7.1 Medical Care and the Social Welfare System

7.1.1 Medical Care

In 1961, the national health insurance policy was established for all Japanese citizens, and all were able to enroll in public healthcare insurance. This social policy guarantees all citizens access to medical care. The system employs a fee-for-service model, while remuneration for medical services controls expenditure. In a fee-for-service system, insurance pays the same amount for a procedure, regardless of whether a well-trained surgeon or a new resident performs it. In other words, it is not a system in which the well-trained physician makes the most money. Thus it guarantees access to a decent minimum of medical care, but not to a high quality of medical care. Financially speaking, the fee-for-service system itself does not reduce costs because it does not prevent over-examination and treatment. However, the Ministry has set relatively low fees, in consultation with the Central Social Insurance Medical Council, an advisory body which represents the public as well as payers and providers. In addition, processes for medical services and drugs are strictly and centrally controlled [1].

In the second half of the twentieth century, when the national health insurance system was established, World War II had recently ended, and medical caregivers worked long hours—unimaginably long by our current standards—and were working endlessly to improve the health of the nation. “For the patients, for the citizens” was the mantra of medical care professionalism at the time. If we were to compare the working hours to those of today, Japanese physicians and nurses did not earn a high hourly wage. Surprisingly, this universal health care system, balanced precariously on the public service attitude of medical caregivers, still managed to function.

However, once Japan entered the twenty-first century, the system began to crumble. Due to excessive financial burden, the portion shouldered by patients increased, and universal health care began to change, so that today, medical care has become something that only the rich can afford. Medical caregivers also began to reject excessive work hours. The progress celebrated in medical technology and a sharp escalation in medical fees rendered the system, as it stood, unsustainable.

My aim here is not to provide a detailed account of Japan’s medical care system, and thus I will end this passage by emphasizing the “equality” in Japan’s medical care: universal access to decent minimum medical care that comprises a fee-for-service system with the fees set relatively low by the government, where well-trained and experienced physicians cannot earn more.

7.1.2 Social Welfare: Public Livelihood Assistance and Pensions

In 2017, roughly 2.14 million persons (1.8% of the total population) were eligible for and received welfare benefits. Of these, 45.5% were 65 years or older. In Japan, those eligible for welfare receive a monthly amount of JPY 137,400 in addition to free medical care and medicines. Thus the living costs alone add up to roughly JPY 3.84 trillion, and such costs are increased if the health benefits for welfare recipients are added.

If a Japanese citizen is employed at a private company between the ages of 20 and 60, a portion of his or her salary is withheld from each paycheck as a pension. As of 2019, a couple who are 65 years and older receive a pension of average JPY 220,000. This is close to an average starting salary of a university graduate. This is another example of outcome egalitarianism. While some discrepancy remains in the amount set aside for each individual, all citizens receive nearly the same amount in their pensions. However, the pension alone is insufficient to cover the cost of living, so those who are able to do so will also prepare by saving for retirement. As regards health care, 10–30% of medical fees for those receiving a pension are covered out-of-pocket.

One may argue that investing heavily in welfare is one form of outcome egalitarianism, in that a nation chooses to assist others so that the outcomes (living standards) are “equal” (with as few disparities as possible). In Japan, this is demonstrated by a general intent “by all citizens to help those in need so that they can all live at roughly the same level as everyone else.” The philosophy of outcome egalitarianism—represented in this case by equal burden and mutual aid—plays a major role in this system. This outcome egalitarianism guaranteeing access to medical care and social welfare is rooted not only in medical care, but also in many other policies in Japanese society.

7.2 The Education System

In Japan, the education system is a good measure of outcome equality. It is anticipated that those who enter elementary school in first grade will all move up together to the next class, and that all will graduate together. Teachers and peers help the slow learners. Teachers conduct home visits for troubled students during their free time in order to determine reasons for a high frequency of absences or low grades.

In the period of compulsory education (elementary and junior high schools), students do not skip grades. During these years, individuality is restricted and mutual cooperation is sought from all. Even in higher education, some systems allow for one to skip grades, but these cases are extremely rare in Japan.

Many opinions exist about the ideal form of education. Individuality is important, as is teamwork. In recent years, Japan has been revolutionizing education in an effort to cultivate student individuality and offer a more flexible form of education, among other objectives. However, the ethos in a village society like Japan is teamwork.Footnote 1

7.3 Taxation, Salaries, a Stimulation Policy, and Equal Burden on Individuals

7.3.1 Income Tax and Salary

Japan employs a progressive taxation system in which individuals are taxed according to their income. Until 1988, the maximum ceiling for income tax was 70%. Even among developed Western nations, this was a very high ceiling. Revisions made in 1988 changed this ceiling to 50%, but even so, the trend in which “the more you make, the more they take” has not changed. The income ratio for the lowest to highest segment of the population was 1 to 2.8 (1994) in Japan, 1 to 8.9 (1985) in the USA, and 1 to 7.0 (1987) in Canada. This mechanism that strives to ensure that all citizens end up in the middle-income bracket is based upon outcome egalitarianism.

Opportunity-based egalitarianism is the opposite. In many Western countries, “equal opportunity” is listed clearly in all job postings. So long as the starting point is the same, any inequality in outcome is acceptable. Therefore, regardless of the huge difference in pay between the CEOs and regular employees of a company, this is not considered “unequal.”

7.3.2 Restoration Tax Following the Great East Japan Earthquake and Fukushima Nuclear Power Plant Accident

Following the earthquake and the Fukushima nuclear accident, the government increased income tax by 2.1% and implemented a restoration tax increase over 25 years as a way to help with recovery. The equal burden and mutual aid components of this measure are justifiable because this restoration tax increase is to be used for the restoration of citizens who suffered from natural disaster, so that the victims do not have to shoulder the costs themselves.

Ironically enough, a good portion of the restoration tax (JPY 19 trillion over the 5 years beginning in FY 2011) was reportedly spent in regions outside of those affected by the disaster. For example, some of this tax funded the repair of national highways in Okinawa (far from Tohoku/Fukushima area and unaffected by the earthquake), measures against anti-whaling groups, and restoration of national sports stadiums. The government’s underlying rationale for this was—apparently—that (equal) restoration is needed across Japan. However, the restoration tax increase was a policy to enable an equal burden increase by all citizens to help earthquake victims and not to restore Japan overall.

7.3.3 A Stimulation Policy

The government frequently implements an “equal” stimulation policy wherein all citizens become targets for a stimulus package. Many of these have been political in nature, but Japanese citizens have a particular fondness for the term “equality.” In addition, most citizens do not distinguish between “opportunity” and “outcome” equality.

Example 1: Regional Promotion Tickets (1999)

Regional promotion tickets were issued by all municipalities in Japan and were worth JPY 20,000 for persons fulfilling the criteria below. In total they cost the Japanese government JPY 619.4 billion. Individuals fulfilling the following conditions as of January 1, 1999 received this funding:

  • A head of household with children aged 15 years or younger

  • Any recipient of the Old Age Welfare Pension (rōreifukushi nenkin), Basic Disability Pension (shōgai kiso nenkin), Basic Survivors Pension (izoku kiso nenkin), Mother and Child Pension (boshi nenkin), Quasi-Mother and Child Pension (jun boshi nenkin), Full Orphan’s Pension (iji nenkin), Child Rearing Allowance (jidō fuyō teate), Benefits for Children with Disabilities (shōgaiji fukushi teate), and Special Disability Allowance (tokubetsu shōgaisha teate).

  • Recipients of livelihood subsidies and those placed in a social welfare facility

  • Individuals aged 65 years or older who were exempt from municipal taxation

Example 2: Supplementary Income Payments (2009)

Supplementary income payments (teigaku kyūfu kin) represent one measure employed as part of the emergency economic stimulus package that was enacted in March 2009, and represented a flat-rate tax reduction policy in the form of supplementary payments.

Every Japanese resident received JPY 12,000. Those who were 65 years and older and those 18 years and under received an additional JPY 8000.

Neither of these two interventions had significant economic effect.

7.4 Japanese Socialism

“Japanese socialism” is a term derived from the assessment that the Japanese economy following World War II “possessed socialist components.” The term was used by economists such as Yasuo Takeuchi.

On the one hand, this term holds positive nuance in that it implies that Japanese socialism differs from that of the Soviet Union, in its upholding of freedom and democracy, while creating a communal society in which social disparities are few. However, it also has some negative connotations, such as the fact that the government conducts excessive economic restrictions and interventions. It is often used to criticize the reality that socialist nations have larger disparities and inequalities than those in Japan. It is used ironically to label Japan as the most successful of all communist countries in the world.

Nonetheless, Japan is a democracy. For the 75 years following World War II, through interactions with the USA, including the creation of the Japanese constitution, Japan has been able to avoid direct involvement in any wars that have subsequently developed. Economically, it has become one of the world’s economic powerhouses. Despite these achievements I speculate that a good number of Japanese people are dissatisfied with the current structure based upon outcome egalitarianism. With the massive emigration of many specialists and trained professionals, Japan is in danger of losing strength. Among other laudable qualities of our government are freedoms of speech and academia, both of which allow me to write these words here without fear of imprisonment. Of course, as the village society structure continues to be upheld, I assume that sanctions from some parties will be felt at some point. For now, I am grateful for the current climate in Japan in which I can publish this book, even while knowing that some will interpret my words as criticism.

The concept of equality varies by culture and society. This chapter will teach us that we must not only understand, but also become sensitive to the fact that differences exist not only in how equality is conceptualized by region, but also in the values considered important therein.

Do either of these two forms of egalitarianism function in the global setting? Do equal opportunities actually present themselves to children born in LMICs as readily as they do to children born in developed nations? Is it realistic to strive for economic outcome equality across the world? What kind of equality does UNESCO have in mind when they advocate for this? Do representatives of Africa, for example, wholeheartedly proclaim that they have achieved outcome equality? Is this equal opportunity, outcome equality, or both? Can the two theoretically coexist? It is highly unlikely that we can form consensus about distributive justice at this time.