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.

This is an English translation of an article originally published by The Asahi Shimbun. 

Stanford University Professor of Sociology Kiyoteru Tsutsui is a recipient of the Suntory Prize for Arts and Sciences and the Ishibashi Tanzan Prize for his book Human Rights and the State (Iwanami Shinsho, 2022). Although he has published many works in English, this was his first publication in Japanese. After earning a master's degree at Kyoto University, he moved to the United States. Before Stanford, he served as a professor at the University of Michigan. “I wanted to make a difference in the United States first,” he says. “I had not thought about publishing in Japanese.”

However, since he joined Stanford in 2020 and has undertaken the role of director of the Japan Program at the University's Asia-Pacific Research Center (APARC), Tsutsui has become increasingly aware of the importance of Japanese studies and publishing in Japanese. He recognizes the decline of Japanese studies and the necessity of revitalizing the field and connecting Japan and the United States. Tsutsui is currently the only professor of Japanese studies at APARC. In the 1990s, there were three or four faculty experts in Japanese studies at the center.

With the popularity of Japanese anime, manga, video games, and other forms of Japanese culture, the number of Japanese-language students in the United States is not decreasing," notes Tsutsui. However, “the departure from Japan in the social sciences is severe.” The reason for this, according to Tsutsui, is that area studies are declining, and there is an increasing emphasis on theories and models. “But Chinese studies are growing, and the subjects of German, French, and other area studies maintain interest.” In 2019, a session titled "The Death of Japanese Studies" was held at the North American Association for Asian Studies, attracting much attention.

Tsutsui worries that the declining interest in Japanese studies could negatively impact public opinion and policymaking toward Japan in the United States. For example, during the Japan-U.S. trade friction of the 1980s, the Japan-U.S. relationship was hardly a focus of Japanese studies scholars in the United States.

Tsutsui works to advance U.S.-Japan dialogue, promote Japanese studies research, and clear up misunderstandings about Japanese affairs. Last year, he launched the Stanford Japan Barometer (SJB), a periodic public opinion survey on political, economic, and social issues concerning contemporary Japan — a project he started in hopes of fostering young researchers’ interest in Japan.

“We have already researched gender and policy and the Taiwan contingency and security,” he says. “In the future, we will continue to cover a wide range of topics in Japanese politics, economy, and society, including techno-media, artificial intelligence, Japan’s declining birthrate, and its Constitution.” Unlike a typical public opinion survey, SJB focuses on types of questions that move people’s opinions. Therefore, SJB asks questions on different issues with different assumptions, comparing people’s responses.

In the case of the questions on same-sex marriage, the respondents randomly received one of eight explanations, such as “In Japanese society, it is a tradition to see marriage as a heterosexual relationship” and “In Japanese society, there is a tradition of toleration towards same-sex relationships stemming back from the Sengoku Period.” The study examined the difference between respondents who received no explanation and those provided with arguments supportive of same-sex marriages. “Our results showed that respondents tend to become more supportive of same-sex marriage when presented with an argument that not allowing same-sex marriage is unfair from the point of view of human rights and gender equality,” Tsutsui explains.

“I hope that many young scholars will eventually participate in the project and that it will provide an opportunity for the next generation of outstanding researchers to enter Japanese studies and increase their opportunities to work abroad.”
 

As the AI boom fuels an unprecedented surge in demand for chips and computing power, the global semiconductor supply chain has become critical in everything from smartphones and medical devices to cars and fighter jets. At the heart of this industry stands Taiwan, a leader in chip-making infrastructure, encompassing fabrication to cutting-edge research and development. With the People's Republic of China’s threat to Taiwan’s prosperity and stability becoming more acute, it is time for the United States and Taiwan to deepen their partnership in the semiconductor industry, argue Hoover Institution Research Fellow Kharis Templeman and FSI Center Fellow Oriana Skylar Mastro.

In a chapter that is part of a new report, titled “The Silicon Triangle: The United States, Taiwan, China, and Global Semiconductor Supply,” Templeman and Mastro show what the United States might learn from Taiwan’s successful experience in building a leading global role in the semiconductor supply chain and offer concrete opportunities for deeper collaboration given the two nations’ shared interests in chips.  The report is a product of the Working Group on Semiconductors and the Security of the United States and Taiwan, a joint project of the Hoover Institution and the Asia Society Center on U.S.-China Relations.

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Templeman and Mastro’s chapter, “Deepening US-Taiwan Cooperation through Semiconductors,” outlines the history of the Taiwanese semiconductor industry, accounts for its meteoric rise to prominence, and proposes that the United States and Taiwan should seek to use the semiconductor industry to “promote Taiwan’s prosperity and stability by creating an environment that fosters deeper business-to-business, research, academic, individual, and civil ties with Taiwan and other global partners in the semiconductor arena.”

To do so, the authors argue, the United States should actively promote Taiwan semiconductor firm activities, including manufacturing, design, and joint research and development in the United States; income tax abatement for cross-border workers; two-way semiconductor internship programs and academic exchange; semiconductor supply chain information sharing and resiliency planning; and defense industry co-production in Taiwan.

Deterring Invasion

According to Templeman and Mastro, further investment in Taiwan’s semiconductor industry would strengthen long-term U.S. interests there and represent an opportunity for the two nations to broaden their shared civil and business ties that will help to “deepen U.S. commitments to Taiwan’s democracy—and [deter] efforts to end it.”

The authors consider the PRC’s increasingly aggressive rhetoric of reunification and suggest that “leaders in the United States and Taiwan should be realistic about the real threat that the island faces, and their response to that should be to build the capabilities and the confidence of their people to weather coercion and deter attack.” As such, semiconductors represent a natural opportunity for the two nations to “grow substantive people-to-people, business, and even appropriate government ties at the working level […] we can use this momentum to break through long-standing bureaucratic frictions and improve interoperability in our economic and security relationships.”

The PRC threat to Taiwan’s autonomy will continue to grow as the island is increasingly isolated from the broader international community, the authors write. Reversing this trend, they say, “requires both symbolic and substantive assistance on the part of the United States and other countries.”

Deepening collaboration in the semiconductor industry represents a path for the United States to demonstrate its commitment to Taiwan, independent of the rhetorical debate over strategic clarity or ambiguity. The momentum gained through this collaboration would aid Taiwan’s resilience and incentivize other governments and opinion leaders in the region to deepen their commitments to the island, further enhancing cross-strait deterrence.

During the first three years of the Vietnam War, the United States made over 2000 attempts to open negotiations with the North Vietnamese. North Vietnam ignored or denied all of these overtures to open talks. By April 1968, following repeated rebuffs, Hanoi changed its position after President Johnson announced that the U.S. would halt bombing above the 20th parallel. What explains Hanoi’s initial firm position against talks and the sudden policy change in 1968? What are the drivers behind a state’s willingness to talk with the enemy while fighting, what considerations do leaders account for when deciding when and how peace talks can begin, and why do some states reject or ignore overtures to come to the negotiating table?

In a new Journal of Theoretical Politics article, FSI Center Fellow Oriana Skylar Mastro and Duke University’s political scientist David Siegel advance a new theory of wartime diplomacy to answer these questions. Using a formal model, they find that states are inclined to initiate negotiations when two conditions are met: firstly, when their adversaries perceive escalation as excessively costly, and secondly, when there is an indication of exceptional resilience that only those possessing high resilience value. To shed light on the dynamics of the second condition, Mastro and Siegel present an in-depth case study examining the evolving negotiation approach of North Vietnam throughout the Vietnam War.

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The second condition arises when the opponent does not view escalation as overly costly and when the likelihood of successful escalation is hard to assess, but there is a signal of high resilience that helps identify resilient entities. “States will choose typically open stances, potentially inviting escalation, only when they have demonstrated enough resilience to mitigate the escalation risk,” write Mastro and Siegel. This dynamics explains why North Vietnam’s diplomatic posture changed during the second phase of the Vietnam War.

Early on in the war, both the United States and North Vietnam believed that a willingness to talk would convey weakness. North Vietnam needed to sense hesitancy in U.S. confidence in the effectiveness of escalation before opening to negotiations. In 1968, the Tet Offensive allowed North Vietnam to demonstrate its resilience and constrain U.S. strategic capacity by inflicting casualties and steadily depleting its resources.

Even though North Vietnam was materially weaker and Tet failed by all operational measures, it represented a psychological shock to U.S. leadership and “finally convinced the U.S. of Hanoi’s resilience, reducing the likelihood that an open diplomatic posture would be interpreted as weakness.” North Vietnam had been reluctant to negotiate before it could adequately signal its resilience, maintaining a closed diplomatic posture for three years. But after Tet, having communicated its resilience to Washington, Hanoi “no longer viewed an open diplomatic posture as a liability in the war effort.”

The authors’ findings suggest that states are concerned about the negative material consequences that their diplomatic approach might have on the enemy. Thus, face-saving measures from the adversary are limited because the enemy would still perceive an open stance as a sign of weakness, potentially leading to further escalation. These findings are significant, as they demonstrate how counterproductive attempts to coerce opponents to negotiate can be.

At the same time, the study highlights new opportunities for external mediators “who can provide guarantees in ways that lessen the strategic costs of conversation,” Mastro and Siegel argue.

This essay was first published by Foreign Affairs magazine.

Nuclear deterrence has been a cornerstone of U.S. defense since the end of World War II, but now the United States finds itself grappling with the prospect of managing a three-way nuclear rivalry that is disrupting the deterrence strategies that have successfully prevented nuclear conflict. The confluence of China's military modernization and buildup of its strategic nuclear forces, on the one hand, and Russia's deployment of new armaments and threats to use battlefield nuclear weapons against Ukraine, on the other hand, are forcing policymakers to confront unprecedented challenges in maintaining global stability. Is arms control still possible?

This and other related questions were the focus of a recent discussion about the uncertain future of nuclear deterrence. Hosted by the Commonwealth Club of California, the conversation featured Shorenstein APARC Fellow Thomas Fingar and the Lawrence Livermore National Laboratory’s Center for Global Security Research Director Brad Roberts.

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Fingar highlighted the eroded mutual understanding between Russia, China, and the United States since the fall of the Soviet Union as a major challenge to the effectiveness of current deterrence efforts. He stressed the imperative of grasping the nuanced motivations and intentions of these nations, asserting that such comprehension should be an integral component of any successful deterrence strategy. "For deterrence to be effective, it has to be based on a correct understanding of those we seek to deter," Fingar noted.

Regarding Russia, Fingar pointed out the shift in the longstanding assumption, previously accepted by both Washington and Moscow, that the danger of escalation to a nuclear conflict was a check on willingness to engage in a conventional war. “Putin's invasion of Ukraine has erased any confidence in that assumption,” said Fingar. Another significant shift has been the transition from Russian conventional superiority to U.S. dominance in conventional forces, which has compelled Russia to increase its reliance on nuclear weapons for deterrence in its security calculus compared with the Cold War period. Fingar warned that this heightened dependence on nuclear capacity necessitates a refined understanding of Russia's willingness to employ these weapons.

In the case of China, Fingar noted Beijing’s perception of the U.S. as a threat that drives China’s modernization efforts. "They perceive that more is needed to deter the United States militarily, politically, and economically than before."

According to Fingar, missile defense systems and advanced conventional capabilities emerged as shared concerns for both Russia and China. These systems raise uncertainties about the stability of second-strike capabilities and command-and-control structures. Disruption of these structures could challenge China's longstanding commitment to a No-First-Use policy. Furthermore, concluded Fingar, China's refusal to participate in arms control negotiations until the United States and Russia reduce their arsenals to China's unannounced level is “the biggest impediment” to bringing nuclear expansion and modernization under control for all three countries, for U.S. allies, and for all other countries affected by their competition.

Amid escalating tensions between the United States and China and as the U.S. government is exploring how to further limit China's access to U.S. technology, discussions about the possibility of decoupling between the two countries have intensified. As businesses operating in China grapple with the potential consequences of decoupling, APARC’s China Program hosted a panel of executives across industries from tech, retail, and finance currently engaged in reshaping their China businesses to provide a view from the ground and consider the future of decoupling with China.

The event was the second installment in a special series celebrating APARC’s 40th anniversary. Titled Asia in 2030, APARC@40, the series highlights core areas of the center’s expertise, examines Asia’s transformation over the past four decades, and considers the drivers and shapers of the region’s future.

The panel featured Dan Brody, the managing director of Tencent Investments, who is responsible for the company’s overseas investments; Frits Van Paasschen, a change management expert, former CEO of Starwood Hotels and Resorts, and former president of EMEA at Nike; and Stuart Schonberger, a founding partner of CDH Investments, one of the leading China-focused alternative asset managers. China Program Director Jean Oi chaired the panel.

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Risks and Opportunities

Van Paasschen described his extensive experience developing strategies for expanding licensing and retail in China, which involved navigating the country's infrastructure and legal framework and, as CEO of Starwood Hotels, overseeing the construction of over 100 hotels. He ascribed his success in the country to his recognition of China’s strengths and weaknesses and his finding ways to interact positively with Chinese stakeholders.

The term decoupling is an oversimplification of the relationship between the complex Chinese and U.S. economies, said Van Paasschen. He noted that retailers in many cases are looking to sources from alternative markets to China, but that he believes there are still opportunities for investment in and co-development with China that remain unaffected by current frictions. He highlighted in this context the interplay between the U.S. and Chinese travel and tourism industries before the COVID-19 pandemic.

Schonberger, who also challenged the notion of decoupling as a misleading shorthand, emphasized the need for cognitive empathy between the world’s two great powers and understanding the motivation behind China's actions. He noted that the challenges facing China today are complex, including debt problems, real estate slowdown, and productivity stagnation, but said these are "known knowns" that the Chinese government is actively working to correct.

Schonberger sees two distinct issues facing institutional equity investors worried about China: government policies that negatively affect growth and corporate prospects, and longer-term risks arising from China's geopolitical position. For private investors who are focused on total return and can tolerate overt political pressures, China remains investable, as Chinese stocks have been some of the best performers on the public markets recently, said Schonberger. The challenges are greater, however, for public entities and bond investors who are more affected by political risk in their decisions. While the risks are higher, Schonberger's firm continues to invest in Chinese companies in multiple sectors.

Changes Underway

Brody said that China remains a key player in the global economy. As a personal anecdote, he noted that, while he makes fewer trips to the United States, he is traveling more frequently to Europe, India, Japan, and Southeast Asia. According to Brody, the extent to which the Chinese economy would be affected by international fluctuations is unclear, but he expects the country to continue its economic growth and attract foreign investors. He stated that a huge amount of value in the tech sector is still being created in America, so economically driven foreign investors in the tech sector still pay close attention to developments in Silicon Valley.

Van Paasschen, by contrast, pointed out that by decoupling with China, the United States would miss out on a generational opportunity for development and could potentially lose out to other countries. China still presents an enormous opportunity for businesses, he said, particularly in the hotel industry, given the country’s rate of urbanization. He reminded the audience that every country and region presents its own set of challenges and risks for investors. The imperative is to ensure Beijing and Washington maintain a dialogue and businesses are willing to take risks to invest in China.

Van Paasschen went on to describe how the U.S.-China political tensions are affecting business operations in various sectors. For instance, in the biotechnology sector, companies might consider protecting intellectual property and ensuring sustainability in their supply chain. In the apparel business, there is a growing concern about human rights and the opacity of the cotton supply chain. Overall, Van Paasschen sees a transition underway from a bilateral and straightforward approach to trade to a much more nuanced and complicated approach.

When asked if political tensions would affect some sectors more than others, Van Paasschen responded affirmatively. He gave the example of a sovereign wealth fund that refused to support investments in Chinese hotels because of the uncertainty zero-COVID policies had created. He also said that further uncertainty could arise from countries' reactions to China’s foreign policy stance, such as China's support of Russia in Ukraine.

What advice would the three business experts give Washington?

Van Paasschen expressed his hope the United States finds ways to avoid being reactive. Schonberger, urging policymakers to keep working towards peaceful coexistence, emphasized it would be counter-productive to frame China as an enemy. He also highlighted the importance of redundancy and efficiency in trade relationships and cautioned against overlooking the cost of decoupling, reminding the audience that engagement with China has boosted global trade, lifted millions out of poverty, and created a vibrant society.

From Brody’s perspective, predictability is crucial for business, regardless of the country one is conducting business in. He also stressed that, from a personal perspective and regardless of one’s political stance on China, the reduction in people-to-people ties between China and the United States due to recent travel restrictions is unfortunate. Ultimately, these ties have always been a net positive, and it is important to recognize their value even in the midst of tensions between the two nations. While political leaders may grapple with complex geopolitical issues, the connections between ordinary citizens remain a vital foundation for maintaining a constructive relationship. By fostering personal exchanges, the United States and China can build bridges and promote mutual understanding, even in the face of challenging circumstances.