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.

Donald K. Emmerson, director of the Southeast Asia Forum at Shorenstein APARC, and Thitinan Pongsudhirak, FSI-Stanford Humanities international visiting scholar this year, were among the contributors to a major new report from the Asia Society, addressing the most effective strategy for engaging Burma's authoritarian regime. Pongsudhirak offered the Thai viewpoint for the Asian perspectives section of the report. The Task Force's report, titled Current Realities and Future Possibilities in Burma: Options for U.S. Policy, recommends framing U.S. policy toward Burma based on internal changes and a careful balance of both positive engagement and sanctions to encourage political and economic reform.

Prominent Indonesian Muslim intellectual Nurcholish Madjid once declared “Islam Yes; Islamic political party No!” Voters in contemporary Indonesia seem to agree with this basic sentiment. Despite the recent Islamic revival that has dramatically increased public expressions of piety, Islamic political parties have failed to gain any significant electoral traction in Indonesia. In fact, between the 2004 and 2009 national elections, support for Islamic parties actually decreased from 38 percent to approximately 28 percent. Yet during those same five years, the Islamic political parties that failed to win at the ballot box mobilized enough political and popular support to pass one of Indonesia’s most divisive pieces of legislation—the Anti-Pornography Law. These seemingly contradictory elements of Indonesian politics provide starkly different impressions of Islam’s political role. Does a weak showing in the country’s electoral politics indicate the imminent demise of Islam in Indonesian politics? Or does the politically adept maneuvering of Islamists—who seek political power through legislation about bodily discipline—foretell gloomy days ahead?

Explanations for this paradox depend largely on where we look for “the political.” Political scientist Greg Fealy has described Islam in Indonesia as a mosaic. If we spend too much time focusing our gaze on one single area, he observes, we lose sight of other patterns elsewhere in the mosaic. To understand political Islam by ballot box alone is to miss the cultural undercurrents that have direct bearing on Islam and politics in Indonesia.

The anti-pornography bill was not only a political battle waged inside the parliament building; it was also a media drama that played out in the newspapers, televisions, and on the Internet. Human rights and women’s advocacy groups vehemently protested an early version of the bill, which stipulated that women would be prevented from leaving their homes during certain evening hours. From a different vantage point, the mostly Hindu island province of Bali threatened to secede, arguing that the article prohibiting “revealing” clothing in public would wreak havoc on the island’s tourism industry, still sluggish after devastating bomb attacks in 2002 and 2005. Whereas many non-Muslims worried about the “Islamization” of Indonesia, proponents of the bill lamented the “degradation of national morality.”

Popular Muslim television preachers were among the bill’s most vocal supporters. Eager to parlay their celebrity appeal into political clout, TV preachers Ustad Jefri Al-Buchori and Arifin Ilham helped to lead the so-called Million Muslim March to rally public support for the anti-pornography bill. Celebrity preacher and self-help guru Abdullah Gymnastiar led a sophisticated multimedia campaign to promote the bill through television, radio, the Internet, text messages, and public rallies. All of these popular preachers, in step with the political strategy of the Indonesian Council of Ulamas, invoked the religio-political language of moral crisis in an attempt to control the terms of political debate. Unable to win an election, Islamic groups flexed their moral muscle in the public sphere. From the pulpit of his Sunday afternoon television program, Gymnastiar characterized those against the bill as “having no shame” before God or country. Nearly every single political party, anxious not to appear “un-Islamic,” voted to support the anti-pornography legislation.

The political participation of a new generation of media-savvy religious leaders reveals a sentiment quite different from Nurcholish Madjid’s liberal aspirations. As one proponent of the Anti-Pornography Law put it, “Islamic political party No; Political Islam Yes!” Whereas utopian visions of the international caliphate may not resonate with Indonesian voters, it appears that political Islam—as played out on the public stage—is alive and well. What remains to be seen, however, is whether those who engage in the politics of piety also have the moral courage to champion Indonesia’s more pressing issues of poverty and corruption.

 

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Shorenstein APARC Dispatches are regular bulletins designed exclusively for our friends and supporters. Written by center faculty and scholars, Shorenstein APARC Dispatches deliver timely, succinct analysis on current events and trends in Asia, often discussing their potential implications for business.