In early spring, historic health reform passes, extending insurance to millions of uninsured. Despite problems with workplace-based coverage, controversy over government subsidies for insurance premiums, and disparities across a large and diverse nation, dramatic shift to a single-payer system was seen as impractical.

Instead, reforms focus on expanding current social insurance programs as well as new initiatives to cover the uninsured, improve quality, and control spending. They provide a basic floor, subsidized for the poorest, but preserve consumer freedom to choose in health care. No government body dictates choice of doctor or hospital; investor-owned and private not-for-profits compete alongside government-run providers like community health centers and rural hospitals.

Left to be addressed in later phases are the difficult questions of how to slow the relentless pace of health care spending increases -- driven in part by technological change and population aging, but also perverse incentives embedded in fee-for-service payment and fragmented delivery. Pushed through despite multiple crises confronting the leadership, the final landmark health reform works in conjunction with measures enacted as part of the fiscal stimulus package to strengthen the healthcare system. Some provisions take effect immediately; others will take many years to unfold.

President Obama’s triumph on his top domestic priority? Actually, there were no votes along partisan lines, no controversy over abortion. I am describing health reform in China, which was announced almost exactly a year ago.

We do not hear much about the parallels in the US and Chinese social policy. But we cannot fully understand each other if we ignore these commonalities. We do not hear much about those who, in both societies, have been rendered destitute merely because they or a family member became sick or injured in a system with a social safety net full of gaping holes.

It will surprise many Americans to know that government financing as a share of total health spending was lower in socialist China over the last decade than in the United States. Now China has pledged about US$124 billion over 3 years to expand basic health insurance, strengthen public health and primary care, and reform public hospitals.

In China, the injustice of differential access to life-saving healthcare had sparked cases of social unrest. The April 2009 reform announcement was the culmination of years of post-SARS (2003) soul searching for a healthcare system befitting China’s dynamically transforming society. Special interests block change. (Sound familiar?) The CPC Central Committee and the State Council acknowledge that successful health reform will be “an arduous and long-term task”.  

If the US can pass sweeping health reform despite an unprecedented financial crisis, and China can envision universal health coverage for 1.3 billion while “getting old before getting rich,” then together we should be able to look past our many differences to focus on our common interests. Our two proud nations must work together to confront numerous challenges, such as upholding regional stability (e.g. on the Korean peninsula); redressing global economic imbalances (increasing health insurance can help spur China towards more domestic consumption); and investing in “green tech” for a warming planet and “grey tech” for an aging society.

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When searching for insights about how other countries deal with similar challenges, Americans often look to Europe and Canada. Rarer is the comparison to counterparts across the Pacific. Yet President Obama has clearly articulated the vision of the US as a Pacific Nation, and there are developments around the Pacific Rim that merit consideration in our debates.  

Australia pioneered cost-effectiveness in health care purchasing, while the US continues to debate whether cost should be part of comparative effectiveness research and policy decisions.

Both Japan and South Korea, like Germany, have enacted long term care insurance to smooth the transition to an aging society. Their experiences might be fruitful as we implement the first national government-run long-term care insurance program, a little-heralded component of the newly passed legislation (and a fitting legacy of Senator Edward Kennedy).

Japan and Singapore provide universal coverage to older populations than ours with health systems that, although surprisingly different from each other in terms of public financing and role of market forces, both ranked among the best in the world -- and far higher than the US -- in the World Health Organization’s ranking of health systems in the year 2000. Although one may quibble with the ranking, it is indisputable that Japan spends a much smaller share of GDP on healthcare than the US does, despite being one of the oldest and longest-lived societies in the history of the world and having (like the US) a fee-for-service payment system.

Japan and South Korea are also democracies, where health policies occasionally engender heated debates. In South Korea, physicians went on nationwide strike three times to oppose the separation of prescribing from dispensing. Although Japan’s incremental reforms rarely spur such drama, the passions aroused by end-of-life care – embodied in the bizarre “death panels” controversy in the US health reform debate of 2009 – has its counterpart in the bitter nickname for Japan’s separate insurance plan for the oldest old: “hurry-up-and-die” insurance.

Yet Japan, Singapore, and Hong Kong all offer health systems that provide reasonable risk protection and quality of care for populations older than ours, with a diverse range of government and market roles in financing and delivery, while spending far less per capita than the US.

No system has all the answers. But the US and our neighbors across the vast Pacific have a common interest in sharing what we’ve found that works for health reform. Despite divergence in our political and economic systems, we all value long, healthy lives for ourselves and our children -- and we’re united in health reforms that try to further that goal.

In December 2009, the Asia Health Policy Program celebrates the first anniversary of the launch of the AHPP working paper series on health and demographic change in the Asia-Pacific. The series showcases research by AHPP’s own affiliated faculty, postdoctoral fellows, and visiting scholars, as well as selected works by other scholars from the region.

To date AHPP has released eleven research papers in the series, by authors from China, South Korea, Thailand, Taiwan, Pakistan, and the US, with more on the way from Japan and Vietnam. Topics range from “The Effect of Informal Caregiving on Labor Market Outcomes in South Korea” and “Comparing Public and Private Hospitals in China,” to “Pandemic Influenza and the Globalization of Public Health.”  The working papers are available at the Asia Health Policy website.

AHPP considers quality research papers from leading research universities and think tanks across the Asia-Pacific region for inclusion in the working paper series. If interested, please contact Karen Eggleston.

Joseph C. Martz, a nuclear materials scientist at Los Alamos National Laboratory (LANL), has been named the inaugural William J. Perry Fellow in International Security at Stanford University.

Stanford established the fellowship in 2007 to celebrate the 80th birthday of William J. Perry, the 19th U.S. Secretary of Defense from 1994 to 1997 and co-director of Stanford's Center for International Security and Cooperation (CISAC) from 1988 to 1993. Perry, the Michael and Barbara Berberian professor, and CISAC Co-Director Siegfried S. Hecker currently lead the center's Preventive Defense Project, which seeks to forestall dangerous security developments before they require drastic military intervention.

In a statement announcing Martz's selection as the first Perry Fellow, Hecker said CISAC supports scholarship on nuclear disarmament and nonproliferation, particularly at the intersection of science and policy-making. "Your background in understanding the configuration, manufacturing, design and certification of nuclear systems [that] support deterrence and the accompanying weapons complex is of timely relevance to the evolving policies in these areas," Hecker wrote. "Of particular interest is your evaluation of the elements of agility and confidence of the weapons complex and nuclear stockpile that will facilitate further reductions in nuclear weapons, and what effect these may have on international arms control initiatives."

The new Perry Fellowship honors an early or mid-career researcher from the United States or abroad with a record of "outstanding work in natural science, engineering or mathematics...who is dedicated to solving international security problems." Martz, 44, will spend a year at CISAC conducting research on how the United States might be able to reduce the size of its nuclear arsenal by configuring the nation's weapons stockpile more securely and strategically.

"I am honored to serve as the first Perry Fellow, in particular to salute Dr. Perry's extraordinary career and dedication to making the world a safer place," Martz said.

The scientist said his work dovetails with Perry's efforts to reduce and eliminate nuclear weapons around the globe. Perry, alongside former secretaries of state George Shultz and Henry Kissinger, former U.S. Sen. Sam Nunn and Stanford physicist Sidney Drell have joined together to promote this far-reaching objective, which President Barack Obama and the U.N. Security Council endorsed in a unanimous vote last month. "Dr. Perry's focus is a world with fewer weapons," Martz said. "My goal is to find a roadmap to that world."

At LANL, Martz led projects related to nuclear weapons design and maintenance, plutonium storage and disposal, stockpile life extension and plutonium aging, nuclear operations and nuclear systems analysis. He also directed New Mexico's team in the 2005-2007 nationwide Reliable Replacement Warhead (RRW) design competition sponsored by the federal government.

Martz said he was first drawn to nuclear issues during his senior year of high school. He grew up in Los Alamos -- his father worked at the lab. In 1983, Martz and a group of science-minded students were invited to join a gathering marking the lab's 40th anniversary. For three days, renowned scientists from the Manhattan Project, which developed the atomic bomb, returned to Los Alamos. Martz said one of them, Nobel-winning physicist Hans Bethe, told the students about his generation's atomic legacy and that it was up to Martz's generation to find a way out of what he characterized as the nuclear trap.

Today, Martz is interested in what he calls "capability-based deterrence." As he explained in the March 2008 issue of Currents, LANL's employee magazine: "If we are extremely competent and demonstrate the capability to reconstitute nuclear weapons -- convincing both allies and adversaries that the capability is assured and agile -- that capability in and of itself becomes a component of deterrence. It's a compelling idea. Our security rests not so much on the products of our work, but on our work itself." Martz, who has worked at LANL for 26 years, plans to pursue and refine this argument at CISAC and produce a manuscript during his year in residence. Martz holds a doctorate in chemical engineering from the University of California-Berkeley.

William J. Perry and the Perry Fellowship
Perry earned bachelor's and master's degrees in mathematics from Stanford in 1949 and 1950, and a doctorate from Pennsylvania State University. He went on to found the Silicon Valley electronics company ESL, build a venture capital company and pursue a distinguished career in public service. At the heart of Perry's work is a commitment to bring the rigors of science to international security issues. The William J. Perry Fellow in International Security at Stanford University will pursue this commitment.