Click the link for a full transcript of “What We Need To Talk About When We Talk About Taiwan.“

The Likelihood of Invasion

In stark terms, Oriana Skylar Mastro, a center fellow at the Freeman Spogli Institute for International Studies, believes there’s a 100% chance China will use some sort of force against Taiwan in the next five years. For the last twenty years, China has been making concerted efforts to modernize its military and increase its capabilities not only to assert force against Taiwan, but to deter intervention from the United States.

In the majority of scenarios, the United States wins in a conflict with China over Taiwan. But the United States also carries a distinct geographic disadvantage. The distance across the Taiwan Strait between the island and mainland China is approximately 100 miles, which is roughly the distance between Richmond, Virginia and Washington D.C. If China moves quickly, PRC forces could take Taiwan before U.S. forces have time to move into position.

When considering possible outcomes in Taiwan, it is equally important to consider the motivations driving Beijing’s ambitions. The leadership on the mainland has been planning and thinking about how to retake Taiwan since 1949. With the modernized capabilities coming online, the balance of power has shifted in China’s military favor, and the cost-benefit calculus favors Beijing’s ambitions. The long-term planning stage is now reaching its end, and the prospects of direct action are increasing.

The View from Taipei

Political leaders in Taiwan recognize the growing danger they face across the Strait. In Larry Diamond’s assessment, the end of Hong Kong's autonomy and the suppression of the “one country, two systems” model, the rising military incursions into Taiwan's air defense identification zone and coastal waters, and the whole rising pace of Chinese military intimidation has sobered Taiwan and visibly impacted Taiwanese public opinion.

Concerningly though, while the political elite recognize the real and present danger of the situation, polling of the general Taiwan public suggests that the vast majority of citizens still feel like an attack or an invasion by China is unlikely. Similar majorities suggest that they would be willing to fight in Taiwan’s defense, but volunteering for military service remains at a minimum.

To maximize safety, Taiwan needs to find ways to strengthen itself in its ability to defend, resist, and deter China, while still avoiding any appearance of moving toward permanent independence or any other action that could be deemed by Beijing as a provocation, says Diamond.

What the United States Can Do

When it comes to the defense of Taiwan, the strategic crutch hobbling the United States is geography. Most of the U.S. Pacific forces are not in Asia. The majority are in Hawaii and California, as well as a few bases and airfields in Japan. To be able to effectively deter China, the U.S. needs far greater forward deployed military capability in order to be able to either stop or stall the movement of Chinese troops into Taiwan, says Mastro.

Taiwan needs greater onshore military deterrence capabilities as well. One such strategy is the “porcupine approach,” which increases the number of smaller mobile lethal weapons. By Larry Diamond’s assessment, increased citizen participation in military training is also crucial, with an emphasis on weapons training and urban defense tactics. The U.S. could support these aims by overhauling the current system for weapons procurement to speed up the production and delivery of weapons systems not just for Taiwan, but to the benefit of U.S. defense and other contingencies as well. Working with leadership to create strategic stockpiles of food, and energy should also be a priority, says Diamond.

The U.S. also needs to put much more effort into its diplomatic efforts on behalf of Taiwan. Many U.S. allies and partners are reluctant to ostracize China because of economic ties and concerns over sparking their own conflict with China in the future. A key ally in all of this is Japan. If Japan fights with the United States on behalf of Taiwan, it is a guaranteed win and enough to effectively deter China. But much more needs to be done much more quickly in order to secure those guarantees and present them in a convincing way to Beijing.

“The clock is ticking,” Larry Diamond says. “And the problem is we don’t know how fast it’s ticking. “Taiwan is moving in the right direction. But we need to move faster than we're moving.”

Taiwan is currently the single biggest point of contention in U.S.-China relations, and U.S. allies have a crucial role to play in efforts to prevent a great-power war over the island. South Korea, however, has remained relatively ambiguous about its willingness to support U.S. efforts to push back against China’s growing influence in the region, including in the Taiwan Strait. As the Yoon administration is now creating an opening for a more proactive approach, what can South Korea do in a Taiwan contingency?

A new article in The Washington Quarterly provides a framework for analyzing South Korea’s potential role in this era of strategic competition through the lens of war over Taiwan. The authors — Oriana Skylar Mastro, a Center Fellow at APARC, and Sungmin Cho, a professor at the Daniel K. Inouye Asia-Pacific Center for Security Studies — build upon traditional concepts of balancing to create a nuanced, operationally relevant strategy for South Korea to contribute to the defense of Taiwan.

They explain South Korea’s approach to the Taiwan issue to date; evaluate South Korea’s strategic importance and what it can do to support U.S.-led efforts to compete with China; explore how China and North Korea may respond to increased South Korean cooperation with the United States, along with the potential obstacles this cooperation could create; and recommend ways to leverage the US-ROK alliance to enhance deterrence against China with respect to Taiwan.

Subscribe to APARC newsletters to receive our scholars’ updates.

Mastro and Cho recognize that it is operationally and politically infeasible for South Korea to fight side-by-side with U.S. forces against China in a Taiwan scenario or to build its military sufficiently to deter Chinese aggression against Taipei. South Korean strategists must also consider the costs of China’s and North Korea’s potential responses to greater South Korean involvement in defending Taiwan. Still, Seoul can play a significant role in deterring Chinese aggression.

According to Mastro and Cho, South Korea’s optimal strategy to navigate the U.S.-China rivalry should meet two conditions. First, it should contribute to the vision of a free and open Indo-Pacific, including deterring Chinese aggression against Taiwan. Second, it should be able to make China hesitate to take punitive actions against South Korea. Thus, South Korea can provide rear-area support to the United States, such as intelligence gathering, ammunition supplies, or noncombatant evacuation. It can also support the strategic flexibility of US Forces Korea (USFK) and be more proactive in deterring North Korean aggression and provocation to free up U.S. resources to focus on China in a contingency scenario.

Moreover, South Korea could contribute toward forms of “collective resilience” against China’s economic statecraft, such as collective economic sanctions, and leverage its position as one of the world’s leading producers of advanced semiconductors to complicate China’s calculus. Finally, Seoul’s diplomatic support of U.S.-led efforts to defend Taiwan can influence Beijing to take seriously the international community’s potential united response against any attempt to invade Taiwan.

“Given the heightened urgency over tensions in the Taiwan Strait, Washington and Seoul should pursue these options immediately to maintain peace and stability in the region before it is too late,” the authors conclude.

As healthcare costs for patients with non-communicable diseases such as diabetes have risen, governments and healthcare providers have sought creative measures to align financial incentives with better patient outcomes. One incentive payment system known as “pay-for-performance” (P4P), in which providers are beholden to metric-driven outcomes, represents a potential path forward for healthcare providers to improve healthcare processes, resulting in higher quality and better patient health outcomes. The evidence on the effectiveness of P4P programs, however, is mixed.

To address this uncertainty, a new study, published in The European Journal of Healthcare Economics, assesses the effectiveness, in monetary terms, of a P4P program for patients with diabetes at a hospital system in Taiwan. 

The study coauthors, including APARC’s Asia Health Policy Program Director and FSI Senior Fellow Karen Eggleston, employed new patient-level data on clinical indicators, utilization, and expenditures, combined with data from the national death registry, to better understand the costs and benefits of the P4P program. Their results show that Taiwan’s implementation of the P4P program for diabetic care yielded positive results in terms of net value, defined as the value of life years gained minus the cost of care.

Sign up for APARC newsletters to receive our experts' research updates.

Assessing Net Value of Taiwan’s P4P

Taiwan’s Bureau of National Health Insurance (now National Health Insurance Administration) introduced P4P in 2001 and enhanced the program in 2006 with an incentive for pay-for-reporting of outcomes. Financial incentives were used to encourage continuity of care with metrics such as new patient enrollment, follow-up visits, and annual reports, each tied to a specific monetary value. The program’s features are common across P4P, so the study’s findings have implications in other settings that incorporate similar designs in their P4P programs.

The study compares two different groups of patients at a large regional hospital in Taiwan, one consisting of newly enrolled P4P patients and another using P4P patients who have been enrolled since the beginning of the program. The researchers leverage detailed clinical data not used in previous assessments of the P4P program to better identify both costs and longer-term clinical outcomes based on measured biomarkers and predicted mortality.

Using an economic cost-benefit analysis conducted from a budgetary perspective, the study is the first analysis of any P4P program that estimates changes in the quality-adjusted price index relative to usual care. The authors consider health benefits in terms of survival and predicted survival and convert them into monetary terms. This net value approach is especially useful for policymakers and healthcare administrators who implement value-based purchasing and monitor outcomes for any service delivery innovation over time.

The study finds that Taiwan’s P4P program provided a positive net value for payers and patients, ranging from $40,084 USD to $348,717 USD. These positive net value results are primarily derived from health outcomes as measured by lower mortality rates in the P4P versus non-P4P cohorts, across both newly enrolled and continuously enrolled groups of patients. According to the authors, “these encouraging findings of the positive value of quality improvement net of expenditures adds evidence to the literature that has found mixed results of P4P programs.” 

 This study develops a new model for assessing the net value of service delivery innovations like P4P programs that can be applied in other contexts globally, providing healthcare systems researchers with new tools to better understand an emergent option for incentivized care. With a more economically-translatable understanding of P4P programs, this research helps build the bridge between the oft-disparate worlds of healthcare and policy.

This commentary originally appeared in The Economist.

But even with all these improvements, it is unclear whether China could take Taiwan by force. China has not fought a war since 1979, when it made heavy weather of a “punitive” invasion of Vietnam. An amphibious attack, and to a lesser degree a blockade of the type the exercises off Taiwan were simulating, would demand complex joint operations (involving army, air force and navy), which in turn require impeccable logistics and command and control. Xi Jinping, China’s leader, launched a massive organizational reform to improve in these areas, and the PLA undoubtedly has. But the war in Ukraine may have given him heightened anxiety, given that the Russians struggled precisely with logistics and command.

For this reason, we should see the massive exercises off Taiwan less as a signal, and more as a rehearsal for combat. Mr Xi wants progress on the Taiwan issue, and domestically talk in the press is shifting from peaceful reunification to armed reunification. Chinese leaders knew the PLA had to conduct a series of large, realistic exercises to identify issues and hone their capabilities. If China had done so out of the blue, instead of using Ms Pelosi’s visit as a pretext, international opprobrium would have been stronger.

China will seize the opportunity to practice as much as possible. It has announced already that this round of exercises will continue and that another round in the Bohai Gulf/Yellow Sea is next. And it won’t just be large-scale exercises. It is unlikely that Beijing will return to its previous level of operations. Instead, China might attempt to normalize greater Chinese activity around Taiwan. That makes war more probable. Through a series of exercises the PLA, and the party leadership, might gain confidence that China’s forces are ready to take Taiwan sooner than they would otherwise have thought.

Of course, this all depends on how the exercises and operations go. From the outside, this is hard to assess. The missiles landed where they should have in recent days, and there were no accidents. But we don’t know how much and how well different groups are communicating with each other. To prepare for joint operations, air-force units need to operate in close proximity and coordinate with ground troops and amphibious elements. The PLA needs to practice providing supplies, such as prepositioned fuel stocks, and bringing munitions and medical supplies to forward locations such as Fujian, the province directly across the Taiwan Strait.

This is where the real trouble lies. If activities in the vicinity of Taiwan become more routine, not only does this heighten anxiety in Taipei (and probably other regional capitals as well) but it helps to disguise any preparations for a real military campaign. China needs an element of surprise to be able to take Taiwan before America has time to mobilize adequate forces in the region to defend the island. If China’s forces are simulating formations, blockades, attacks, and amphibious landings, it will be harder to decipher when they are preparing for the real thing. Ms Pelosi’s visit has allowed Beijing to move to a new level of military activity unchallenged, which will make it harder for America to defend Taiwan. No signal of America’s commitment to the island can fix that.

This story was last updated on August 10, 2022.

Amid warnings and condemnations from Chinese leadership, Speaker of the U.S. House of Representatives Nancy Pelosi visited Taiwan on August 2, 2022, becoming the highest-ranking U.S. official to visit the island since 1997. A day after Pelosi's visit, furious China began firing missiles near Taiwan in drills that appear to be a trial run for sealing off the island, and Japan said some missiles landed in its exclusive economic zone. In a series of articles and interviews, Center Fellow Oriana Skylar Mastro examines the implications of Speaker Pelosi's visit, Beijing's response, and what the United States might do to prepare for a Chinese invasion of Taiwan. 

Mastro joined CNN's Fareed Zakaria GPS to discuss what she calls the "unprecedented scale and complexity" of China's military drills near Taiwan. Over the past 20 years, China has invested in building up not only one of the most advanced and sophisticated militaries but also one that can attack and keep out the United States. So now, explains Mastro, beyond the live-fire and missile tests, the Chinese military exercises also included complex air and naval operations designed to demonstrate China's readiness to take Taiwan when it feels ready to do so. Watch:

According to Mastro, when China makes a move on Taiwan there has to be an element of surprise, so they don't want to do it right now when the United States has increased its focus and operations in the region. But we will probably see additional rounds of Chinese military exercises in the future, she predicts, "and the more they get to do it the more confident they become and the more likely we are to see Beijing initiate force against the island." 

A Question of Capability

China's round of military exercises in response to Speaker Pelosi's Taiwan visit was a bit of a “coming-out party” for Beijing, writes Mastro in an invited commentary for The Economist. After years of investments to build up and modernize the People's Liberation Army, China’s armed forces are now comparable to America’s in quality and quantity, Mastro says. But even with all these improvements, it is unclear whether China could take Taiwan by force. Chinese leaders knew the PLA had to conduct a series of large, realistic exercises to identify issues and hone their capabilities, and Pelosi's visit gave them the pretext to do exactly that. "China needs an element of surprise to be able to take Taiwan before America has time to mobilize adequate forces in the region to defend the island," Mastro notes. "If China’s forces are simulating formations, blockades, attacks, and amphibious landings, it will be harder to decipher when they are preparing for the real thing."

In an interview with BBC World News, Mastro argues that the political maneuvering intended to signal U.S. commitment to Taiwan — whether it comes in the form of Speaker Pelosi's visit or President Biden's statements that "the United States must protect Taiwan" — is ultimately unhelpful and does not address the more serious issue at hand, which is whether the United States has the military capabilities needed to defend Taiwan.

Mastro also suggested that Chinese leadership has benefited from Pelosi's visit, using the occasion for their own political purposes and to test some of their military capabilities to take Taiwan by force.

Watch the full discussion:

Subscribe to APARC newsletters to receive our experts' analysis and commentary.

According to Mastro, a noteworthy aspect of Pelosi's visit is that she chose to pursue it despite dissuasion from the Biden administration, signaling to Beijing that the U.S. model is grounded in the separation of powers and that Congress would act independently to pass legislation to supply arms or provide military funding to defend Taiwan.

Chinese Military Projection of Power

In response to Pelosi's visit, China announced military exercises in six regions around Taiwan, pressing its forces closer to the island than ever before. "They’re definitely going to use this as an excuse to do something that helps them prepare for a possible invasion,” Mastro says in a New York Times report. "Under the guise of signaling, they’re trying to basically test their ability to conduct complex maneuvers that are necessary for an amphibious assault on Taiwan.”

Mastro recently outlined the array of weaponry China has amassed for a forceful "unification" with Taiwan, pointing out that China has now the world's largest navy and that its missile force is thought to be capable of targeting ships at sea to neutralize the main U.S. tool of power projection, namely, aircraft carriers, notes a New York Times explainer.

Mastro also joined WBUR's On Point Radio host Meghna Chakrabarti to examine the fallout from China's military exercises around Taiwan, current Chinese military capabilities, and what a modern war over Taiwan would look like. Listen to the full conversation:

Artificial intelligence and machine learning will play a major role in a Taiwan contingency, and these are significant because they change much of China's perceptions of its capabilities, Mastro explains. First, the Chinese are concerned about the capabilities of their personnel, but if they can use AI-enabled systems and take the person out of the loop, then that makes them more confident in their military capabilities. Moreover, the Chinese notion of "war control" is such in which thinking through enables planning and preparing for every possible outcome and contingency in a war. "Algorithmic warfare is exactly what they have in mind. They think, 'If we have the right systems, we can project and ensure victory ahead of time.' So, from my perspective, AI is really significant because of how much more confidence it would give China in its ability to win a war."

Under Xi Jinping, the People's Liberation Army has modernized to a point where "armed reunification" with Taiwan seems increasingly plausible. But experts differ in interpreting China's calculus on Taiwan. "When people talk about whether or not China can or cannot [invade Taiwan], they’re actually talking about something different, the level of operational cost — the loss of ships, casualties — that China would have to pay to do it," Mastro tells the New York Times. "They could do it," she added.

Paths to Deterrence

Mastro also appeared in an interview with NBC Bay Area, explaining the context for the flaring U.S.-China tensions as they pertain to Taiwan. "The issue is that the United States promised not to have official ties with the Taiwan government, and the visit by Speaker Pelosi is understood by the Chinese as an official delegation, meaning the United States is violating its promise."

Pelosi's visit is not the first time the United States has sent an official delegation to Taiwan, and the Chinese follow-up military exercises are not the first sign of Chinese retaliation. What has changed this time around, according to Mastro, is Chinese military capabilities. "China now has a formidable force that could take Taiwan, if it felt like it, and I think that is encouraging a much more aggressive posturing on the part of Beijing," she said.

Mastro emphasized that the U.S. strategy of making symbolic statements of commitment to Taiwan is misguided and does not deter Beijing from aggressive action. "China's uncertainty right now is not about U.S. commitment but is, instead, about U.S. capability [...] I'm sure the Chinese are watching [Pelosi's visit], but the lessons they're learning is not that they should back off Taiwan, but instead that they need to strengthen their position to convince the United States not to engage in these kinds of activities in the future."

For more of Mastro's analysis of the fallout from Pelosi's visit and cross-Strait tensions, visit the links below:

What Does China Want from Taiwan? 
Sky News, August 12, 2022

Will the US and China Go to War Over Taiwan 
BBC, August 11, 2022

What Are the Issues Between the U.S., China, and Taiwan? Stanford Scholar Explains 
Stanford News, August 10, 2022

China’s Military Operations Around Taiwan After Pelosi Visit Show Intent to Change Status Quo 
South China Morning Post, August 5, 2022

China ‘Convinced It Needs to Hit Us With Pearl Harbor-style Surprise Attack’ to Win War Over Taiwan, Expert Warns 
The U.S. Sun, August 5, 2022

Stanford Experts Cast Grim Predictions for U.S.-China Relations Following Pelosi’s Taiwan Visit 
The Stanford Daily, August 5, 2022

China’s War Games May Not Lead to All-out Conflict Against Taiwan... Yet 
The Telegraph, August 4, 2022

Chinese Missiles Strike Seas Off Taiwan, and Some Land Near Japan 
New York Times, August 3, 2022

Taiwan Lives Under the Threat of a Modernized and Reinforced Chinese Army 
Les Echos, August 3, 2022

China’s Military Drills Could Be a Prelude to Something Much Worse in Taiwan 
The Telegraph, August 3, 2022

Why Pelosi’s Taiwan Visit Is Raising U.S.-China Tensions 
New York Times, August 2, 2022

Pelosi's Taiwan Visit Triggering Potential Military Showdown 
VOA Chinese, August 2, 2022

China and US on a Collision Course: Tensions Over Taiwan Continue to Rise 
de volkskrant, July 29, 2022 (in Dutch)

For Taiwan, Pelosi Visit is About Us, China Controlling Risk 
CBS Bay Area, July 29, 2022

Xi Jinping's Phone Call with Biden 
BBC Chinese, July 28, 2022

Pelosi’s Rumored Taiwan Trip Sparks Uproar 
The Dispatch, July 27, 2022

Taiwan Holds Drills Amid Pelosi Visit Concern, China Tension 
AP, July 25, 2022

Guam: The Sharpening of the Spear’s Tip 
Foreign Policy Focus, July 20, 2022

Expert Voices: Interview with Oriana Skylar Mastro 
Center for Advanced China Research, July 18, 2022