costs are hardly a concern. In fact, they go to clinics and hospitals more often. According to the International Comparison Study on Life and Attitude of the Elderly, around 60 percent of the elderly in Japan go to a hospital or clinic at least once a month. In the United States, the number stands at 20 percent. Another study highlighted that a significant portion of emergency patients in

Japan comprised elderly individuals with “less urgent medical needs” which could have been addressed through their primary care providers.

The skewed age demographic landscape in Japan perpetuates a “silver democracy,” where policies disproportionately favor the elderly and, as a result, underrepresent the younger generation. Prime Minister Fumio Kishida pledged to implement “countermeasures to the falling birthrate in a different dimension,” or to pursue them more aggressively than ever before, early in 2023. But insurance premium rates have increased again and no substantial policies have materialized. The structural deprivation of the younger population demands urgent attention and reform.

Considering the context of this situation, a policy that calls for the elderly to bear a greater societal burden has serious merit. A policy to increase out-of-pocket payments for the elderly could alleviate the financial strain on the working generation and discourage unnecessary visits to clinics and hospitals. This not only addresses the economic stress faced by young adults, but also contributes to a more sustainable society.

To be sure, there’s the argument that increasing financial burdens on the elderly would limit their access to essential care. This criticism stems from zero-sum thinking, where any gain by one side is assumed to be at the expense of the other. However, empirical evidence from the 2007 financial collapse of Yūbari, Hokkaido, challenges this notion. Despite losing 90 percent of hospital beds and all specialists, the city did not experience a significant rise in its death rate. Instead of remaining in hospitals all day and rarely being discharged, many elderly people stayed in their homes, engaged in their daily routines, and died in peace. This suggests that excessive medical provision may not necessarily contribute to better health outcomes for aging communities. It also highlights the importance of redirecting resources toward less costly home care, preserving the elderly’s autonomy and freedom. Mutual benefits can be achieved for the entire community.

This issue extends beyond Japan and serves as a cautionary tale for aging societies worldwide. As the front-runner in the aging population race, Japan is facing a dilemma that requires global attention. A policy shift that addresses the structural problems in health equity is imperative, not only for the well-being of the younger generation but for the overall health and sustainability of aging communities.