Health policy

Shorenstein APARC
Stanford University
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2011 Shorenstein-Spolgi Fellow in Comparative Health Policy
Qiulin_Chen3x4.jpg MA, PhD

Qiulin Chen is a postdoctoral fellow of Shorenstein APARC and a member of the center's Asia Health Policy Program. His main interest of research is health economics and public finance, focusing on policy and outcome comparison of health care systems and Chinese health reform. His dissertation focused on performance comparison between public (or governmental) and private health care financing, between local and central government responsibility on health care, between contracted and integrated health care system. In particular, his dissertation examined under Chinese-style decentralization, known as fiscal decentralization with political centralization, how economic competition affect local government's behaviour on health investment, and why public contracted system obstructs health performance and provides one channel of such effects in terms of preventive care and public health. He is currently involved in a comparative research project on demographic change in East Asia based on the National Transfer Accounts data and analysis.

Chen's recent publication is "The changing pattern of China's public services" (with Ling Li and Yu Jiang) in Population Aging and the Generational Economy: A Global Perspective (Ronald Lee and Andrew Mason, editors), forthcoming 2011. Before studying in Stanford, he has published more than 10 papers in academic journals in Chinese, such as Jing Ji Yan Jiu (Economic Research) and Zhong Guo Wei Sheng Jing Ji (Chinese Health Economics), and 5 book chapters. He has participated in about 20 research projects, such as A Design of Framework for Healthcare Reform in China which is commissioned by the State Council Working Party on Health Reform, Strategy Planning Study of "Healthy China 2020" which is commissioned by the Minister of Health, and Health Challenge in the Aging Society and It's Policy Implication funded by Chinese National Natural Science Foundation.

Chen earned his Ph.D. in Economics from Peking University in 2010, and earned a B.A. in Business Administration from Nanjing University in 2001. From 2004 through 2008, he was Executive Assistant of the Director of the China Centre for Economic Research at Peking University (CCER). He is also a postdoctoral fellow of National School of Development at Peking University (Its predecessor is CCER).

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OUR APOLOGIES: THIS WORKING PAPER HAS BEEN TEMPORARILY REMOVED PENDING PEER REVIEW FOR PUBLICATION.

In this study, we discuss the historical and policy background of expanded private health insurance in South Korea. Looking at the public-private mix of health care financing and its impacts, we conduct a comparative study of 30 member countries of the Organisation for Economic Co-operation and Development (OECD) over the period 1980–2007 to ask whether private health insurance can counterbalance limited government financing, high out-of-pocket payments, and the persistent financial deficit of South Korea’s National Health Insurance system. The panel analyses of OECD Health Data 2009 suggest that private health insurance financing is unlikely to reduce government spending on health care and social security. Also we find little evidence that out-of-pocket payments will be replaced by private health insurance payments. Private health insurance payments, however, are found to have a statistically significant positive association with total spending on health care, which indicates that the coverage effect of private health insurance—in addition to national health insurance—may exceed the efficiency gain through the market competition that private insurers may deliver to the health care sector. These findings leave it unclear whether private initiatives in health care financing will be as effective as the policy advocates hope for, in dealing with the challenges of national health insurance in South Korea. Further studies of how public and private insurers, and providers and consumers interplay in response to  a given structure of private-public mix in financing are warranted to decide the right balance between private coverage and publicly provided universal coverage.

Published: Shin, Jaeun. "Private health insurance in South Korea: An international comparison." Health Policy 108.1 (2012): 76-85.

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Asia Health Policy Program working paper #22
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AgingAsia

In the past fifty years, two factors have led to global population aging: a decline in fertility to levels close to—or even below—replacement and a decline in mortality that has increased world average life expectancy by nearly 67 percent. As the population skews toward fewer young people and more elderly who live longer postretirement lives, demographic changes—labor force participation, savings, economic growth, living arrangements, marriage markets, and social policy—are transforming society in fundamental, irreversible ways.

Nowhere are these effects of aging and demographic change more acute—nor their long-term effects more potentially significant—than in the Asia-Pacific region. How will these developments impact the economies and social protection systems of Japan, South Korea, China, and, by extension, the United States?

To assess this question, Aging Asia showcases cutting-edge, policy-relevant research. The first section focuses on demographic trends and their economic implications; the second section approaches select topics from a global comparative perspective, including social insurance financing, medical costs, and long-term care.

Desk, examination, or review copies can be requested through Stanford University Press.

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 The Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea

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Karen Eggleston
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Policy makers and academics have long debated the existence and extent of defensive medicine in the face of medical malpractice liability pressure. In this paper, I investigate how physicians’ test-ordering behavior and propensity to perform cesarean sections were affected first by a series of court rulings in Taiwan that increased physicians’ liability risks, and then by a subsequent amendment to the law that reversed the courts’ rulings. I find that physicians faced with higher malpractice pressure increased laboratory tests as expected but unexpectedly reduced cesarean sections. The reduction in cesarean deliveries may be due to the fact that liability risks were more closely aligned with physicians’ standard of care after the court rulings. After the law was amended to negate the court decisions, physicians reversed their previous behavior, reducing laboratory tests and increasing cesarean deliveries. This pattern of behavior strongly suggests that physicians in Taiwan practice defensive medicine.

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Asia Health Policy Program working paper #13
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Brian Chen
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Populous, economically dynamic, and rapidly urbanizing, the Asia Pacific both reflects and strongly shapes trends in global public health. A comparative assessment of chronic disease prevalence, risk factors, and policy responses in nine Pacific Rim cities shows that chronic diseases are rapidly becoming the leading cause of morbidity and mortality even in the lower income cities of the Pacific Rim. Policy responses are heterogeneous, with few sufficiently funded or adequately informed by evidence. Much could be learned from comparative research and rigorous evaluation of prevention and control initiatives in this region.

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Asia Health Policy Program working paper #21
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Over the past year, the Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) has engaged in leading-edge research on demographic change in East Asia. Karen Eggleston, director of the Asia Health Policy Program at Shorenstein APARC, discusses the recent book Aging Asia: The Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea, and the workshop on the economic, social, and political/security implications of demographic change in East Asia, held January 20-21 at Shorenstein APARC.

Across Northeast Asia, countries are facing the issue of an aging population, which causes socio-economic challenges that have policy implications. You explore this phenomenon in your forthcoming book Aging Asia: The Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea. When did aging begin to become an issue and what are some of the greatest factors that you address in the book?

Aging started at different times in the countries of East Asia. The country with the oldest life expectancy in the world and the oldest age structure of its population is Japan. It had a very short baby boom after the war and has had a steep decline in fertility. Mortality has also been falling around the world, and so this creates a change in the population. Japan is already at the fourth stage of demographic transition. South Korea is rapidly moving towards that and already has one of the lowest fertility rates in the world. Of course, neither of them have policies to reduce fertility; in fact, they are trying to encourage it. China, on the other hand, has long been trying to control fertility and is not as extreme in terms of the population age structure, but it is rapidly changing. China will be older in median age than the United States soon—this is not a trivial factor when you think in terms of the absolute size of the Chinese population.

One of the things that we wanted to study in this project is the premise that the demographic transition is a "problem." It is true that you need to think about and have policy responses to it. But it can also be seen as a sign of success, and as an opportunity. We wanted to reframe the issue and think about evidence on both sides. There is some research highlighted in the book, for example, that looks at the impact of population aging on economic growth, which is one of the first things that comes to many people's minds. For example, if you have a lot of elderly people, they are not in the work force and they need to be supported. It is true that this can be bad for economic growth, but there also are policy and individual responses that may moderate the effects. Our research is trying to highlight several different aspects of aging, including the question of opportunity. For example, there is more investment in individual children now and elderly persons' savings have actually contributed to economic growth. In some aspects, this has been a sign of resiliency for Japan where there are a lot of transfers to the working-age population.

Ronald Lee at the University of California, Berkeley and Andrew Mason at the East-West Center at the University of Hawai'i, who is participating in the January workshop, have been working on the concept of a "second demographic dividend." They find that as countries have an older age structure, there are more people that are saving. In the widely accepted "first demographic dividend," there are more people in the working-age part of the population—more people employed and more people contributing to the GDP. You get a boom contributing to growth. We know that this contributed to Japan and South Korea's earlier growth, and to China's in the 80s and part of the 90s, but only one or two percent of GDP. The question then is whether it is a problem that with aging you are losing that first demographic dividend. A second demographic dividend might arise because people who are preparing for a longer retirement life are saving more, and those savings are then invested in the economy and the investment drives economic growth.

Is there any correlation to demographic issues faced by the United States?

Interestingly, the aging issue is more pronounced in East Asia than in the United States for several reasons. We have a higher fertility rate than in Japan and South Korea, and many other countries in Europe as well. We also historically are much more open to immigration than most other countries, and this has led to a certain vitality in the population mix that has slowed the impact of demographic change. That said, of course, there are issues with having a lot of baby boomers. Sometimes, depending on the specific question or the specific area of policy, you find other factors that are much more important than aging. For example, the growth of healthcare spending has been in the news a lot lately. Although obviously there is an impact from having more elderly people, there are much bigger issues, such as what we are spending per person per age group and the growth of that spending. Just aging per se is not as big of an issue as people might think.

In late January, you will be holding the workshop Comparative Policy Responses to Demographic Change in East Asia: Defining a Research Agenda. What are the major issues you will explore in the conference? Who will be involved? Finally, what is the publication or research project that you will launch from this?

We had an Aging Asia conference in February 2009, co-sponsored with the Global Aging Program at the Stanford Center on Longevity. The outcome of this is the forthcoming volume, co-edited with Shripad Tuljapurkar of the Department of Biology at Stanford University. We started with a basic survey of the region and thought about the basic trends-demographic, social, and economic-and built upon that to figure out where the gaps are in the literature and where the interesting research questions are. That is where the January 2011 workshop comes in as the next step. We are bringing in some of the same and some different people to focus on three specific themes: economics, society, and politics/security. The upcoming event again focuses on East Asia and there will be a public component, but it is a smaller event and its main goal is to dig deeper into these themes to figure out an interesting research agenda on the policy responses to demographic transition.

We decided to focus again on East Asia, which is the research focus of a lot of our Shorenstein APARC faculty. Masahiko Aoki and Michael Armacost are going to chair sessions, and Gi-Wook Shin is going to kick it all off and talk about the social aspects of demographic change. Andrew Walder will be participating in that session as well. Thomas Fingar will be covering the political and security implications. All Shorenstein APARC faculty have been invited to participate and think about how this issue of demographic change—and particularly policy responses—might be related to their own areas of research. 

An illustration that I like to give when people ask about how demographic change is related to other things is from Andrew Walder when he was talking about China's transition in the 1980s. He received a question about whether or not there had been an impact from the One Child policy. He said that obviously there are many different impacts, but the one thing that he noted was that students in China now, especially if they are only children, are under a lot of career pressure. This has changed the space or the freedom for self-exploration. Why does this have broader implications? Young people see access to political power as one key for their careers and this changes their views about joining the Communist Party, which has big implications for China's political future. This is just one illustration of how we are trying to explore the broader implications of demographic change.

Finally, what is the outcome that you would most hope to achieve through Aging Asia and the upcoming demographic change workshop?

I think that the biggest hope would be to develop a much better understanding of what is going on with demographic change: what are the processes and how is society changing? What are the individual challenges that families are facing and what are they are doing about it? What is the broader social or even global perspective on how this is going to shape our future world? For me, I think about the world that my children are going to grow up in.

Through our research, I hope that we will impact not only the understanding of what has driven past developments, but create policy recommendations for each of the societies that were are examining—including our own—on the opportunities and the challenges related to changes in population. That hopefully will be useful as these different societies think about how to respond.

Our research on the economic, the social, and political/security aspects of demographic change is intended to be tangible for individuals and families as well as for broader national policy.

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The Shorenstein Asia-Pacific Research Center and its Asia Health Policy Program have joined with other centers and programs across the university as collaborative partners for the new Stanford Center for Population Research (SCPR). Supporting population research among faculty and students throughout Stanford, the SCPR is led by Professor Shripad Tuljapurkar, co-editor with Karen Eggleston of the book Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea.

The Stanford Center for Population Research, based in the Institute for Research in Social Sciences, has leadership and involvement across campus including the Humanities, Natural Sciences, Environmental programs, and the Medical School. The goal is to promote, support and develop population studies through collaboration among researchers and training for undergraduate and graduate students, serving as both a resource and nexus for faculty at Stanford across disciplines with interests in population studies, broadly defined.  

The Asia Health Policy Program will work with the Stanford Center for Population Research in studying the implications of demographic change in the Asia-Pacific region. For example, Karen Eggleston is undertaking comparative study of population health trends in China and India with other Stanford faculty associated with SCRP.

AHPP will also support the mission of strengthening the teaching of population studies at the undergraduate, graduate and postdoctoral levels, by helping to make connections for students studying demographic change in Asia. The 2011 postdoctoral fellow in Asia health policy, Qiulin Chen, will be studying population aging in China in comparative perspective. Shorenstein APARC’s affiliation with the SCRP will also help to reinforce the new Shorenstein APARC initiative studying policy responses to population aging in East Asia, kicking off with a workshop in January 2011.

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The objective of this paper is to estimate the causal effect of coresidence with an adult child on depressive symptoms among older widowed women in South Korea. Data from the first and second waves of the Korea Longitudinal Study of Aging were used. Analysis was restricted to widowed women aged ≥ 65 years with at least one living child (N=2,449). We use an instrumental variable approach that exploits the cultural setting where number of sons predicts the probability of an elderly woman's coresidence with an adult child but is not directly correlated with the mother's depressive symptoms. Our models adjust for age, education, total assets, residence, functional limitations, self-rated health, and various illnesses. Our robust estimation results indicate that, among older widowed women, coresidence with an adult child has a significant protective effect on depressive symptoms, but that this effect does not necessarily benefit those with clinically relevant depressive symptoms. Future demographic and social transitions in South Korea portend that older women’s increasing vulnerability to poor mental health is an important though less visible public health challenge.
Keywords: living arrangements, coresidence, depressive symptomatology, elderly, KLoSA

Published: Do, Young Kyung, and Chetna Malhotra. "The effect of coresidence with an adult child on depressive symptoms among older widowed women in South Korea: an instrumental variables estimation." The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 67.3 (2012): 384-391.

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Asia Health Policy Program working paper #20
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Young Kyung Do
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Objective: To show the pattern of patient satisfaction with top-level delivery organizations (Level 2 and Level 3 hospitals), and using neo-institutionalism approach to explain the relatively low satisfaction and to explore the limitations with top providers, focusing on how to improve the competence of Level 2 and Level 3 hospitals at both the individual hospital level and the whole delivery system level.

Data Sources/Study Setting: The household survey by the National Bureau of Statistics in China in 2008; China Health Statistics Yearbooks.

Data Collection/Extraction Methods: The analysis uses a 2008 sample medical experiences of 5,036 residents from 17 provinces collected in a household survey by the National Bureau of Statistics in China. The linear regression model, the structural difference regression model, and the ordered probit model are used in our framework.

Principal Findings: The imbalance between the needs of patients and the limited competence of top-level providers, and the conflict between the business expansion and the limited competence of those providers are deeply and widely influenced by patterns of patient needs, the top providers’ expansion, and the institutional environment.

Conclusions: In order to effectively respond to patient needs, top and lower level providers need to set their own individual priorities. The government needs to improve institutional arrangements to respond to patient needs with the development of a fair and appropriate reimbursement and compensation pricing mechanism, and with further evaluation of top level providers’ advanced and limited health services.

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Asia Health Policy Program working paper #19
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Qunhong Shen
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