This commentary originally appeared in The New York Times.

For a half-century, America has avoided war with China over Taiwan largely through a delicate balance of deterrence and reassurance.

That equilibrium has been upset. China is building up and flexing its military power; hostile rhetoric emanates from both Beijing and Washington. War seems likelier each day.

It’s not too late to restore the kind of balance that helped to keep the peace for decades, but it will require taking steps to ease China’s concerns. This will be difficult because of Chinese intransigence and the overheated atmosphere prevailing in Washington. But it is worth the political risk if it prevents war.

Deterrence came in the form of the implied use of U.S. military force to thwart a Chinese attack on Taiwan. Reassurance was provided by the understanding that the United States would not intrude on decisions regarding Taiwan’s eventual political status.

The United States and its regional allies must continue to create a robust military deterrence. But U.S. leaders and politicians also need to keep in mind the power of reassurance, try to understand China’s deep sensitivities about Taiwan and should recommit — clearly and unequivocally — to the idea that only China and Taiwan can work out their political differences, a stance that remains official U.S. policy.

During the Cold War, Beijing and Washington signed a series of communiqués related to Taiwan. One of them said the United States “reaffirms its interest in a peaceful settlement of the Taiwan question by the Chinese themselves.” This and other wording was deliberately ambiguous, but it was accepted by all sides as a commitment to avoid rocking the boat. China still views this arrangement as binding.

To be clear, it was China that began rocking the boat first.

Since 2016, when Tsai Ing-wen of the independence-leaning Democratic Progressive Party was elected president of Taiwan (succeeding a more China-friendly administration), Xi Jinping has repeatedly brandished China’s military power with large-scale military exercises and other pressure tactics apparently meant to discourage independence sentiment on Taiwan.

U.S. political figures have rightly responded with rhetorical support for democratic Taiwan, by supplying it with weapons and by strengthening the U.S. military presence in the region. But the American reaction is also pouring fuel on the fire.

I have worked on U.S. defense strategy in various military roles for more than a decade. I recently traveled to Beijing, where I met with Chinese government and military officials, leading academics and experts from Communist Party-affiliated think tanks. During these talks it was clear that Beijing is far less concerned with U.S. efforts to enhance its military posture in the region — the deterrence side of the equation — than with the political rhetoric, which is seen in China as proof that the United States is moving away from past ambiguity and toward supporting Taiwan’s de facto independence.

They have plenty of evidence to point to.

In December 2016, Donald Trump became the first U.S. president or president-elect since the normalization of China-U.S. relations in 1979 to speak directly with a Taiwanese leader, when Ms. Tsai called to congratulate him on his election victory. President Biden has, on four occasions, contradicted the U.S. policy of ambiguity by saying we would support Taiwan militarily if China attacked. The number of U.S. Congress members visiting Taiwan — which China views as overt support for the island’s independence — reached a decade high last year, including an August 2022 trip by Nancy Pelosi, the speaker of the House at the time and the highest-ranking U.S. official travel to Taiwan since the 1990s. That has continued this year: In June a nine-member congressional delegation, the largest in years, arrived in Taipei.

Provocative legislation has not helped. Last year the Taiwan Policy Act, which articulated support for Taiwan’s role in international organizations, was introduced in the Senate, and in July of this year the House passed a similar act. House Republicans introduced a motion in January to recognize Taiwan as an independent country.

Actions like these put great pressure on Mr. Xi, who won’t tolerate going down in history as the Chinese leader to have lost Taiwan. That would be seen in Beijing as an existential threat, potentially fueling separatist sentiment in restive regions like Tibet and Xinjiang.

For now, lingering doubts over Chinese military capabilities and the specter of U.S. and allied retaliation are enough to restrain Mr. Xi. But if he concludes that the United States has broken, once and for all, from its previous position on Taiwan and is bent on thwarting unification, he may feel that he must act militarily. The United States might be able to build the necessary military power in the region to deter a Chinese war of choice. But the level of dominance needed to stop Mr. Xi from launching a war he sees as necessary might be impossible to achieve.

Reassuring China would require Mr. Biden to reiterate that the United States does not support Taiwanese independence or oppose the island’s peaceful unification with China and that, ultimately, Taiwan’s fate is up to Taipei and Beijing. It would mean moving away from attempts to create international space for Taiwan and chastising Beijing when it pulls away Taipei’s diplomatic partners. The White House would also need to use what leverage it has to discourage members of Congress from visiting Taiwan and threaten to veto provocative legislation.

There would doubtless be blowback in Washington and Taipei, and Mr. Xi may already have made up his mind to seize Taiwan, regardless of the U.S. stance. But a politically neutral position on Taiwan is what the United States has followed for decades. Presidents Bill Clinton, Barack Obama and George H.W. and George W. Bush advocated peaceful dialogue between Taipei and Beijing to resolve their differences.

There also are longer-term repercussions to consider: If the combination of deterrence and reassurance fails and China attacks Taiwan, it will set a precedent in which Chinese leaders kill and destroy to achieve their goals. But if a pathway remains for China to eventually convince Taiwan’s people — through inducements or pressure — that it is in their interest to peacefully unify, then that may be a China that we can live with.

In the best-case scenario, the United States and China would reach a high-level agreement, a new communiqué, in which Washington reiterates its longstanding political neutrality and China commits to dialing back its military threats. This would avert war while giving China political space to work toward peaceful unification. That might mean using its clout to isolate Taiwan and eventually convince the island’s people that it should strike a deal with Beijing. But it isn’t Washington’s place to prevent the unification of the two sides — only to ensure that doesn’t happen through military force or coercion.

A war between the United States and China over Taiwan could be the most brutal since World War II. As politically difficult as it may be, U.S. leaders have a duty to try to prevent conflict, and that means speaking more softly but carrying a big stick.

Amidst evolving geopolitical shifts, the foundation of U.S. nuclear deterrence, forged in the crucible of the Cold War, faces a new set of challenges. The principle of mutually assured destruction (MAD), once the bedrock of deterrence, is now being tested by Russia's aggressive posturing and China's strategic advancements. In the wake of Russia's invasion of Ukraine and signals of a willingness to employ tactical nuclear weapons, questions arise about the efficacy of traditional deterrence strategies. Concurrently, China's expanding nuclear arsenal adds complexity to the equation. Do these developments mean America needs to rethink its deterrence strategy? 

In a new paper, “China’s Nuclear Enterprise: Trends, Developments, and Implications for the United States and Its Allies,” FSI Center Fellow Oriana Skylar Mastro focuses on the Chinese perspective of the equation and examines recent trends in Chinese military doctrine and their implications for U.S. deterrence strategy. Mastro’s contribution is part of a new report, Project Atom 2023: A Competitive Strategies Approach for U.S. Nuclear Posture through 2035, produced by the CSIS Project on Nuclear Issues.

A fundamental premise underlying Mastro’s analysis is that China merits distinct scrutiny differently from Russia, and that the two countries should not be considered  “nuclear peers.” Although China is indeed engaging in nuclear force modernization, Mastro contends that the nation is still adhering to its fundamental nuclear policy: minimal retaliation capability and a no-use-first pledge.

While some have been troubled by China’s turn to regional nuclear options like the DF-26, an intermediate-range ballistic missile capable of carrying both conventional and nuclear warheads, Mastro asserts that this is because “they are regional weapons lower on the escalation ladder.” Rather than trying to achieve parity with the United States, she contends that Beijing’s objective is to preserve a credible second-strike capability, which is essential to the concept of deterrence.

Instead of prescribing specific alterations to U.S. force posture or nuclear modernization, Mastro suggests that any changes in U.S. defense strategies carefully consider the impact on Chinese nuclear strategy. The key is to preserve China’s minimal retaliation capability and its pledge to refrain from initiating nuclear warfare: “the most important goal for U.S. deterrence policy should be to ensure it does not encourage a change in China’s nuclear policy and in posture.”

Other steps the United States should take, according to Castro, include preventing the “co-mingling” of nuclear and conventional weapons on vessels apart from ballistic missile submarines. This precaution aims to eliminate ambiguity and mitigate the risk of possible conflict escalation. She also believes that there may be “more costs than benefits” in the proliferation of nuclear weapons among Asian allies — South Korea, Japan, and Australia. These threaten the non-proliferation regime and increase the possibility of accidents. The answer, Mastro holds, is not deployment of U.S. nuclear weapons on foreign soil, but rather increased consultations and joint planning with allies. Such collaborative efforts could reassure allies and partners of U.S. intentions even as they have minimal impact on Chinese contingency planning. 
 

In 2018, the South Korean Supreme Court passed a series of rulings requiring Mitsubishi Heavy Industries and Nippon Steel of Japan to compensate 14 Korean citizens for their unpaid labor. As of yet, neither company has agreed to comply with the ruling. The South Korean government has since announced plans to compensate survivors who were forced to work in Japanese mines and factories during the wartime period, but this remains a unilateral decision on the part of the Yoon administration, not a bilateral position between South Korea and Japan.

These tensions have ripple effects far outside of East Asia. Writing for Toyo Keizai, Daniel Sneider, an FSI Lecturer in International Policy with a focus on Asia, explains the broader geopolitical implications of these issues:

“The Americans have been urging the two countries to settle these problems in order to ease the way to the kind of security cooperation that has become visible in recent months. Joint military exercises for missile defense and other small steps to intensify trilateral coordination are taking place and a resolution of the history of problems may be key to moving ahead.”

Steps Forward

The last year has seen increased efforts to restore more functionality to the South Korea-Japan relationship. President Yoon and Prime Minister Kishida met briefly on the sidelines of the September 2022 UN General Assembly meeting in New York, which was followed by respective visits of Yoon to Tokyo in March 2023 and Kishida to Seoul two months later in May, the first such visits in over 11 years.

The Camp David summit, which brought the U.S., South Korea, and Japan together as strategic partners, is the latest step on the hoped-for road to institutionalized security cooperation between the three nations.

Speaking to NBC, Shorenstein Fellow Thomas Fingar explained the significance of the weekend.

“The importance of this [summit] is that it was a genuine trilateral meeting, which means the Japanese and the Koreans are talking to one another as opposed to the U.S. dealing separately with each of them.”

In contrast to the idyllic Camp David setting, the three leaders are faced with a weighty set of issues, noted Sneider, including the crisis triggered by the Ukraine war, North Korea’s aggressive posture, as well as growing concerns about China.

Oriana Skylar Mastro, an FSI Center Fellow and an expert on security, conflict resolution, and the Chinese military elaborated further on the mutual pressures South Korea, Japan, and the United States face:

“Since President Biden came into office, he’s really stressed strengthening alliances and partnerships as a way of protecting U.S. interests abroad. I'm sure there has been much work behind the scenes to try to get these two countries to come together. In terms of the timing [of this summit], it's of course partially because of the accumulation of these concerns over China. I think also the war in Ukraine has done a lot to really open up leaders' eyes to the dangers of having neighbors with territorial hopes and claims that also have strong militaries that could potentially be undeterred from using force. I think it's fair to say that this has also pushed these two countries to rethink their own strategies for security.”

An Uncertain Future

The official summit documents outline both a vision of partnership and offer a variety of practical agreements on everything from annual leadership summits to meetings on economic and cyber security, and a proposal for how to move forward with joint military exercises. Notably, the two-paragraph ‘commitment to consult’ on responses to ‘regional challenges, provocations, and threats affecting our collective interests and security’ — while not a fully embodied collective security agreement — is nonetheless a “stunning achievement,” says Daniel Sneider.

Despite agreeing on a hefty laundry list of shared concerns and security goals, the way forward for additional trilateralization between the United States, Japan, and South Korea is not necessarily clear. Oriana Mastro explained: 

“Even though they might have shared threat perceptions, there is still a lot of trust that has to happen between nations for them to take coordinated military approaches. If two countries, for example, exercise together — and that's one of the things that the Biden administration is hoping to get out of this summit: more routine trilateral exercises — you get to learn a lot about another country's military, and that only really happens between friends. That’s also true of intel sharing. When you share intelligence, you’re not only sharing information, you're sharing how you get intelligence, which can also be sensitive. So while they've shared these threats for a while, it hasn't really gotten to the level in which they were willing to take risks in terms of the relationship between South Korea and Japan to become closer in the security space in a way that would help them combat these issues together.”

Besides the challenges of international diplomacy, Yoon, Kishida, and Biden also face domestic hurdles that could hinder further cooperation.

In a comment to the Wall Street Journal, Gi-Wook Shin noted that, “Yoon only entered politics a few years ago. If his party loses the election, I don’t know who will stay with him.” Improving South Korea-Japan relations was a major platform of the Yoon campaign, and backlash against his administration could yield disinterest or even renewed hostility toward continuing his efforts. 

Daniel Sneider sees similar challenges for Biden and Kishida. Writing in East Asia Forum, he cautioned:

“President Joe Biden is already embroiled in an election campaign that threatens to bring Donald Trump and his isolationist views back to power. The Camp David summit was barely noticed amid the constant flow of domestic political news, though it mostly received welcome praise in the media. . . Imprisoned by domestic politics, the White House will likely be unable to give substance to this emergent partnership.”

In the case of Kishida, the decision to release wastewater from the Fukushima nuclear site, which came just days after the conclusion of the summit, has been particularly counterproductive. Sneider continued:

“Prime Minister Fumio Kishida has been waiting for a bump from the Camp David summit. But he is experiencing a deepening slide in opinion polls. The Fukushima release faces opposition within Japan, including from fishermen and others worried about boycotts of Japanese products in China and South Korea. Talk of an early parliamentary election in Japan, intended to consolidate Kishida’s claim to long-term leadership, is now on hold.”

Where is the trilateral U.S.-Japan-South Korea relationship headed next? Follow FSI scholars to stay informed about the latest developments. Register to receive alerts to your inbox either weekly or monthly.   

This story was updated on September 18, 2023, to reflect the passing of Victor Fuchs.

It is hardly news that America’s health care system is complicated, expensive, and, in many ways, dysfunctional and that the nation’s health care outcomes are falling behind those of other, even sometimes poorer, countries. The problems of rising costs and disparities in access and outcomes were already well established in 1974, when Victor Fuchs, the late Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy at Stanford, first published his seminal book Who Shall Live? Health, Economics and Social Choice. In what turned out to be the first edition of the book, Fuchs applied fundamental concepts from economic theory to health and medical care in an innovative manner that hadn't been attempted previously, presenting an economic framework for addressing health and medical care challenges and emphasizing the importance of choice at both individual and societal levels. The publication became a classic introduction to health economics and is recognized for pioneering the field.

Now a third edition of Who Shall Live? has been released by World Scientific Publishing, co-authored by Karen Eggleston, director of Shorenstein APARC’s Asia Health Policy Program. This edition adds supplemental research and an all-new section that focuses on the decade 2012–21, specifically looking at the Affordable Care Act, the COVID-19 pandemic, the intersection of health and politics, and the state of expenditures and outcomes during that period.

Eggleston was honored to be able to work with Fuchs, who had also been a senior fellow emeritus at the Freeman Spogli Institute for International Studies and the Stanford Institute for Economic Policy Research, but noted that “it was a little depressing to hear him conclude that the pandemic would not be the 'wake-up call’ for systemic reforms that he has spent a lifetime showing the United States needs.” Fuchs passed away peacefully in his longtime home on Stanford’s campus on September 16, 2023. He was 99.

Part of the story of U.S. health care is its poor showing compared to other, often less-affluent nations. Japan is one of the comparison countries in the updated section on the last decade; in one example, Eggleston describes, “between 2012 and 2019 (pre-pandemic), life expectancy at birth did not increase at all in the United States, while it increased 0.18 years per annum in Japan, and 0.16 years per annum across 10 other high-spending OECD countries.” This is despite the fact that “in 2019, Japan spent only 63% of what the United States spends on healthcare (as a share of GDP)… Why can’t we do better for Americans?” 

This question is precisely the one that Who Shall Live? aims to answer—that the state of any health care system is a result of “the necessity of choice at both the individual and social levels.” To shrink the costs of health care in the United States and improve outcomes, different choices have to be made—by patients (in their personal lifestyles and behavior), by physicians, by hospitals, and by the U.S. government.

This commentary originally appeared in Shukan Toyokeizai.

Military tensions between China and Taiwan rise, and the U.S. government informs the Japanese government that it wants to deploy U.S. forces in Japan to defend Taiwan. At the same time, China sends a message through various channels that it will not touch Japan at all if it does not cooperate with the U.S. military and remains neutral.

In the event of a Taiwan contingency, It is highly likely that military conflict between China and Taiwan will lead to a decision by the U.S. military to intervene, followed by the deployment of fighter jets and naval vessels from U.S. military bases in Japan. In the process, Japan will be forced to make a major choice. 

If U.S. forces are deployed to the area around Taiwan, U.S. bases located in Japan, including Okinawa, will serve as bases. Under the so-called “Far East Clause” of Article 6 of the Japan-U.S. Security Treaty, U.S. forces can use Japanese facilities and areas “to contribute to the maintenance of international peace and security in the Far East.” However, the deployment of U.S. forces under the Far East Clause requires prior consultation with the Japanese side. Nevertheless, there is little chance that the Japanese government will turn the US down for fear of a confrontation with China. If Japan were to refuse at the last minute, the trust between Japan and the U.S. would be damaged, and the Japan-U.S. Security Treaty regime would effectively collapse. As a result, Japan would have no choice but to confront China alone. This would be a bad move that would only be a temporary fix. 

However, some officials from the Ministry of Defense and the Self-Defense Forces are concerned about how the public would react. From China's point of view, this is a point to take advantage of, and by communicating that "Japan will be safe if it declares its neutrality," it may be able to divide Japan, the U.S., and Taiwan. 

The phrase "a Taiwan contingency is a Japan contingency" was introduced by former Prime Minister Shinzo Abe at a symposium sponsored by a Taiwanese think tank in 2006. This comment was followed by the statement, "It is also a contingency for the Japan-U.S. alliance." How will Japanese public opinion react to the "ultimate choice" in the face of a Taiwan contingency? 

An interesting study, part of the Stanford Japan Barometer, conducted by Stanford University sociologist Kiyoteru Tsutsui and his colleagues examined this issue using a method called conjoint experiments. 

The subjects were presented with two scenarios: "In the event of an emergency in Taiwan, under what circumstances would you be more likely to support military involvement by the Self-Defense Forces?" The subjects were presented with two scenarios and asked to choose the one in which they would be more likely to support Japan's military involvement. 

In the event of a Taiwan contingency, the researchers presented three options in each of five categories: "Chinese actions," "U.S. actions," "Chinese actions toward Japan," "U.S. actions toward Japan," and "international community reaction. In an experiment in which each of more than 7,000 subjects was asked to answer which of two scenarios in which they were randomly combined would support Japan's military involvement in the event of an emergency in Taiwan. The series of scenarios reflect the opinions of security experts who participated in simulations of a Taiwan contingency conducted by various agencies in the United States. The results show whether support for Japan's military involvement strengthened or weakened when each scenario was presented.

One of these scenarios is precisely related to the aforementioned issue. When China promised Japan that it would not touch Japanese territory, including the Senkaku Islands, support for Japan's military involvement weakened. On the other hand, if China landed on and occupied the Senkaku Islands at the same time as its invasion of Taiwan, support for Japan's military involvement increased. The result is clear: "Japanese people place the highest priority on the impact on Japanese territory," said Professor Tsutsui. 

The survey results indicate that Japan is hesitant to fight China but would respond to a request from the U.S. military for logistical support. How will Japan be involved in a Taiwan contingency? Public opinion is not yet settled. 

In reality, many experts believe that if U.S. forces deployed from bases in Japan clash with Chinese forces, the next request will be for cover by the Self-Defense Forces. It is quite a narrow pass to say that they will not participate in combat and only provide logistical support. 

As for why Japan should get involved in a Taiwan contingency, the debate tends to settle on supply chain issues, particularly in the area of semiconductors, or geopolitical importance. Many Japanese, however, may feel that such reasons alone are not sufficient to make a decision to put the lives of Self-Defense Force personnel on the line and the residents of the Nansei Islands at risk. 
The supply chains that Japanese firms have built in East Asia, including China, would also be severely damaged. In addition, Chinese nationalism would flare up violently if it were to fight Japan again. The cost of fighting China as a neighbor is extremely high for Japan. 

Where Did You Get the Money To Pay for the Succession?
 

The issue of money is also unavoidable. In order to prepare for contingencies, we must also consider financing the cost of war. 

If the armed conflict with China is prolonged, huge fiscal outlays will be required not only for the continuation of the war but also for the repair of domestic infrastructure. In addition to supplementary budgets, it will be necessary to issue government bonds. 

However, Japanese financial institutions alone may not be able to digest the Japanese Government Bonds. For this reason, a simulation by the Japan Strategy Research Forum this year called for the direct underwriting of Japanese Government Bonds by the Bank of Japan. 

Junichi Kanda, a Bank of Japan alumnus in the House of Representatives who served as finance minister, opposed this proposal, saying, "It would cause a sudden loss of confidence in Japan's finances and the yen, leading to a significant depreciation of the yen to over 300 yen to the dollar and an increase in interest rates to over 10%. Such an extreme depreciation of the yen would also hinder the purchase of equipment and materials in foreign currency. 

Instead, Kanda suggested issuing foreign currency-denominated government bonds for foreigners. However, since there has been no such issuance since 1988, it is necessary to gradually issue these bonds from normal times to develop investors, he said. 

The prerequisite is that confidence in Japan's finances is secured. Japan needs to maintain fiscal discipline on a regular basis in case of emergency," said Kanda. Even in peacetime, there is a strong argument in Japan for using government bonds as a source of funds for increased defense spending. If the government cannot even raise taxes, China will question its seriousness. More open and substantive discussions are needed if the Japanese people are to be convinced to accept the costs of a Taiwan contingency.