Encina Hall, E301
Stanford University

1
Visiting Scholar at APARC, 2021-2022
sheen_woo.jpg PhD

Sheen Woo, Special Policy Advisor to the South Korean Ambassador in China, joined the Korea Program at Shorenstein APARC as a 2021-22 visiting scholar. He is a specialist in China-North Korea relations with expertise in Chinese aid and sanctions against North Korea. He has worked at and with a variety of organizations including NGOs, start-ups, art centers, and state-run think tanks in Korea and China. While at APARC, his research focus was on the development and changes of China's aid to North Korea. He holds a PhD in Management Science from Tsinghua University.

-

This is a virtual event. Please click here to register and generate a link to the talk. 
The link will be unique to you; please save it and do not share with others.

Co-sponsored by the Stanford Center at Peking University.

In honor of its release, contributors Mary Bullock, Thomas Fingar, and David M. Lampton will join editor Anne Thurston for a panel discussion of their volume Engaging China: Fifty Years of Sino-American Relations (Columbia University Press, 2021).

Recent years have seen the U.S.-China relationship rapidly deteriorate. Engaging China brings together leading China specialists—ranging from academics to NGO leaders to former government officials—to analyze the past, present, and future of U.S.-China relations. Bullock, Fingar, Lampton, and Thurston will reflect upon the complex and multifaceted nature of American engagement with China since the waning days of Mao’s rule. What initially motivated U.S.’ rapprochement with China? Until recent years, what logic and processes have underpinned the U.S. foreign policy posture towards China? What were the gains and the missteps made during five decades of America’s engagement policy toward China? What is the significance of our rapidly deteriorating bilateral relations today? Speakers will tackle these questions and more at this critical time when tensions between the U.S. and China continue to intensify.

For more information about Engaging China or to purchase a copy, please click here.


Image
Portrait of Mary Bullock
Mary Bullock, president emerita of Agnes Scott College, is an educator and scholar of U.S. – China relations. She served as the founding executive vice-chancellor of Duke Kunshan University from 2012-2015. Previous positions include distinguished visiting professor at Emory University, director of the Asia Program of the Woodrow Wilson Center, and director of the Committee on Scholarly Communication with the People’s Republic of China. She is vice-chair of the Asia Foundation, a trustee of the Henry Luce Foundation, and a member of the Schwarzman Academic Advisory Committee and the Council on Foreign Relations. She received her M.A. and Ph.D. in Chinese history from Stanford University. Her most recent publications include The Oil Prince’s Legacy: Rockefeller Philanthropy in China (2011) and, as co-editor, Medical Transitions in Twentieth Century China (2014).
 

Image
Portrait of Tom Fingar
Thomas Fingar is a Shorenstein APARC Fellow in the Freeman Spogli Institute for International Studies at Stanford University. He was the inaugural Oksenberg-Rohlen Distinguished Fellow from 2010 through 2015 and the Payne Distinguished Lecturer at Stanford in 2009. From 2005 through 2008, he served as the first deputy director of national intelligence for analysis and, concurrently, as chairman of the National Intelligence Council. Fingar served previously as assistant secretary of the State Department’s Bureau of Intelligence and Research (2000-01 and 2004-05), principal deputy assistant secretary (2001-03), deputy assistant secretary for analysis (1994-2000), director of the Office of Analysis for East Asia and the Pacific (1989-94), and chief of the China Division (1986-89). Between 1975 and 1986 he held a number of positions at Stanford University, including senior research associate in the Center for International Security and Arms Control.

Fingar's most recent books are The New Great Game: China and South and Central Asia in the Era of Reform, editor (Stanford, 2016), Uneasy Partnerships: China and Japan, the Koreas, and Russia in the Era of Reform (Stanford, 2017), and Fateful Decisions: Choices that will Shape China’s Future, co-edited with Jean Oi (Stanford, 2020).
 

Image
Portrait of David M. Lampton
David M. Lampton is Senior Fellow at the SAIS Foreign Policy Institute and Professor Emeritus at Johns Hopkins--SAIS. Immediately prior to his current post he was Oksenberg-Rohlen Fellow at Stanford University’s Asia-Pacific Research Center from 2019-2020. For more than two decades prior to that he was Hyman Professor and Director of China Studies at the Johns Hopkins University School of Advanced International Studies. Lampton is former Chairman of the The Asia Foundation, former President of the National Committee on United States-China Relations, and former Dean of Faculty at SAIS. Among many written works, academic and popular, his most recent book (with Selina Ho and Cheng-Chwee Kuik) is Rivers of Iron: Railroads and Chinese Power in Southeast Asia (University of California Press, 2020). He received his B.A., M.A., and Ph.D. degrees from Stanford University in political science where, as an undergraduate student, he was a firefighter. Lampton has an honorary doctorate from the Russian Academy of Sciences’ Institute of Far Eastern Studies. He is a Life Trustee on the Board of Trustees of Colorado College and was in the US Army Reserve in the enlisted and commissioned ranks.


Image
Portrait of Anne Thurston
Anne Thurston is the director of the Grassroots China Initiative, where she works with local NGOs in China. Thurston is a former associate professor at Johns Hopkins SAIS, assistant professor at Fordham University, and was a China staff member at the Social Science Research Council. She has been the recipient of fellowships from the Rockefeller Foundation, the John D. and Catherine T. MacArthur Foundation, the United States Institute of Peace, the Woodrow Wilson International Center for Scholars and the National Endowment for the Humanities. Thurston is also a member of the National Committee on US-China Relations. Thurston is the author of numerous publications, including The Noodle Maker of Kalimpong: The Untold Story of My Struggle for Tibet (2015), and Muddling Toward Democracy: Political Change in Grass Roots China (1998). She received her Ph.D. in political science from the University of California, Berkeley.

Via Zoom Webinar. Register at: https://bit.ly/38ME0m3

Mary Bullock <br>President Emerita, Agnes Scott College<br><br>
Thomas Fingar <br>Shorenstein APARC Fellow, Stanford University<br><br>
David M. Lampton <br>Professor Emeritus, Johns Hopkins School of Advanced International Studies (SAIS); Senior Fellow, SAIS Foreign Policy Institute<br><br>
Anne F. Thurston <br>Director, Grassroots China Initiative; China Studies Affiliated Scholar, Johns Hopkins--SAIS
Seminars
-

This is a virtual event. Please click here to register and generate a link to the talk. 
The link will be unique to you; please save it and do not share with others.

 

Peter Martin joins us to discuss his recent book, China's Civilian Army: The Making of Wolf Warrior Diplomacy. Chinese diplomacy in the past several years has become more assertive and its diplomats have used sharper language, earning them the title "wolf warriors." The book traces the roots of China's approach to diplomacy back to the communist revolution of 1949 and tells the story of how it's evolved through social upheaval, famine, capitalist reforms and China's rise to superpower status. It draws on dozens of interviews and -- for the first time -- on the memoirs of more than 100 retired Chinese diplomats.


Image
Portrait of Peter Martin
Peter Martin is a political reporter for Bloomberg News. He has written extensively on escalating tensions in the US-China relationship and reported from China's border with North Korea and its far-western region of Xinjiang. He previously worked for the consultancy APCO Worldwide in Beijing, New Delhi, and Washington, where he analyzed politics for multinational companies. In Washington, he served as chief of staff to the company's global CEO. His writing has been published by outlets including Foreign Affairs, the National Interest, the Guardian, the Jamestown China Brief, the Diplomat and the Christian Science Monitor. He holds degrees from the University of Oxford, Peking University and the London School of Economics.

Via Zoom Webinar. Register at: https://bit.ly/3zDZ3D0

Peter Martin Defense Policy and Intelligence Reporter, Bloomberg News
Seminars
Authors
Oriana Skylar Mastro
News Type
Commentary
Date
Paragraphs

In her recent Foreign Affairs essay, The Taiwan Temptation: Why Beijing Might Resort to Force, Center Fellow Oriana Skylar Mastro argues that Chinese leaders now consider a military campaign to take Taiwan a real possibility and cautions that the United States cannot by itself alter Beijing’s calculus on Taiwan. The essay sparked a heated debate. In the September/October issue of Foreign Affairs, several scholars — Rachel Esplin Odell and Eric Heginbotham, Bonny Lin and David Sacks, and Kharis Templeman — provide counterarguments to Mastro's analysis and she responds to their criticism. Read her complete rebuttal below.


Sign up for APARC newsletters to receive our experts' analysis and commentary. 


Rachel Esplin Odell and Eric Heginbotham, Bonny Lin and David Sacks, and Kharis Templeman all argue that China is unlikely to attempt armed unification with Taiwan. Although I appreciate their perspectives, they do not present any new evidence that would make me reconsider my assessment that the risk of Chinese aggression across the Taiwan Strait is real and growing. To the contrary, they repeat many of the increasingly dangerous misperceptions that I sought to dispel in my original article—namely, that China does not have the military capabilities to pull off an amphibious invasion, that the economic costs of an invasion would be sufficient to deter Chinese President Xi Jinping, and that China can afford to wait indefinitely to achieve its most important national goal of unification. My critics assume that insofar as there are risks, they can be dealt with through relatively limited adjustments in U.S. policy and military posture — a position with which I still strongly disagree. 

Let’s take these arguments in order. My critics say that I have exaggerated China’s military capabilities and understated the difficulties of an invasion. But their assessments rely on outdated or largely irrelevant comparisons. Odell and Heginbotham, for instance, note that the United States needed more naval tonnage to capture Okinawa from Japan in 1945 than China has today. But this example is inapposite. Japan’s military was more than six million strong in 1945 and had been fighting for over a decade; Taiwan’s military consists of 88,000 personnel and two million reservists, of whom only 300,000 are required to complete even a five-week refresher training course. Tonnage, moreover, is not a useful metric. Modern navies have moved to lighter, more flexible fleets. Odell and Heginbotham point out that civilian ships were of only limited use in the Falklands War, but the United Kingdom used just 62 of them in that campaign. The People’s Armed Forces Maritime Militia has many thousands of ships and is closer to a naval force than a civilian one. If China were to mobilize all its naval vessels, including its new large amphibious transport ships and civilian ships, it could hypothetically carry hundreds of thousands of troops across the 80-mile-wide Taiwan Strait in a short period of time. Even if the United States had enough warning to optimally position its submarines, it does not have enough munitions to target such a large force. 

For their part, Lin and Sacks argue that to believe China can take Taiwan by force is to fall for a Chinese misinformation campaign. They warn that “analysts should not accept at face value China’s claim that it could easily win a fight against Taiwan.” But no one, not even the cockiest of People’s Liberation Army analysts, argues that a full-scale attack on Taiwan would be easy, only that the PLA could prevail at an acceptable cost. Moreover, my assessment of Chinese military capabilities is not based on Chinese discourse or the results of war games alone. Reams of unbiased and rigorous analysis—from the U.S. Department of Defense’s annual report to Congress on China’s military modernization to Congressional Research Service reports on Chinese naval modernization to hundreds of studies by think tanks and defense-affiliated organizations, such as the RAND Corporation—suggest that the PLA has made unparalleled advances in the past two decades and could take on the United States in certain scenarios. Indeed, Heginbotham himself argued in 2017 that “the balance of power between the United States and China may be approaching a series of tipping points, first in contingencies close to the Chinese coast (e.g., Taiwan).” 

I do not mean to suggest that a Chinese invasion would be a cakewalk. Taiwan could get some shots in, but it does not have the ability to defend itself. Luckily, the United States would, I believe, come to Taiwan’s aid and could still prevail in many scenarios. Taiwan is far from a lost cause. But ten years ago, the United States would have prevailed in any scenario. Because there are now some scenarios in which U.S. strategists think the United States could lose, it is not unfathomable to think that Chinese strategists have come to a similar conclusion. 

My critics also argue that economic considerations will deter Beijing. Should China attempt to use force to assert control over Taiwan, the international response would be severe enough to imperil Xi’s ambitious development goals. But as I argued in my original article, Chinese analysts have good reason to think the international response would be weak enough to tolerate. China could even reap economic benefits from controlling Taiwan, whose manufacturers accounted for more than 60 percent of global revenue from semiconductors last year. The United States is heavily reliant on Taiwanese semiconductors. Should China take Taiwan, it could conceivably deprive the United States of this technology and gain an economic and military advantage. 

But economic costs or benefits, while part of Beijing’s calculus, are unlikely to be the determining factor. Xi’s top priority is protecting China’s sovereignty and territorial integrity—as Beijing defines it. China’s Belt and Road Initiative, its militarization of the South China Sea, and its sanctions against countries that offend it, such as Australia or South Korea, all demonstrate that Chinese leaders are willing to subordinate economic considerations to considerations of power and prestige. In a speech marking the 100th anniversary of the Chinese Communist Party in July, Xi warned against foreign attempts to bully or oppress China, declaring that “anyone who dares try to do that will have their heads bashed bloody against the great wall of steel forged by over 1.4 billion Chinese people.” Those words should be taken seriously. 

Finally, my critics argue that China has no need to attempt to forcibly unify with Taiwan. Lin and Sacks think peaceful unification is working; Templeman believes China can wait indefinitely to resolve the issue. I disagree because I think unification is a top priority for the Chinese Communist Party and Taiwan will not give up its autonomy without a fight. 

A Chinese invasion is by no means imminent or inevitable, but Beijing is now seriously considering initiating a conflict to gain political control over Taiwan, whereas in the past the only scenario in which it would have used force was to prevent Taipei from declaring independence. I agree with Templeman that China is unlikely to invade in the next four years (although I think this is largely because China could benefit from more time to prepare, not because it fears U.S. President Joe Biden’s resolve), but his argument that China can wait indefinitely is logically and empirically flawed. As I argued in my original article, Xi has made numerous statements that suggest he wants to achieve unification during his reign. It would be unwise to dismiss these as mere rhetoric, since he has repeatedly voiced his intention to assert control over other territorial claims before doing exactly that — in the South China Sea, by building military infrastructure and conducting naval drills, and in Hong Kong, by imposing a harsh national security law last year.

Beijing still needs to put boots on the ground to gain full political control of Taiwan.
Oriana Skylar Mastro

Templeman argues that if China believes the United States is in decline, then it has every reason to wait on Taiwan. But in the eyes of Chinese strategists, American decline actually hastens the need for action. Power transition theory, which holds that war becomes more likely as the gap between a rising power and an established great power diminishes, is also studied in Beijing. And although U.S. strategists fret that a rising China, dissatisfied with the U.S.-led international order, will become aggressive and start a conflagration, Chinese strategists fear a different pathway to war. They worry that the United States, unable to accept its inevitable decline, will make a dangerous last-ditch effort to hold on to its unrivaled great-power status. By this logic, a declining United States is more dangerous than a stable, ascendant one. 

Lin and Sacks make a different argument for why Beijing does not need to attempt armed unification. They believe that Chinese leaders remain committed to their long-standing approach of limited coercion coupled with economic incentives showcasing the benefits of unification because that strategy is working. As evidence of Beijing’s progress, Lin and Sacks point to polling that shows the majority of people in Taiwan support the status quo, not independence. But it is an enormous leap from not supporting independence to desiring or conceding to unification. As Lin and Sacks themselves acknowledge, China has employed this strategy of limited coercion and economic inducements for decades, but Taiwan is no closer to being a part of mainland China. In a September 2020 poll conducted by National Chengchi University, only six percent of Taiwanese citizens preferred eventual or immediate unification. So although Lin and Sacks are correct that Beijing will likely continue with its carrot-and-stick approach, it will still need to put boots on the ground to gain full political control of Taiwan. 

My critics also raise concerns about some of the policy implications of my argument. Odell and Heginbotham warn against focusing too much on the credibility of the U.S. military threat when it comes to deterrence, rightly highlighting the equal importance of reassurance. They warn that changes in U.S. policy toward Taiwan could convince Beijing that the United States now supports Taiwanese independence — a misperception that could lead to war. But my argument is for a change in posture, not in policy: the United States should develop the force posture and operational plans to deny China its objective in Taiwan and then credibly reveal these new capabilities. It should not make dangerous policy changes that would risk provoking a Chinese military response. Indeed, I have argued elsewhere that even if a war breaks out over Taiwan and the United States wins, Washington should not demand Taiwan’s independence as one of the terms of peace. 

Templeman raises a separate concern: that highlighting the potential costs of defending Taiwan could bolster the case of those advocating that Washington abandon Taipei. If this were a serious worry, I would be the first to shift my work to more private channels. But those calling for the United States to reconsider its commitment to defend Taiwan are still in the minority, and the Biden administration has been clear that it would come to Taiwan’s aid in the event of an invasion.

Moreover, the reaction of the U.S. Department of Defense to the threat posed by China’s growing military power has been not to back down but to ramp up efforts to counter it. From new doctrines that enhance joint capabilities between the U.S. Air Force and the U.S. Navy to base-resilience initiatives to efforts to improve U.S. early warning systems in the region, the Pentagon is firing on all cylinders to ensure it can deter and, if necessary, defeat China in a wide range of conflict scenarios. U.S. Cyber Command, the U.S. Space Force, and the Department of Defense’s Joint Artificial Intelligence Center were all established partly to counter Chinese advantages in those organizations’ respective domains. If Lin and Sacks are correct that China exaggerates its capabilities to try to convince the United States to give up, Beijing has achieved the opposite.   

In the end, all my critics highlight an important truth: the situation across the Taiwan Strait has been relatively stable for 70 years because of the United States. Washington has managed to convince Beijing that armed unification would fail and that China would pay a hefty price for trying. But China is not the same country it was 70 years ago. Its rapid military modernization, spectacular economic ascent, and growing global influence have changed Beijing’s calculus on many issues. It has taken a more assertive approach to international institutions; built one of the world’s largest, most capable militaries; and extended its economic influence deep and far throughout the world. It would be wishful thinking to assume that China has not also changed its thinking on Taiwan.

Indeed, although my critics argue that China is unlikely to invade, they still recommend that Taiwan improve its defenses and that the United States enhance its military posture in the region — not exactly a vote of confidence in Beijing’s restraint. I had hoped to convince skeptics that China is now seriously considering armed unification, but at least our debate has yielded a consensus that more must be done in Taipei and Washington to enhance deterrence across the Taiwan Strait.

Read More

An Island that lies inside Taiwan's territory is seen with the Chinese city of Xiamen in the background.
Commentary

The Taiwan Temptation

Why Beijing Might Resort to Force
The Taiwan Temptation
A case holding lunar rock and debris collected from the Moon by China's space program that is part of a display at the National Museum of China is seen on March 2, 2021 in Beijing,
Commentary

Chinese Space Ambition

On the American Foreign Policy Council Space Strategy podcast, Center Fellow Oriana Skylar Mastro discusses how China views space and why the United States must not surrender global leadership in pursuing aspirational and inspirational space goals.
Chinese Space Ambition
Indian Prime Minister Narendra Modi rides in a tank at Longewala in Jaisalmer, Rajasthan, 14 November 2020.
Commentary

India, China, and the Quad’s Defining Test

The Ladakh crisis between China and India seems to have settled into a stalemate, but its trajectory could again turn suddenly. If it flares into a limited conventional war, one of its incidental victims could be the Quad.
India, China, and the Quad’s Defining Test
Hero Image
Figures of Kuomintang soldiers are seen in the foreground, with the Chinese city of Xiamen in the background, on February 04, 2021 in Lieyu, an outlying island of Kinmen that is the closest point between Taiwan and China.
Figures of Kuomintang soldiers are seen in the foreground, with the Chinese city of Xiamen in the background, on February 04, 2021 in Lieyu, an outlying island of Kinmen that is the closest point between Taiwan and China.
An Rong Xu/ Getty Images)
All News button
1
Subtitle

Debating Beijing’s Threat to Taiwan

Date Label
Authors
Noa Ronkin
News Type
News
Date
Paragraphs

Around the world, societies are aging at a rapid pace. The demographic transition and the challenges surrounding elderly care are defining issues of our time. Aging populations strain public finances and existing models of social support, affect economic growth, and change disease patterns and prevalence. Many countries, therefore, contemplate policy changes to their retirement, pensions, and health care systems. China, which faces a fast-growing trend of aging cohorts, is no exception.

To alleviate the pressure of elderly care on public finances, the Chinese government has been considering raising retirement ages and corresponding changes in social health insurance and pension policy. A new study now helps evaluate such retirement reforms and provides evidence to inform policy in China and elsewhere by probing the effects of retirement on health care utilization.


Sign up for APARC newsletters to receive our latest research updates.


The study’s co-authors, including Karen Eggleston, director of the Asia Health Policy Program at APARC, leverage administrative data from medical claims for over 80,000 insured adults in a megacity in eastern China to explore the effect of retirement on outpatient and inpatient care utilization. In this case, urban employee insurance beneficiaries receive a reduced patient cost-sharing rate upon retirement. By focusing on a relatively well-insured population with comprehensive administrative data on insurance plan design and overall resource use at retirement, the study provides new evidence about mechanisms such as the reduced out-of-pocket price of health care, the opportunity cost of time, and the interaction of these demand-side factors with supply-side incentives. Eggleston and her colleagues report on their findings in the journal Health Economics.

Our study reveals that increased utilization at retirement primarily comes in the form of outpatient services.

In this relatively well-insured population, annual health care utilization significantly increases primarily because of more intensive use of outpatient care at retirement. This increase in outpatient care stems from a decline in the patient cost-sharing rate, the reduced time constraints upon retirement, and the interaction of these factors with supply-side incentives such as prescribing antibiotics. There is no evidence of change in inpatient care at retirement.

The economics of medical expenditure growth and its interaction with population aging is of considerable policy importance for countries in all income groups. “Our findings may provide useful evidence as one consideration for policymakers in other cities in China and elsewhere looking to increase insurance benefits and control medical spending for burgeoning elderly populations.

Read More

Closeup on hands holding a glucometer
News

A New Validated Tool Helps Predict Lifetime Health Outcomes for Prediabetes and Type 2 Diabetes in Chinese Populations

A research team including APARC's Karen Eggleston developed a new simulation model that supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes among Chinese and East Asian populations, for whom existing models may not be applicable.
A New Validated Tool Helps Predict Lifetime Health Outcomes for Prediabetes and Type 2 Diabetes in Chinese Populations
A parent holds a child waiting to be given an infusion at an area hospital in China.
News

In China, Better Financial Coverage Increases Health Care Access and Utilization

Research evidence from China’s Tongxiang county by Karen Eggleston and colleagues indicates that enhanced financial coverage for catastrophic medical expenditures increased health care access and expenditures among resident insurance beneficiaries while decreasing out-of-pocket spending as a portion of total spending.
In China, Better Financial Coverage Increases Health Care Access and Utilization
Two women standing in a street in Rajasthan, India
News

Why Insurance Alone May Not Improve Women's Access To Healthcare

A new study of the Rajasthan government's Bhamashah health insurance program for poor households has found that just providing health insurance cover doesn't reduce gender inequality in access to even subsidized health care.
Why Insurance Alone May Not Improve Women's Access To Healthcare
Hero Image
n elderly Chinese man pushes an elderly woman in a wheelchair through a local shopping mall in Beijing, China Kevin Frayer/ Getty Image
All News button
1
Subtitle

The study’s co-authors, including Karen Eggleston, find that health care expenditures among Chinese covered by relatively generous health insurance significantly increase at retirement, primarily due to an increase in the number of outpatient visits.

Paragraphs

Previous studies, mostly analyzing data from high-income economies, present mixed evidence on the relationship between retirement and healthcare utilization. This study leverages administrative data for over 80,000 urban Chinese workers to explore the effect of retirement on outpatient and inpatient care utilization using a fuzzy regression discontinuity design. The analyses of medical claims from a large city in China complement and extend the current literature by providing evidence of potential mechanisms underlying increased short-run utilization. In this relatively well-insured population, annual total healthcare expenditures significantly increase primarily because of more intensive use of outpatient care at retirement, especially at the right tail of the distribution of outpatient visits. This increase in outpatient care appears to stem from a decline in the patient cost-sharing rate and the reduced opportunity cost of time upon retirement, interacting with supplier-induced demand, not from any sudden impact on health. We do not find evidence of change in inpatient care at retirement. The results hold for both females and males and are robust to a number of sensitivity analyses.

All Publications button
1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Health Economics
Authors
Karen Eggleston
Paragraphs

China’s national health reforms over the past two decades have brought the system closer to the modern, safe, reliable, and accessible health system that is commensurate with China’s dramatic economic growth, improvement in living standards, and high hopes for the next generation.

China’s national health reforms of 2009—continuing many reforms undertaken since SARS (2003)—consolidated a system of social health insurance covering the entire population for basic health services, contributing to a surge in healthcare utilization while reducing out-of-pocket costs to patients – which declined from 56% to 28% of total health expenditures between 2003 and 2017. An expanded basic public health service package, funded by per capita government budget allocations that include a higher central government subsidy for lower-income provinces, provides basic population health services to all Chinese. Now the governance structure consolidates the purchaser role for social health insurance schemes under the National Healthcare Security Administration, with most other health sector functions under the National Health Commission. China’s world-leading technological prowess in multiple fields spanning digital commerce to artificial intelligence—and accompanying innovative business models such as WeDoctor that have not yet been fully integrated into the health system—hold promise for supporting higher quality and more convenient healthcare for China’s 1.4 billion.

However, many challenges remain, from dealing with COVID-19 and its aftermath to other lingering challenges, from promoting healthy aging to the political economy of addressing patient-provider tensions, changing provider payment to promote “value” rather than volume, and deciding which new medical therapies qualify as “basic” for the basic medical insurance schemes. To make China’s investments in universal health coverage and the accompanying rapid medical spending growth sustainable in the longer run, policies need to help the most vulnerable avoid illness-induced poverty, increase health system efficiency, strengthen primary care, and reform provider payment systems.

All Publications button
1
Publication Type
Testimonies
Publication Date
Subtitle
Testimony before the U.S.-China Economic and Security Review Commission
Authors
Karen Eggleston
Paragraphs

Cross-strait deterrence is arguably weaker today than at any point since the Korean War. Impressive Chinese military modernization, U.S. failure to build robust coalitions to counter Chinese regional aggression, and Xi Jinping’s personal ambition, all coalesce to create a situation in which Chinese leaders may see some aggregate benefit to using force. Mastro supports this assessment in her response to the Commission’s specific questions. 

All Publications button
1
Publication Type
Testimonies
Publication Date
Subtitle
Statement before the U.S.-China Economic and Security Review Commission on “Deterring PRC Aggression Toward Taiwan”
Authors
Oriana Skylar Mastro
Authors
Noa Ronkin
News Type
News
Date
Paragraphs

Diabetes is one of the fastest-growing health challenges of the 21st century. On the frontlines of the epidemic rise in the number of people with diabetes is the Asia-Pacific region. China, in particular, has by far the largest absolute burden of diabetes, with an estimated 116 million adults living with the disease accounting for one-quarter of patients with diabetes globally. By 2045, the number of adults living with diabetes in the country is expected to increase to 147 million, not including the large diaspora community China provides worldwide.

Evaluating the health and economic outcomes of diabetes and its complications is vital for formulating health policy. The existing predictive outcomes models for type 2 diabetes, however, were developed and validated in historical European populations and may not be applicable for East Asian populations with their distinct epidemiology and complications. Additionally, the existing models are typically limited to diabetes alone and ignore the progression from prediabetes to diabetes. The lack of an appropriate simulation model for East Asian individuals and prediabetes is a major gap for the economic evaluation of health interventions.

New collaborative research now addresses these limitations. The research team includes APARC’s Asia Health Policy Program Director Karen Eggleston. The researchers developed and validated a patient-level simulation model for predicting lifetime health outcomes of prediabetes and type 2 diabetes in East Asian populations. They report on their findings in the journal PLOS Medicine


Sign up for APARC newsletters to receive our research updates

Modeling Health Outcomes Among East Asian Populations

The chronic progression to diabetes-related complications is apt for computer simulation modeling due to the long-term nature of health outcomes and the time lag for interventions to impact patient outcomes. It is problematic, however, to estimate the impacts of health interventions on East Asian populations with diabetes using existing models, which were developed and validated in European and North American populations with different epidemiology and outcomes.

To fill in this gap, Eggleston and her colleagues set out to develop and validate an outcomes model for the progression of diabetes and related complications in Chinese populations. They compared this new model, called the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME), to two widely used existing models developed and validated in the United Kingdom (known as the United Kingdom Prospective Diabetes Study Outcomes Model 2, or UKPDS-OM2) and in the United States/Canada (called Risk Equations for Complications of type 2 Diabetes, or RECODe). Despite the continuum of risk across the spectrum of risk factor values, these two existing models ignore the progression from prediabetes to diabetes.

The CHIME integrates prediabetes and diabetes into a comprehensive model comprising 13 outcomes. These include mortality, micro- and macrovascular complications, and the development of diabetes. The researchers developed the CHIME simulation model using data from a population-based cohort of 97,628 participants in Hong Kong with type 2 diabetes (43.5%) or prediabetes (56.5%) from 2006 to 2017. Known as the Hong Kong Clinical Management System (CMS), this cohort makes one of the largest Chinese electronic health informatics systems with detailed clinical records. 

The CHIME outperformed the widely used United Kingdom Prospective Diabetes Study Outcomes Model 2 (UKPDS-OM2) and Risk Equations for Complications of type 2 Diabetes (RECODe) models on real-world data.
Karen Eggleston et al

The next step was to externally validate the CHIME model against individual-level data from the China Health and Retirement Longitudinal Study (CHARLS) cohort (2011-2018), a nationally representative longitudinal cohort of middle-aged and elderly Chinese residents age 45 and older. The researchers validated the CHIME model against six outcomes measures recorded in the CHARLS data and an additional 80 endpoints from nine published trials of diabetes patients using simulated cohorts of 100,000 individuals.

Towards Reducing the Disease Burden of Diabetes

The researchers found that the CHIME model outperformed the widely used UKPDS-OM2 and RECODe models on the data used, meaning that the validation of the CHIME model was more accurate for trials with mainly Asian participants than trials with mostly non-Asian participants. The results indicate that the CHIME model is a validated tool for predicting the progression of diabetes and its outcomes, particularly among Chinese and East Asian populations, for which the existing models have been unsuitable.

With the new model, clinicians and health economists can evaluate population health status for prediabetes and diabetes using routinely recorded data and therapies related to the long-term management of diabetes. In particular, the CHIME outcomes model enables them to assess patients' quality of life and measure cost per quality-adjusted life-years over the long-time horizon of chronic disease conditions. The new model thus supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes, address micro- and macrovascular complications associated with these conditions, and improve life expectancy.

Read More

A parent holds a child waiting to be given an infusion at an area hospital in China.
News

In China, Better Financial Coverage Increases Health Care Access and Utilization

Research evidence from China’s Tongxiang county by Karen Eggleston and colleagues indicates that enhanced financial coverage for catastrophic medical expenditures increased health care access and expenditures among resident insurance beneficiaries while decreasing out-of-pocket spending as a portion of total spending.
In China, Better Financial Coverage Increases Health Care Access and Utilization
Logo of the New South Wales Ministry of Health's podcast Future Health
News

Robotics and the Future of Work: Lessons from Nursing Homes in Japan

On the Future Health podcast, Karen Eggleston discusses the findings and implications of her collaborative research into the effects of robot adoption on staffing in Japanese nursing homes.
Robotics and the Future of Work: Lessons from Nursing Homes in Japan
A woman walks past a mural referring to the Covid-19 coronavirus painted on a wall on December 10, 2020 in New Delhi, India.
News

How COVID-19 Disproportionately Impacts People with Chronic Conditions in India

A collaborative study by a group of researchers including APARC’s Karen Eggleston documents the adverse effects of COVID-19 on people with chronic conditions in India, particularly among poor, rural, and marginalized populations. The pandemic’s impacts extend beyond health disparities to encompass psychosocial and economic consequences, the study shows.
How COVID-19 Disproportionately Impacts People with Chronic Conditions in India
Hero Image
Closeup on hands holding a glucometer
All News button
1
Subtitle

A research team including APARC's Karen Eggleston developed a new simulation model that supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes among Chinese and East Asian populations, for whom existing models may not be applicable.

Paragraphs

Background

Existing predictive outcomes models for type 2 diabetes developed and validated in historical European populations may not be applicable for East Asian populations due to differences in the epidemiology and complications. Despite the continuum of risk across the spectrum of risk factor values, existing models are typically limited to diabetes alone and ignore the progression from prediabetes to diabetes. The objective of this study is to develop and externally validate a patient-level simulation model for prediabetes and type 2 diabetes in the East Asian population for predicting lifetime health outcomes.
 

Methods and findings

We developed a health outcomes model from a population-based cohort of individuals with prediabetes or type 2 diabetes: Hong Kong Clinical Management System (CMS, 97,628 participants) from 2006 to 2017. The Chinese Hong Kong Integrated Modeling and Evaluation (CHIME) simulation model comprises of 13 risk equations to predict mortality, micro- and macrovascular complications, and development of diabetes. Risk equations were derived using parametric proportional hazard models. External validation of the CHIME model was assessed in the China Health and Retirement Longitudinal Study (CHARLS, 4,567 participants) from 2011 to 2018 for mortality, ischemic heart disease, cerebrovascular disease, renal failure, cataract, and development of diabetes; and against 80 observed endpoints from 9 published trials using 100,000 simulated individuals per trial.

The CHIME model was compared to United Kingdom Prospective Diabetes Study Outcomes Model 2 (UKPDS-OM2) and Risk Equations for Complications Of Type 2 Diabetes (RECODe) by assessing model discrimination (C-statistics), calibration slope/intercept, root mean square percentage error (RMSPE), and R2. CHIME risk equations had C-statistics for discrimination from 0.636 to 0.813 internally and 0.702 to 0.770 externally for diabetes participants. Calibration slopes between deciles of expected and observed risk in CMS ranged from 0.680 to 1.333 for mortality, myocardial infarction, ischemic heart disease, retinopathy, neuropathy, ulcer of the skin, cataract, renal failure, and heart failure; 0.591 for peripheral vascular disease; 1.599 for cerebrovascular disease; and 2.247 for amputation; and in CHARLS outcomes from 0.709 to 1.035.

CHIME had better discrimination and calibration than UKPDS-OM2 in CMS (C-statistics 0.548 to 0.772, slopes 0.130 to 3.846) and CHARLS (C-statistics 0.514 to 0.750, slopes −0.589 to 11.411); and small improvements in discrimination and better calibration than RECODe in CMS (C-statistics 0.615 to 0.793, slopes 0.138 to 1.514). Predictive error was smaller for CHIME in CMS (RSMPE 3.53% versus 10.82% for UKPDS-OM2 and 11.16% for RECODe) and CHARLS (RSMPE 4.49% versus 14.80% for UKPDS-OM2). Calibration performance of CHIME was generally better for trials with Asian participants (RMSPE 0.48% to 3.66%) than for non-Asian trials (RMPSE 0.81% to 8.50%). Main limitations include the limited number of outcomes recorded in the CHARLS cohort, and the generalizability of simulated cohorts derived from trial participants.
 

Conclusion

Our study shows that the CHIME model is a new validated tool for predicting progression of diabetes and its outcomes, particularly among Chinese and East Asian populations that has been lacking thus far. The CHIME model can be used by health service planners and policymakers to develop population-level strategies, for example, setting HbA1c and lipid targets, to optimize health outcomes.

All Publications button
1
Publication Type
Journal Articles
Publication Date
Journal Publisher
PLOS Medicine
Authors
Karen Eggleston
Subscribe to China