On the surface, Japan’s health care system seems robust. The
country’s National Health Insurance (NHI) provides for universal
access. Japan’s citizens are historically among the world’s
healthiest, living longer than those of any other country.
Infant mortality rates are low, and Japan scores well on public-
health metrics while consistently spending less on health care
than most other developed countries do. Yet appearances can
deceive. Our research indicates that Japan’s health care system,
like those in many other countries, has come under severe stress
and that its sustainability is in question. The conspicuous
absence of a way to allocate medical resources—starting with
doctors—makes it harder and harder for patients to get the care
they need, when and where they need it. A vivid example: Japan’s
emergency rooms, which every year turn away tens of thousands
who need care. Furthermore, the quality of care varies markedly,
and many cost-control measures implemented have actually damaged
the system’s cost ef