In 2022, China's National Health Commission released a report indicating that during the "14th Five-Year Plan" period, the aging of the country's population will deepen, with the proportion of people aged 60 and above exceeding 20% of the total population, marking the transition to a moderately aged society. The health of the elderly is concerning, with the aging process leading to declines in cognitive, physical, and sensory functions, as well as increasing health issues related to nutrition and psychology. Over 78% of the elderly suffer from at least one chronic disease, and the number of disabled elderly people will continue to rise. In comparison to the health needs of the elderly, there is insufficient institutional, workforce, service, and policy support related to healthy aging. There is also a lack of specialized institutions for promoting elderly health, as well as efforts in preventing and controlling key diseases in the elderly.

Existing studies point out that the aging of the population in China has these characteristics: larger scale, rapid growth, regional imbalances, urban-rural reversal, a higher number of elderly women than men, and a trend of aging before accumulating sufficient wealth. Rapid aging has led to an increase in chronic disease patients, rising social healthcare costs, declining quality of life for patients, and posing severe challenges to China's healthcare system. At the same time, high-quality medical resources in China are heavily concentrated in large and medium-sized cities and large hospitals, with a significant imbalance in resource distribution and insufficient financial security. In recent years, the government has repeatedly pushed for the decentralization of medical resources to adapt to China's "9073" elderly care pattern (90% of elderly care is family-based, 7% community-based, and 3% institutional), investing significant efforts in building community medical resources, which has achieved some progress.

However, researchers at ANBOUND believe that aging is a highly complex phenomenon with highly diverse social impacts, and effectively addressing this issue requires consideration of multiple dimensions. The successful resolution of this issue is crucial for maintaining social stability and consolidating social trust, while ineffective responses to it could lead to severe social consequences. In this regard, Japan can serve as a valuable lesson for China.

From 1992 to 2002, Japan's healthcare system faced a contraction in medical insurance due to the economic recession, compounded by a surge in patients following the acceleration of aging. This ultimately led to a rise in medical accidents and incidents of doctor-patient conflicts across the country, resulting in a large-scale resignation of the doctors.

Between 1992 and 1997, the number of patients aged 65 and above in Japan surged from less than 2 million to 3.6 million. Major hospitals quickly faced a severe shortage of doctors, and even with full workloads, doctors were unable to meet the rapidly increasing demand. The 1994 Public Health White Paper revealed that the gap in the number of doctors reached 94,000 that year, while there were only 230,000 doctors nationwide at the time, causing work pressures to rise rapidly. According to statistics from the Ministry of Health, Labor and Welfare, in 1995, 40% of doctors worked more than 80 hours per week, reaching the danger zone for overwork-related deaths, while Japan was only in the early stages of accelerated aging.

Existing studies point out that the Japanese government's miscalculations are to blame. It is undeniable that the Japanese government was aware of the aging issue well in advance, as this phenomenon itself was not new. However, the preventive measures taken by the government were far from sufficient.

First, when Japan's aging population reached 7% in 1970, the government introduced the strategy aimed at doubling the number of doctors. Over the next 15 years, the total number of doctors gradually increased from 100,000 to 200,000. Thanks to this expansion, Japan's medical resources were quite abundant in the 1980s. However, the government optimistically assumed that the medical reserves were sufficient and even proposed the so-called theory of an oversupply of doctors, calling for a 10% reduction in doctors in the 1990s. In 1995, the Ministry of Health, Labor and Welfare reported that elderly patients aged 65 and above consumed four times the medical resources of adults, far exceeding the forecasted numbers of the 1970s.

Second, there was insufficient preparation for the disease characteristics of the aging population. In the 1970s, medical care for the elderly was primarily focused on conventional infectious diseases, which only required short-term treatment before patients could be discharged. Chronic diseases, which require long-term care, were still considered rare "diseases of the rich" and were not fully considered by the government. However, by the 1990s, elderly people in Japan, who had become wealthier, began facing the long-term challenges of chronic diseases. Due to the prolonged hospitalization required for chronic illnesses, 14% of the elderly population occupied 60% of hospital beds, with 20% of elderly patients being hospitalized for more than a year. This severely occupied medical resources and made it difficult for the younger population's medical needs to be effectively met, leading to the rise of "anti-elderly" sentiments.

Faced with this dilemma, the Japanese government had only two available options: strengthen doctor training and increase medical investment. However, training a high-quality doctor takes up to 10 years, making it a "distant solution to an immediate problem". After the collapse of the bubble economy, the Japanese government's financial resources were severely limited, making it difficult to effectively meet funding needs. The government estimated that to solve the shortage of medical resources, annual medical investment would need to increase by more than 100%, with healthcare spending accounting for 12% of GDP. In comparison, the economic stimulus plan, which supported millions of jobs, accounted for only 3% of GDP.

In 1995, Japan's healthcare fiscal expenditure surpassed JPY 27 trillion, up from JPY 22 trillion in 1992, an increase of nearly JPY 5 trillion over three years. This primarily came from the costs of hospitalization and medications for elderly patients. Under immense expenditure and fiscal pressure, the Ministry of Health, Labor and Welfare introduced a medical cost-cutting bill, and Japan's healthcare system shifted to a development model focused on cost control.

Starting in 1995, the Ministry of Health, Labor and Welfare proposed a new doctor evaluation system centered around controlling costs, with a particular focus on reducing hospitalization and medication expenses. The government hoped to treat more patients without increasing the medical budget by lowering costs. They then linked patient expenses with doctor incomes, forcing doctors to actively reduce patient costs. The government also implemented cost-control reforms in the pharmaceutical industry, initiating large-scale collective procurement and price reductions for over 10,000 drugs, forcing pharmaceutical companies to significantly reduce production costs. This series of measures successfully controlled healthcare fiscal spending and prevented the collapse of the medical fiscal system, but its negative effects were also significant.

First, the quality of healthcare rapidly declined. After the reform, doctors were evaluated based on their ability to cure patients at a lower cost. At that time, even the frequent use of expensive drugs for treatment was considered a mistake. Patient treatment was no longer based on the severity of the illness, the patient's health condition, or actual medical needs. Instead, it was strictly based on the principle of minimizing expenses, which led to a rapid decline in the quality of care in public hospitals.

Second, pharmaceutical research and development companies faced immense pressure, and medical accidents became more frequent. Faced with the pressure of collective procurement, pharmaceutical companies had to drastically reduce production and research and development spending. Under the new system, cheap drugs were overused, but many of these low-cost drugs did not have effective therapeutic outcomes. In 1997, Japan saw a famous pharmaceutical fraud incident, where the giant pharmaceutical company Tsumura Juntendo, with revenues in the billions, was found guilty of causing aa number of deaths and ultimately declaring bankruptcy. However, even when doctors were aware of the quality issues with certain drugs, they had no choice but to continue using them. Patients became the victims of cost-cutting healthcare, and in 2000, more than 60% of the 620 medical accidents nationwide were related to excessive cost control.

Third, doctor-patient relationships became increasingly tense. Under the logic of low-cost healthcare, patients experienced a direct decline in the quality of medical care. However, they often found it difficult to understand the complex policy logic behind these changes, and as a result, patients often directed their frustration at the doctors who implemented the policies. The media failed to play its expected guiding role and instead portrayed doctors as those who "feed off patients", fueling social animosity. In 1997, medical disputes in Japan began to surge, and by 2000, the number of doctor-patient disputes nationwide had exceeded 3,000, compared to fewer than 300 in 1995, marking a tenfold increase in just five years.

Faced with social sentiment and public pressure, the responsible authorities and police did not conduct a thorough review or response. Instead, they continued to put pressure on doctors, and the standards for medical malpractice were repeatedly relaxed. According to statistics, between 1998 and 2003, 120 doctors were sentenced, which was nearly equal to the total number of doctors sentenced over the previous 40 years, highlighting the widespread impact of these criminal penalties. As a result, trust between doctors and patients nearly collapsed. For doctors, those who chose to stay in the system often had to opt for treatment plans with the least legal risk, rather than those with the best medical outcomes, leaving patient health inadequately protected. For doctors who adhered to the principles of patient-centered care, discouragement and resignation became inevitable. Statistics show that in the first five years of the cost-control reform, 11,000 doctors resigned from public healthcare systems, with dissatisfaction with the medical system being the main reason for their departure. In 2003, nearly 3,000 doctors left public hospitals, with the highest proportion being clinical surgeons. The mass resignation of doctors further exacerbated the shortage of medical personnel, and the group most affected by this was still the patients.

Final analysis conclusion:

Japan's experience with the deterioration of its healthcare system during the later stages of aging is marked by unique characteristics and underlying causes, which should not be generalized. Since 2020, as China's population born in the 1960s and 1970s has begun retiring, the country's healthcare and fiscal challenges have thus become increasingly pronounced, sharing many parallels with Japan's situation in the 1990s. Therefore, it is crucial to carefully examine Japan's experiences and lessons to guide China in addressing similar issues effectively.