Over more than six decades, the partnership between the United States and the Republic of Korea has been subject to many stresses and strains, from the Korean War to coping with the challenge of North Korea’s nuclear ambitions. More recently, the democratization of South Korea has opened the alliance to much greater public scrutiny and pressures from an active and mobilized Korean public. Managing this strategic alliance in an era of democracy has been a focus of the research work on Korea conducted by FSI’s Walter H. Shorenstein Asia-Pacific Research Center.

With the election in December of Lee Myung-bak as South Korea’s president, ending two terms of progressive rule, Shorenstein APARC decided to launch a nonpartisan group of former senior U.S. government officials, scholars, and other American experts on Korea to explore how to revitalize the U.S. alliance with the Republic of Korea (ROK) after a decade of tensions. In partnership with the New York-based Korea Society, Shorenstein APARC assembled this policy study group at Stanford in early February for in-depth discussion of the challenges facing the alliance and then took the group to Korea for meetings with key figures, from President-elect Lee and his advisors to leaders of the opposition, Korean businessmen, and American diplomats and security officials.

Based on these intensive meetings, the members of this “New Beginnings” policy study group concluded that the United States now has a major opportunity to bolster and broaden its relationship with the ROK. Lee, Korea’s first businessman to be elected president and a self-proclaimed “pragmatist,” has stressed that he gives top priority to the United States in his foreign policy. His fixed five-year tenure will coincide with the entire first term of the next U.S. president, allowing the two new leaders an extended period of cooperation.

Immediately before Lee’s first visit to the United States as president in mid-April, New Beginnings members led by Shorenstein APARC Director Gi-Wook Shin, APARC Distinguished Fellow Michael H. Armacost, and Korea Society President Evans J.R. Revere visited Washington, D.C., and New York City to release their report, New Beginnings in the U.S.-ROK Alliance: Recommendations to U.S. Policymakers. They also addressed a forum in San Francisco co-hosted by the World Affairs Council and the Asia Society of Northern California on June 3 to discuss their recommendations and subsequent developments in U.S.-South Korean relations. The report received extensive coverage in the South Korean news media and was noted in American media as well.

Surrounded by a rising China, a more assertive Russia, a Japan seeking a greater international role, and a nuclear North Korea, the ROK can play a key role in working with the United States to maintain peace and stability in East Asia. No effort to address the nuclear and other challenges posed by North Korea is likely to succeed without the closest U.S.-South Korean cooperation. The ROK, as the world’s 13th-largest economy and one of Asia’s most democratic countries, is a model of the virtues of a market economy, of the values of freedom and human rights, and of alignment with the United States. The two countries are also bound by personal ties: 2 million people of Korean descent live in the United States, and 100,000 Koreans come to the United States each year for study and exchanges, more than from any other country.

President Lee’s election reflects four key changes in South Korea: (1) a shift from the political left back toward the center; (2) greater skepticism about North Korea; (3) increased wariness of China; and (4) enhanced support for the U.S.-ROK alliance. The protests against the United States seen in South Korea in 2002 were the result in part of transitory circumstances and no longer reflect the reality there.

President Lee seeks a global partnership with the United States while maintaining good relations with Korea’s neighbors, Japan, China, and Russia. He favors improved relations with North Korea and has stated his willingness to meet North Korean leader Kim Jong-Il. In major departures from the earlier “sunshine” policy of the South Korean government toward North Korea, however, Lee will not provide large-scale economic assistance to the North until after it abandons its nuclear weapons program. In another major departure from the previous ROK policy, he has also criticized human rights abuses in North Korea. Lee supports continued food and other humanitarian aid to the people of North Korea.

New Beginnings group members believe that the United States cannot afford to lose the opportunity presented by President Lee to build a global partnership with one of the United States’ most important allies. The group identified a number of steps that the United States, in cooperation with the ROK, could take to move the alliance into a new era (see sidebar).

The New Beginnings group has announced that it plans to continue its efforts in support of strengthened U.S.-South Korean relations. Among other projects, the group intends to present recommendations early next year to the South Korean government on how to develop a close relationship and bolster the alliance with the incoming U.S. administration.

Recommendations to United States Policymakers

• Global Partnership — Building on the cooperation between Presidents Bush and Lee, the new U.S. president next year should issue a vision statement with Lee detailing their partnership and goals for the alliance. To advise them, the two new presidents should establish a bi-national panel of distinguished Koreans and Americans. The United States and the ROK should also give increased emphasis to the foreign ministerial strategic dialogue they initiated in 2006.
• Security Alliance — We support the ongoing realignment of U.S. forces in the ROK. Congress should increase its budget for the relatively small U.S. portion of the total cost of its implementation. The decision to transfer wartime operational control of Korean forces back to the ROK in 2012 was likewise correct, but the United States should respond positively to any South Korean proposal to discuss conditions related to the transfer. We welcome the Lee administration’s apparent desire to review the main North Korea war plan and to prepare jointly for other contingencies, including that of a North Korean collapse. The United States should conduct regular, joint consultations with South Korea and other allies in East Asia to determine whether security conditions warrant changes in our respective force levels and, if so, in what direction.
• North Korea — The ROK election has brought the United States and South Korea into essential agreement, for the first time in seven years, on how to deal with North Korea and its nuclear aspirations. To avoid the danger that their North Korea policies will again diverge, they must establish stronger consultative mechanisms, including with Japan.
• Economy and Trade — Congress should ratify the U.S.-ROK Free Trade Agreement now. U.S. failure to approve the FTA would not only represent foregone business opportunities; it would damage U.S.-ROK relations and be seen by the international community as a weakening of U.S. self-confidence and engagement, in East Asia and around the globe.
• People-to-People Ties — The U.S. government should set an early target date to include the ROK in the Visa Waiver Program and encourage the Korean government to support a major expansion of the Fulbright Program’s English Teaching Assistant Program. The United States should create a new program to allow U.S. federal employees to intern in Korean ministries and increase the budget for the State Department’s International Visitor Program for young South Korean leaders. U.S. military personnel stationed in Korea should be joined by their families. The United States should, at long last, construct a new U.S. embassy in Seoul.

The July/August issue of Health Affairs, the leading U.S.-based health policy journal, focuses on China and India. The special issue includes an article on China’s pharmaceutical policy by five contributors to Prescribing Cultures and Pharmaceutical Policy in the Asia-Pacific, a book forthcoming in 2009 from the Shorenstein Asia-Pacific Research Center series with Brookings Institution Press. Chapters on Korea and Japan by Soonman Kwon (Seoul National University) and Toshiaki Iizuka (Aoyama Gakuin University) also appear in Chinese translation in the journal Bijiao (Comparative Studies), along with an overview paper (“Pharmaceutical policy reforms to separate prescribing from dispensing in Japan and South Korea: Possible implications for China”) by Karen Eggleston, Asian Health Policy Program Director.

As Eggleston writes in the introduction to Prescribing Cultures, pharmaceuticals and their regulation play an increasingly important and often contentious role in the health care systems of the Asia Pacific.  For example, some economies such as China have extraordinarily high drug spending as a percentage of total health spending; India and a few others host thriving domestic pharmaceutical industries of global importance, while controversy surrounds patents, trade-related aspects of intellectual property (TRIPS), and pharmaceutical pricing within bilateral trade agreements (Australia-US, Republic of Korea-US); nations throughout the region struggle with appropriate regulation of drugs, from patents to evidence-based purchasing (e.g., Australia’s Pharmaceuticals Benefit Scheme) and direct-to-consumer advertising; deeply-rooted traditions of indigenous medicine are modernizing and integrating into broader health care systems; and policies to separate prescribing and dispensing re-write the professional roles of physicians and pharmacists, with modifications to accommodate cultural norms and strong economic interests. Effective prescribing and pharmaceutical use will be central to controlling infectious diseases, both old and emerging; protecting the global public good of antimicrobial effectiveness; and treating the growing burden of chronic disease in the Asia Pacific.

The forthcoming book will explore these issues in detail, through a multi-disciplinary lens. The first section of the book features chapters on pharmaceutical policy within seven selected health care systems of the Asia Pacific: South Korea, Japan, Thailand, Taiwan, Australia, India, and China. The second section focuses on the cross-cutting themes of prescribing cultures and access versus innovation. Taken as a whole, the contributions aim to provide an evidence base for policy while acknowledging the historical and cultural context that makes policies distinctive.

Clear evidence suggests the importance of health service provider payment incentives for achieving efficiency, equal access, and quality, including attention to primary, secondary, and tertiary prevention. “Pay for performance” may be on the cusp of significant expansion in Asia, and reform away from fee-for-service has been underway for several years in several economies. Yet despite the policy relevance, the evidence base for evaluating payment reforms in Asia is still very limited.

China in particular has been undertaking significant reforms to its health care system in both rural and urban areas. With the expansion of insurance coverage and need to resolve incentive problems like “supporting medical care through drug sales,” there is an urgent need for evaluating alternative ways of paying health service providers. Evidence from policy reforms in specific regions of China, as well as other economies of the Asia-Pacific, can provide valuable evidence to help inform policy decisions about how to align provider incentives with policy goals of quality care at reasonable cost.

To illuminate these questions, the Asia Health Policy Program and several collaborating institutions are planning to convene a conference on health care provider payment incentives on November 7-8, 2008 in Beijing. The conference will highlight and seek to distill “best-practice” lessons from rigorous and policy-relevant evaluations of recent reforms in China and elsewhere in the Asia Pacific.

The organizing committee – including health economists from Shorenstein APARC, Peking University, Tsinghua University, and Seoul National University – reviewed submissions in June 2008 and accepted sixteen. The conference papers cover payment issues in Korea, Japan, China, Taiwan, Thailand, Tajikistan, the Philippines, and the US, and the disciplines of economics, health services research/health policy, public health, medicine, and ethics. Topics include institutionalized informal payments; the impact of global budget policies on high-cost patients; public-private partnerships; public-sector physicians owning private pharmacies; evidence-informed case payment rates; payment and hospital quality; bonuses and physician satisfaction; physician prescription choice between brand-name and generic drugs; and differences in pharmaceutical utilization across insurance plans that pay providers differently (fee-for-service versus capitation).

Policymakers from China’s National Development and Reform Commission and Ministry of Health will also speak at the conference. Selected research papers will be published through the Shorenstein Asia-Pacific Research Center either in a special volume or in a special issue of an English-language health policy journal.