Suicide is a global public health concern. Close to 80 000 people die by suicide every year. Suicide cuts across every sociodemographic level and all regions of the world. Suicide is a consequence of social exclusion in which a person has been left without assistance. Hence social inclusion is critical in development and implementation of suicide prevention strategies. Suicides in Japan currently hold more than a quarter of global cases. National suicide rates began to rise following the economic crisis in 1998. The Basic Act for Suicide Prevention was implemented in 2006. The goal was to reduce the annual suicide rate from 24.2 in 2005 to 19.4 by 2016. In fact, the annual suicide rate in 2016 was 17.3 and lower than the target. However, the decline in mortality rates may be due to the onset of the Tohoku earthquake and tsunami of 2011. Reduction of harmful alcohol use, trauma-­informed care practices, and representation of minorities remains to be integrated into suicide prevention strategies in Japan. The co-production of the suicide prevention strategies should be sought to incorporate views from people with lived experiences into effective actions for social inclusion.

We evaluate a relationship between income and medical care and long-term care (LTC) expenditures, focusing on the population aged 66 and over of a small anonymous municipality (called city "X") in Japan. We analyze an individual-based administrative monthly claims data, for medical care and LTC, merged with the annual income data of city "X" from 2014 to 2015 (8,727 observations). Our dependent variables are a total expenditure of medical care and LTC, and each of medical care and LTC expenditures. Our independent variables are current annual household income (weighted by the square root of the number of family members) and the logarithm of annual employee pension.

The novelties of this study are as follows: First, the claims data includes elderly people who consumed neither medical care nor LTC services. Second, we consider the copayment ratio by using the income data. Third, we use pension as an indicator of past lifetime socioeconomic statuses such as industries, job statuses, average monthly salaries, and educational achievements since economic statuses of households often depend not only on current income.

Applying the multi-level hybrid model to our data, we obtain the following three major results. First, for every copayment ratio, there exists no positive correlation between each expenditure and current income. This result implies that the population aged 66 and over would enjoy medical care and LTC regardless of current income status. It would show that Japanese universal health care system is effectively working to achieve the equity of access to medical care and LTC for the old population. Second, we find a negative correlation between each expenditure and current income in a group of all samples or all employee pensioners. There are two possible reasons for this result: (i) health statuses of high-income persons are relatively better and therefore lower demands of medical care and LTC and (ii) a high copayment ratio reduces the demands. Third, in a group of employee pensioners whose copayment ratio for medical care services is 20%, we find a positive correlation between each expenditure and the logarithm of employee pension. This result indicates that the Japanese universal health care system could not remove the gap of expenditures owing to the past lifetime socioeconomic statuses. Their averages of current income and the logarithm of employee pension are almost the same as those of employee pensioners whose copayment rate for medical care services is 10%.