Phillip Lipscy examines Trump administration's decision to withdraw U.S. membership from the United Nations Educational, Scientific and Cultural Organization in an article in The Hill.

There is plenty of research on how the rapid warming of the planet is going to have growing adverse impacts on global economies, health, food supplies and natural disasters.

A new study now suggests that as temperatures continue to rise — particularly with more and more 90-plus-degree days — more fetuses and infants will experience economic loss by age 30.

“There is a growing body of evidence that finds that shocks to the fetus and young child — whether nutritional, environmental, economic or stress-related — have long-term consequences on health, education and economic outcomes throughout the life cycle,” said Maya Rossin-Slater, an assistant professor of health research and policy at Stanford Medicine and a faculty fellow at the Stanford Institute for Economic Policy Research.

Rossin-Slater published her study Dec. 4 in the Proceedings of the National Academy of Sciences, indicating early-life exposure to extreme temperatures is linked to potential losses in human capital. Her co-authors are Adam Isen, an economist with the U.S. Department of Treasury, and Reed Walker, an assistant professor at University of California, Berkeley.

The researchers used data from the U.S. Census Bureau’s Longitudinal Employer Household Dynamic Files, which contain information on adult labor market outcomes linked to county and exact date of birth. They looked at weather in counties in 24 states on any given day, and then measured how many days with average temperatures above 90 degrees a child born on that day in that county would have experienced during gestation and during the first year of life. They then compared the earnings of individuals who were exposed to different numbers of such hot days, but who were of the same race and gender, and born in the same county and on the same day of the year (but in different years).

Each day a fetus or infant experiences 90-plus-degree temperatures, Rossin-Slater and her co-authors found that he made $30 less a year on average, or $430 over the course of his lifetime. While that may not seem like a huge loss of income, the authors point out that their study is best understood from a population-level perspective rather than from an individual one.

“There is a lot of research already showing that extreme heat has immediate effects on labor market productivity and GDP,” she said. “What we are saying is that there is another wrinkle to this — that there can be consequences many years later, on cohorts who are still in the womb.”

Most Americans today only experience one day a year that is 90 degrees or hotter. But the Climate Impact Lab has indicated that if countries continue to take only moderate action on climate change, by the end of this century there will be about 43 such days a year.

So, if you multiple a $30 annual loss a day by 43 days, you come up with an average $1,290 a year — and compounded in large populations of pregnant women in hot climates.

“Prior research shows that exposure to extreme heat in utero leads to lower birth weight and increases infant mortality,” said Rossin-Slater, who is also a core faculty member at Stanford Health Policy. She said poor fetal and infant health could impact adult earnings in three ways: cognitive impairment, poor health that causes people to miss school or work, and less non-cognitive skill development such as self-control.

“With regard to exposure to heat specifically, fetuses and infants are especially sensitive because their thermoregulatory systems are not fully developed and they have less capacity to self-regulate when their bodies are exposed to extreme temperatures,” Rossin-Slater said.

Hot Zones and Air Conditioners

The obvious questions that arise from such research: What happens to the babies of women who already live in very high temperatures? And why not just ensure that all pregnant women have air conditioners, at least in the developed world where it would be more affordable?

Women in warm zones such as parts of Africa and South Asia, as well as U.S. cities like Phoenix and Washington, D.C., shouldn’t worry too much. The loss of income is relatively little and people living in hot climates may actually adapt over time to exposure to extreme heat.

“Our study is not saying that individual people should be doing something differently to avoid exposure to extreme heat,” Rossin-Slater said. “Instead, we think we are providing additional evidence for the possible population-level consequences of climate change and the projected increase in the number of days with extreme temperatures.”

And what about those air conditioners? The cohorts in the study are actually born in the 1970s, during a period of rapid expansion in air conditioning across American households. The researchers found the earning losses went away in areas where most people got air conditioners installed.

“If we think that there is something biological going on as a result of the fetus being overheated, then it makes sense that AC, which prevents the overheating, can mitigate this negative effect,” Rossin-Slater said.

But it’s important to recognize, she said, that air conditioners come with costs, both financial from the perspective of individuals and households who can and can’t afford such systems, and environmental from the perspective of the country or planet as a whole.

“So this is not a `free’ solution and any cost-benefit calculations related to climate change should take into account this adaption response,” Rossin-Slater said. “But we ought to think about what these results imply at the global level — in many countries that are much hotter than the United States and still don’t have AC. So if we are trying to understand global inequality and the impacts of climate change on developing countries, our results suggest that climate change could play a role in perpetuating global inequality across generations.”

"The problems with our democracy—ever-deepening polarization, incivility, gridlock, dysfunction, conflicts of interest, and disregard for democratic norms—are not just problems of political culture and behavior. Politicians are driven by incentives, especially the desire to get re-elected. Institutions heavily shape these incentives, and our institutions are in need of reform. Unless we reform our democracy, we will be increasingly hard-pressed to improve the health of democracy globally." Listen to Larry Diamond, Senior Fellow at the Freeman Spogli Institute for International Studies, explains in this podcast what are the options from here, by Hoover Institution. 

CVS Health announced it would buy Aetna, the country’s third-largest health insurance company for $69 billion, a deal that could revamp the nation’s health-care industry and impact millions of consumers who are always on the lookout for better delivery and costs.

The merger, which must still undergo an antitrust review by the government, could impact the cost of drugs and the way patients visit health-care providers.

“This combination brings together the expertise of two great companies to remake the consumer health-care experience,” CVS Health President and CEO Larry J. Merlo said in a statement on Dec. 3. “With the analytics of Aetna and CVS Health’s human touch, we will create a health-care platform built around individuals.” 

Merlo said that by using CVS’s 10,000 pharmacy locations around the country, they would make health care more affordable and accessible.

We asked Stanford Health Policy’s Laurence Baker, chair of Stanford Medicine’s Department of Health Research and Policy and an expert on health-care delivery and costs, several questions about the potential merger.

Q. Could this lead to lower drug prices for the consumer?

Baker: One of the hoped-for effects is that a combined Aetna-CVS would be better able to negotiate favorable prices for prescription drugs. It is possible I suppose, since together they would have a considerable amount of information and strengthened incentives to control costs. In a model where a pharmacy benefit manager, like CVS, did most of the negotiating with the pharmaceutical companies, and insurers like Aetna separately paid the costs, there might be less ability and incentive to negotiate for favorable prices than if the two do merge. 

At the same time, there is no guarantee that there will be savings and if there are it is not clear that they would be very large. CVS and others have been negotiating for drug prices already, and the advantages conveyed by the merger need not be that big.  I can only imagine that if there were lots of low-hanging fruit Aetna and CVS, and others, would already have had some good opportunities to pursue changes. 

One place where a combined Aetna-CVS could make a difference would be in working with doctors and patients, doing more to promote the use of better or higher-value drugs. A merged entity might be more effective at getting patients to use appropriate generics rather than expensive branded drugs, for example.  This effect could be even stronger if a merged company were to be successful in their announced plan to do more to integrate physicians and other health-care providers with CVS pharmacies.

Q: If there were savings, would consumers see them?

Baker: If a combined Aetna-CVS were to negotiate better drug prices, whether or not those are passed on to consumers or just retained by the company depends on things like the degree of competition in the insurance marketplace. If the company could benefit from lowering prices for, say, Aetna insurance policies because of the lower drug prices, at least some of the savings could be passed on to consumers. But we often worry that many insurance markets are not competitive enough, so it would remain to be seen whether consumers would see the benefits or not.

The effects of stronger efforts to move patients toward higher-value or lower-cost drugs also might or might not flow through directly to patients. Overall savings may or may not be passed on, but it is possible that some patients would see changes in their copayments that could be beneficial.

Q: Could the potential merger lead to new and improved methods of delivering care?

Baker: Leaders of CVS and Aetna talked about the potential for building new and improved methods for health care delivery, including having more care delivered through clinics associated with CVS stores. These are intriguing ideas, consistent with many discussions going on about the next generation of health-care delivery. It isn’t entirely clear why a merger is needed to develop this, nor is it clear that it would lead to widespread improvements in health care, but innovation in this area doesn’t seem likely to do harm either and would probably benefit some people.

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Q:  Would this result in reduced consumer choice of health care provider?

Baker: It does stand to reason that a merged Aetna-CVS might prefer that people with Aetna insurance use CVS rather than other competitors. They might develop restrictions or incentives that would steer their customers in this direction, and that could certainly be a concern for some people. This gets at a larger question facing the health-care system these days. It may be that the formation of more integrated care networks, with less provider choice overall, but with providers that are carefully chosen and better at working together, offers opportunities to improve care and lower costs.  This could have advantages, but would also come with tradeoffs for choice.

Q: Would a merger lead to a company that is “too big” with too much power?

Baker: One thing analysts have worried about lately is the amount of consolidation in the health-care marketplace. This would be another example of that, combining two already large players. Sometimes people argue that bigger can be better if it helps align the activities of different players in ways that could push us toward lower costs or improve quality. Often enough, however, we have seen consolidation lead to higher prices without seeing improved quality. This particular type of merger — combining a health insurer with a health care provider — is a bit less common than the consolidation we’ve most commonly seen such as hospitals merging and has some different features, so the overall effects will be something analysts will want to keep an eye on.

There is no denying the Affordable Care Act has significantly increased the number of Americans with health insurance. Yet many policymakers and consumers question the value of Marketplace plan coverage under the ACA because cost-sharing can get pretty high.

A survey by the Kaiser Family Foundation and The New York Times last year found that 22 percent of people who purchased health insurance through an ACA Marketplace plan had trouble paying their medical bills due to copayments, high deductibles, and co-insurance payments.

Out-of-pocket costs under a typical silver plan, for example, can be twice as high as they are in the average plan provided by employers.

So Stanford health policy researchers conducted a study, published online in Health Affairs, in which they simulated out-of-pocket spending for bronze, silver and gold Marketplace plans — those having actuarial values of 60 percent, 70 percent and 80 percent, respectively.

They found that while Marketplace plans significantly reduce exposure to the financial risk of a catastrophic illness, the use of actuarial values can be misleading. For the vast majority of consumers, the proportion of covered spending is likely to be far less than their actuarial values.

“Many Americans may find themselves not using their health insurance plan in a given year because they didn't get sick,” said Maria Polyakova, an assistant professor of health research and policy at Stanford Medicine and lead author of the paper.

In fact, only when annual health-care spending exceeds $16,500 for bronze plans, $19,500 for silver plans, and $21,500 for gold plans do plans in these metal tiers cover the proportion of costs matching their actuarial values. These metal levels are intended to provide standardized information on coverage generosity to help consumers choose among plans.

Marketplace plans provide relatively comprehensive coverage for the small proportion of people who experience extremely high health-care spending, the authors wrote. But the vast majority of enrollees experience relatively little direct benefit from their coverage in any given year because most of their services out of pocket because their expenses fall below the deductible limits.

But Polyakova, who is also a faculty research fellow at the National Bureau of Economic Research, said it’s important not to conclude that purchasing health insurance is a waste of money for the young and healthy.

“Indeed, most working-age adults do not use much health care,” she said. “The idea of health insurance, however, is to protect household finances in those cases when someone does get sick and needs expensive care. In this paper, we find that for many consumers, Marketplace plans are likely to provide valuable risk protection.”

The mismatch between expected and experienced coverage for the majority of people who have low health-care expenditures is one factor that may have inhibited enrollment in Marketplace plans among relatively healthy people, the authors wrote, a phenomenon that could have contributed to Marketplace instability.

“More generally, a weakness of using actuarial value is that doing so distracts consumers from the key purpose of insurance, which is financial risk protection,” said Polyakova and co-author Kate Bundorf, an associate professor of health research and policy and chief of the Division of Health Services Research at the Stanford School of Medicine.

“Policymakers should consider alternative ways of communicating plan generosity that more accurately convey to consumers their likely out-of-pocket spending in a plan and how much risk protection plans provide,” they wrote. “Moreover, it may be important and valuable to emphasize the risk protection value of plans in the public debate.”

One fairly easy fix, Polyakova said, would be for healthcare.gov to show consumers their expected spending under different “sick” and “healthy” scenarios. Currently, the health site asks consumers whether they expect to be sick or healthy and then shows which out-of-pocket costs would result. But it doesn't show people who expect to be healthy what would happen to their spending if they did get sick.

The high cost of prescription drugs in the United States came under scrutiny in a new report from the National Academies of Sciences, Engineering, and Medicine, “Making Medicines Affordable: A National Imperative,” co-authored by Stanford Law Professor Michelle Mello, who is also a professor of health policy and a core faculty member at Stanford Health Policy. Published on November 30, the report aims to increase both affordability and accessibility to crucial—often lifesaving—drugs for Americans, with recommendations such as better government negotiated prices, quicker turnaround for generic drugs, and increased financial transparency for biopharmaceutical companies.

In the discussion that follows, Mello explains some of the key challenges facing Americans in need of prescription drugs and key recommendations in the report.

You note in the report that Americans are paying significantly more for their healthcare but are significantly less healthy when compared to developed countries. Do we also pay more for prescription drugs?

Yes. In fact, many countries use “reference pricing” schemes, through which the price that their national health programs pay for prescription drugs is actually calculated as a percentage of what we pay!  One of the ethical issues that weighed on the Committee as we deliberated was that interventions that tamp down prices in the U.S. could have ripple effects in other, less wealthy countries if drug makers seek to recoup their losses by giving fewer price concessions elsewhere.

What is the most important factor leading to higher prescription drug costs in the U.S.? 

The old adage that “every system is perfectly designed to get the result it gets” really came to mind as we investigated why drugs cost so much.  It’s not just one factor, but a whole ecosystem in which multiple actors and factors are contributing.  At the root of it, though, is that there are distortions in the market for drugs that permit things to happen that wouldn’t occur in a truly competitive market.

Which of the 27 action points recommended in the report stand out to you as a priority—and achievable? 

We view our recommendations as a package that should be implemented together, but there are three that we think are especially promising. First, the federal government should directly negotiate drug prices on behalf of all federal programs (and any state programs that want to join in). To create leverage in these negotiations, federal programs should have the flexibility to exclude certain drugs, such as when less costly drugs provide similar clinical benefit.  Second, to improve transparency about where the money is going and where opportunities exist to recapture some of it, biopharmaceutical companies and insurance plans should make public information about the net prices they receive and pay for drugs, including discounts and rebates. Third, insurance plans—especially Medicare plans— should provide better protection against out-of-pocket drug costs. There should be limits on total out-of-pocket costs, and patients’ deductibles and coinsurance payments should be based on the net price of the drug, not the list price.

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A number of the recommendations seem quite procedural, such as eliminating misapplication of funds and inefficiencies in federal discount programs, ensuring financial incentives are not extended to widely sold drugs, and increasing information sharing about reimbursement incentives. Is part of the high cost we pay due to bureaucracy and inefficiency?  

We identified ways in which federal programs are being misused, to the detriment of consumers. One example is what is known as the “340B program,” which was intended to ensure that hospitals and other facilities that serve low-income populations receive deep discounts on drug prices, but is being used by a broad range of facilities that don’t necessarily pass those savings on to patients. Another example is the orphan drug program, which provides very valuable financial incentives for manufacturers to develop drugs for rare diseases.  Companies have obtained these rewards even when they also sell their drug for other indications for which there is a huge market, and in some cases have gotten the rewards multiple times for the same drug.  These problems aren’t about bureaucracy, they’re about gaming the system.  These programs were good ideas that have been very successful in achieving their goals, but have had unintended effects that need to be addressed.

Biopharmaceutical companies have gotten a bad rap in the press, but you note that the cost of developing drugs is very high, and success rates low, with 9 out of 10 investigational products never making it to market. So there is an acknowledgment of the high stakes, high-cost nature of the sector. The report recommends accelerating market entry and use of generic and biosimilar drugs. How can this be implemented without discouraging development of new drugs?

Ensuring affordability of drugs while not discouraging innovation is the central tension that our committee had to grapple with. It’s not easy.  The recommendations in the report strike a balance between these two important objectives.  With regard to generics, our patent system creates a workable deal with drug innovators: create a useful new product, and we’ll give you a period of market exclusivity; generics can’t enter until after that period is up. One problem that our report addresses, though, is that companies have developed ways to extend that period of exclusivity. One is to pay generic companies to delay market entry. Another is to seek follow-on patents on incremental changes to their drug. For example, one company got a new patent by demonstrating their drug could be administered by crushing it up and mixing it with applesauce. The use of this tactic, called “evergreening”, should be curbed.

One recommendation in the report is that the federal government consolidate and apply its purchasing power to directly negotiate prices with the producers and suppliers of medicine, and strengthen formulary design and management. Do government-sponsored medical plans, such as Medicaid and Medicare, already do this? 

By law, the federal agency that runs these programs isn’t allowed to negotiate directly for drug prices for Medicare patients. Instead, all the individual, private plans that provide drug coverage under Medicare Part D do the negotiating. They get discounts, but we think the discounts would be deeper if the bargaining was consolidated in one mighty purchaser.

You noted that private investment is increasingly important to drug development. How much of drug development is supported by public funding, via grants to universities, etc., that then go on to become small startups with private investment? If it is significant, does the public get a good deal on its seed investments?

American taxpayers foot the lion’s share of the bill for the basic-science research that generates information about which molecules are promising to pursue. Private companies pay most of the development costs—that is, testing the molecule in clinical trials to see if it’s safe and effective. The public has gotten a great return on investment in the sense that the industry, particularly in the last decade or so, has been turning out a lot of very innovative, useful products. The work that remains to be done is ensuring that those products are financially accessible to everyone who needs them.

One recommendation is that biopharmaceutical companies and insurance plans disclose net prices received and paid, including all discounts and rebates, at a National Drug Code level. Would this cover all international transactions too, so that we could see costs/prices in other countries? 

No, our recommendation relates to the drug supply chain in the U.S., which is highly complex and highly opaque.

Can you talk about this a bit—why this transparency is important?

One of the things that was frustrating about studying drug affordability is that the various players in our system—such as drug manufacturers, health insurance plans, and intermediary organizations called pharmacy benefit managers, or PBMs—all point fingers at one another when you ask them who is responsible for consumers’ high drug costs.  Yet, there’s very little information available by which to assess their claims. Is the problem that drug makers launch their products at excessive list prices? Or that PBMs buy them at a discounted price, which is kept confidential, and don’t pass those savings along to health plans? Or that health plans get drugs at a deep discount but make subscribers pay cost-sharing (for example, the 20% coinsurance you pay at the pharmacy) as though the drug’s cost was the list price?  Nobody will cough up the data necessary to make these judgments.  Our recommendation addresses that problem.

Are there any next steps for you and the authors of this report? Will there be subsequent research by the group—or coordination with policy makers?

We are working hard to make sure policy makers, journalists, and key stakeholders understand our recommendations and the evidence behind them.  This week, for example, our report was presented to a packed room of Senate staffers.  We have also identified some areas where additional research is needed, and hope that research sponsors will respond to that need.  There is a lot of work to be done.

SPICE Director Gary Mukai has been named a recipient of the 2017 Autumn Conferment of Japanese Decorations. On November 3, the government of Japan announced that Dr. Mukai will be awarded the Order of the Rising Sun, Gold and Silver Rays for his contributions to the promotion of friendship and mutual understanding between Japan and the United States.

The Order of the Rising Sun is a decoration in the Japanese honors system that dates back to 1875. It was established as the first national decoration awarded by the Japanese government, and it recognizes individuals who have made significant contributions to Japan or its culture. It is one of the highest decorations conferred by the government.

“I am very humbled by this honor,” reflects Mukai. “I still find it hard to believe. But as someone who has always cared deeply about the U.S.–Japan relationship, this decoration truly means a lot to me. I’m just thankful I’ve had so many opportunities to be involved.”

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After receiving his Bachelor of Arts degree and teaching credential from UC Berkeley, Dr. Mukai moved to Japan to teach in 1977 and has since worked to promote cross-cultural education between the United States and Japan. Besides working as a teacher in both countries, he has served as a longtime interviewer for the Japan Exchange and Teaching (JET) Program and has been a selection committee member of the United States-Japan Foundation’s Elgin Heinz Teacher Award since its inception. At SPICE, he has developed numerous curriculum guides on Japan for K–12 classrooms as well as overseen the creation of both the Reischauer Scholars Program and Stanford e-Japan—a pair of nation-wide online courses that teach American and Japanese high school students about each others’ countries.

A date for Mukai’s formal conferment ceremony has not been announced.

To read the Consulate’s announcement of the recipients of the Order of the Rising Sun, visit http://www.sf.us.emb-japan.go.jp/itpr_en/17_1103.html.

To stay informed of SPICE-related news, follow SPICE on Facebook and Twitter.

The same logic that kept a nuclear war from breaking out between the United States and former Soviet Union is the best strategy to now pursue with North Korea, several scholars said Tuesday at Stanford.

The panel, convened at Stanford’s Center for International Security and Cooperation (CISAC), included political scientist Scott D. Sagan of CISAC; political scientist Mira Rapp-Hooper of Yale University; and political scientist Vipin Narang of MIT. The moderator was James D. Fearon, a political scientist at the Freeman Spogli Institute for International Studies. The event was titled “Can the U.S. Deter a Nuclear North Korea” and held in the William J. Perry Conference Room in Encina Hall.

Nuclear decision-making

The discussion revolved around whether North Korea will have the ability to strike the U.S. with nuclear warheads, and can the U.S. depend on a deterrence strategy like it did during the Cold War?

Deterrence theory holds that nuclear weapons are intended to deter other states from attacking with their nuclear weapons, through the promise of retaliation and possibly mutually assured destruction 

Sagan, who recently wrote an essay in Foreign Affairs magazine on the North Korea nuclear crisis, said he has come to decide deterrence is the best approach to the issue.

“I am not one who gladly listens to the siren song of nuclear deterrence,” he said, noting that while he is a self-described dove on disarmament issues, he is more hawkish on allowing countries to obtain nuclear weapons, which deterrence implies. “I accept deterrence reluctantly.”

In North Korea, he said, no military alternatives exist to solve the problem. For example, even if a decapitation strike were successful – and several U.S. attempts have failed in the past with regard to Saddam Hussein and Muammar Gaddafi – there’s no way to know if North Korean leader Kim Jong-un has already given his generals the green light to unleash nuclear or powerful conventional attacks in the case of his demise.

For Sagan, deterrence is a more complicated issue today than during the Cold War when the U.S. and U.S.S.R. were rational actors with thousands of nuclear weapons. He is especially concerned with the rhetoric and the preventive war suggestions emanating from the Trump Administration.

Senior U.S. military leaders, Sagan said, have a duty not to follow “impaired-decision making” that might come from the president. He invoked the prospect of using the Cabinet and the 25th Amendment to halt such an order and remove the president from office. Currently, he belives the nuclear decision process is problematic, as the president alone can directly order the Strategic Air Command to launch nuclear weapons.

Sagan advises that a revised nuclear chain of command should include both the U.S. Secretary of Defense and the U.S. Attorney General. A U.S. Senate hearing, led by Sen. Bob Corker, is actually studying the nuclear authorization process due to concerns with Trump's rhetoric and escalation of the North Korean issue.

“We need more checks on how we decide to use nuclear weapons,” said Sagan, who studies nuclear strategy, ethics and war, public opinion about the use of force, and nuclear non-proliferation and arms control.

He noted that U.S. National Security Advisor H.R McMaster recently criticized his predecessor, Susan Rice, for saying the U.S. could "tolerate" nuclear weapons in North Korea the same way we tolerated nuclear weapons in the Soviet Union​.

He quoted McMaster: “'A regime that poses a continuous threat to the its neighbors in the region and now may pose a threat, direct threat, to the United States with weapons of mass destruction? A regime that imprisons and murders anyone who seems to oppose that regime, including members of his own family, using sarin nerve gas in a public airport?'”

But Sagan said we have long tolerated such authoritarian regimes that have nuclear weapons. 

Stumbling accidentally into war with North Korea also seems like a rising risk. On Sept. 27, several U.S. service members and their families received a fraudulent “noncombatant evacuation operation” order via text and social media, he said. The fake notices were quickly reported up the chain of command and the U.S. issued a statement denouncing their validity – the perpetrators have not been found. But Sagan says it illustrates how easy it is to create a situation where North Korea felt a U.S. invasion and attack is imminent – and as a result, could choose to unleash a nuclear first strike.

‘Western fantasy’

Narang, who was once a CISAC visiting assistant professor, studies nuclear proliferation and strategy, South Asian security, and general security studies.

“Deterrence is your friend,” he said in explaining why it can work with North Korea. If the U.S. believes North Korea seeks to preserve its regime – a status quo intention – then deterrence theory works much like it did with the former Soviet Union.

On the other hand, if the U.S. believes North Korea has darker motives, such as reunifying the Korean peninsula through an invasion, then that perspective could lead to a U.S. first strike. Also, the existing U.S. demand of rolling back North Korea’s nuclear program – “denuclearization” – is a “Western fantasy.” They will not give up nuclear weapons, he said.

He said the U.S. does not like to be deterred from making a first strike – as in preventive war – but that is what it must accept if it decides to follow the deterrence course. North Korea, once it possesses an ICBM capable of hitting the U.S. mainland, would pose such a deterrence in the balance of power between the two countries.

“The good news is that deterrence can work, coupled with coercive diplomacy,” Narang said. “We know how to play this game.”

He believes Jong-un is a rational actor, though a cruel dictator. “There’s nothing to suggest he’s crazy.” Ultimately, he said, an effective deterrence policy depends on clarity, consistency, coherence and communications.

U.S. nuclear shield, alliances

An expert on security in the Asia-Pacific region and alliance politics, Rapp-Hooper talked about the U.S. relationships, especially with Japan and South Korea, and the “nuclear shield” over these countries that those agreements offer. As a result, neither country has developed nuclear weapons.

This dynamic, however, could change if a North Korean missile could reach the U.S., said Rapp-Hooper, who earned a bachelor’s degree in history at Stanford.

“North Korea is eroding U.S. security guarantees over time,” she said, adding that once those missiles are capable of hitting a U.S. city, would the U.S. government still protect Seoul from attack and let an American city be hit?

The Korean situation, Rapp-Hooper said, is much different than Europe in the Cold War, when such an American nuclear shield existed against a Soviet invasion. Many different U.S. agreements exist now than during that time; no U.S. nuclear weapons are forwardly deployed in northeast Asia, like in Europe then; and the unilateral threats coming from the Trump Administration are unprecedented in nuclear diplomacy.

On the latter point, she called it the “Trump multiplier” effect. “That’s the most exacerbating thing of all,” she said, noting that elements of the White staff are pushing a “better-use-it-now” or preventive attack approach, whereas Secretary of Defense James Mattis and Secretary of State Rex Tillerson see North Korea as more concerned with preserving its regime.

Sagan also pointed out how President Trump’s speech at the United Nations in September led to a realization among the North Koreans that they had no choice but to continue to develop nuclear weapons.

That’s when the president said, “’Rocket Man is on a suicide mission for himself and for his regime,’” Sagan noted.

​He then recalled Kim Jong Un’s response to Trump’s speech, quoting the North Korean leader: “’His remarks which described the U.S. option through straightforward expression of his will have convinced me, rather than frightening or stopping me, that the path I chose is correct and that it is the one I have to follow to the last.’”​