VIEWED from the United States, our account of Japanese health policy must seem strange indeed. The most general differences can be seen, allowing some oversimplification, at the level of values. The three standard criteria for assessing health policy are access, quality, and cost. These are usually seen as trade-offs: It is assumed that maximizing any one criterion means that one cannot do very well with the other two. The Japanese have put the emphasis on access, and equal access at that, while the American system highly values quality.

Cost has been a big concern in both countries. American experience until the mid-1990s indicated that an emphasis on quality made it difficult to control costs and inhibited progress on access. The more recent success in holding down costs seems to be at some expense of both access and quality. However, we would argue, the Japanese case demonstrates that universal egalitarian access is compatible with cost control – in fact, it may well be necessary for effective cost control. Japan's current challenge is to improve quality.

In this concluding chapter, we review the key mechanisms that link egalitarian access with cost control in Japan, noting as well the economic, political, and cultural factors that have allowed this successful linkage to persist. We then look again at the downside of Japanese success and offer a few suggestions for improvement.