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.

* * *

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.

North Korea is usually described as the “most isolated country on earth,” its people effectively cut off from the outside world. My research tells a different story—that perhaps one million North Koreans are secretly listening to foreign radio broadcasts. The number of listeners is believed to be growing, which is all the more amazing when one considers that North Korean authorities only distribute radios with fixed dials, assiduously jam foreign broadcasts, and send citizens caught listening to foreign radio to the country’s notorious gulags for as long as ten years.

Over a dozen radio stations from the United States, South Korea, and Japan currently broadcast to North Korea. Voice of America (VOA), one of the most popular stations, has been broadcasting to the North since 1942, while the equally popular Radio Free Asia (RFA) began its Korean broadcasts soon after being created by Congress in 1997. VOA focuses on news of the United States and the world, while RFA concentrates on the two Koreas. RFA also carries commentaries by two Korean speakers who grew up in the former Soviet Union and Romania. RFA serves as a substitute for the lack of a “free” station in North Korea, but unlike a typical “surrogate station”—which would be staffed largely by émigrés—RFA only employs one North Korean defector.

South Korea’s “Global Korean Network” has been declining in popularity since it ceased to focus on North Korea and adopted a decidedly soft approach after the election of Kim Dae-jung as president in 1997. However, three stations run by North Korean defectors have sprouted up over the past few years, led by Free North Korea Radio (FRNK). These stations employ stringers in North Korea who can communicate by cell phone or smuggle out interviews through China. As a result, information is flowing in and out of the North more rapidly than ever. For example, when major economic reforms were undertaken in 2002, it was months before the rest of the world knew. In contrast, when the regime launched a disastrous currency reform on November 30, 2009, FNKR filed a report within hours.

How do we know that North Koreans are actually listening to foreign broadcasts? First, on dozens of occasions, authorities in Pyongyang have used their own media to attack foreign broadcasters. The North reserves the insult “reptile” exclusively to describe foreign broadcasters. In late March 2010, the regime likened defector broadcasters to “human trash.” Ironically, this diatribe also contained the first official mention of the currency revaluation, so broadcasters have clearly struck a nerve. If they were in fact irrelevant, the regime would ignore them instead of lavishing them with free publicity.

Broadcasters to North Korea frequently receive heartbreaking messages from North Koreans in China, thanking them for their efforts. One listener described RFA as “our one ray of hope.” More importantly, over the past several years, thousands of North Korean defectors, refugees, and visitors to China have been interviewed about their listening habits. An unpublished 2009 survey of North Koreans in China found that over 20 percent had listened to the banned broadcasts, and almost all of them had shared the information with family members and friends. Several other surveys confirm these findings. While we cannot generalize the listening habits of a self-selected group to the general population, it is not unreasonable to conclude that there are more than a million surreptitious listeners. The North Korean regime is not only losing its monopoly on the control of information; defectors also cite foreign radio listening as one of the leading motivations to defect.

Despite valiant efforts and growing impact, much more could be done to improve broadcasting to North Korea. VOA and RFA only broadcast five hours a day, and the defector stations limp along with shoestring budgets, due to a pervasive indifference within South Korea.

President Obama’s human rights envoy for North Korea, Robert King, has pledged to expand funding for Korean broadcasting. For its part, Pyongyang claims that foreign broadcasts are part of the Obama administration’s “hostile policy” toward the North. Only time will tell if these efforts will lead to change we can believe in—both in Washington and Pyongyang.

------------------

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.

The First Quarter 2010 issue of the International Association for Energy Economics (IAEE) Energy Forum has published an article written by PESD research fellow Varun Rai and PESD affiliated faculty David G. Victor. This issue of the forum  looks at the far east, particularly China and India. There are six articles that look at multiple facets of energy economics in that area and the forum will continue with this focus in the second quarter issue.

Rai and Victor's article titled "Identifying Viable Options in Developing Countries for Climate Change Mitigation: The Case of India" offers a framework for identifying viable and credible climate change mitigation actions in developing countries. The framework is applied to the case of India to suggest that a large number of options to control warming gases are in India's own self-interest, and that leverage on emissions from each of these options could amount to several hundred million tons of CO₂ annually over the next decade and an even larger quantity by 2030.

Robert Hormats, Under Secretary of State for Economics, Energy, and Agricultural Affairs, gave an S.T. Lee seminar at FSI on March 11, addressing "The Rise of the New Economic Powers: How the United States Can Meet the Challenge." He set the stage by discussing the vast new economic geography.

• The global economy is now multi-polar, with a number of players in global trade, finance, and technology development, especially China, India and Brazil.  The rising powers, however, still have large numbers of poor people and see their domestic needs and objectives differently than developed nations.
• Second, the big sovereign risk questions now surround the developed, not the developing economies, and the pressures of the global financial crisis have made them more concerned with domestic recovery, rather than global systemic issues, particularly trade.
• Third, the Internet and rising importance of services has brought gains as well as perils. Global integration of production and supply chains is efficient, but disruptions are readily transmitted across national borders. As increasing portions of investment are devoted to services and intangibles, rapid dissemination puts intellectual property at risk.

Asking how to develop a new international system, Hormats emphasized that the Group of 20 was designed to foster greater inclusion and dialogue, calling cooperation during the recent financial crisis the "largest multilateral collaborative endeavor since World War II." In an effort to move forward with strategic concerns, rather than immediate deliverables, the U.S. government is fostering a number of dialogues with key partners - including Russia, China, and Brazil. Hormats also cited the need to address issues more efficiently. Noting that large scale negotiations like Copenhagen no longer work, he identified a new focus on building coalitions of the willing and able.