In an article for Foreign Policy, Karl Eikenberry argues that the drifting Taiwan-U.S. relationship puts the stability of the Asia-Pacific region at risk. He observes that other regional allies are hedging their bets against a rising military power in China because of skepticism that the United States can keep its commitments, and outlines key weaknesses that Washington must overcome with Taipei.

Scarborough Shoal, a tiny rocky outcropping and lagoon off the west coast of the Philippines, sits at the center of the latest South China Sea tug-of-war. Protesters took to the streets in Manila on May 11 to criticize China’s support of fishermen who entered the disputed territory a month ago and sparked a yet unresolved naval standoff between the Philippines and China. On May 9, while ships from both sides maneuvered in the area, Manila's secretary of defense assured Filipinos that if Beijing attacked, Washington would come to the country’s defense.  

That expectation had been strengthened in Manila in November 2011 when the visiting American secretary of state, Hillary Clinton, referred to the South China Sea as the “West Philippine Sea.” Clinton’s slip of the tongue was not a major diplomatic incident. But some Flipinos saw it as a sign of U.S. support for their government's maritime claims.

Washington’s refusal to side with any of the claimant states had not changed. What had changed was the level of American concern. In the November 2011 issue of Foreign Policy Clinton had defended the idea of a “pivot” toward Asia, meaning a renewed U.S. focus on Asia after a decade of intense military activity in Afghanistan and Iraq.

The term “pivot” has fallen out of favor in Washington, but the Obama administration’s heightened interest in Asia is real and ongoing, says Donald K. Emmerson, director of Stanford’s Southeast Asia Forum. He recently discussed the nuances of what he describes as an important but “lopsided pivot.”

How does the pivot fit into the larger global picture?

In the continuing debate as to whether the United States is in decline, the key question is: relative to what? Certainly, if we compare the situation now with the period immediately after World War II, the United States is less powerful relative to the power of other states. But 1945 ushered in a uniquely unipolar moment in American history. Americans had escaped the physical devastation wreaked on Europe and much of Asia. Germany and Japan lay in ruins. Twenty million Russians were dead. China’s long-running civil war would soon resume. Suddenly America had no credible competitors for global power.

Today? Conventional wisdom holds that Asia has become the center of gravity in the global economy. Yet even if we use purchasing power parity rather than exchange rates to measure the American share of world GDP, that share has only modestly decreased. Meanwhile, China’s remarkable rise may be leveling off. The evidence is less that the United States is in secular decline than that the world is changing in ways to which Americans need to adapt if they are to regain economic health. If the pivot facilitates that adaptation, it will have been a success.

Do you interpret the pivot to the Asia-Pacific as more hype or reality?

The pivot is definitely a reality, but the reality is partly about symbolism and atmospherics. The pivot conveys reassurance, particularly to Southeast Asia, that the United States cares about the Asia-Pacific region and that it is willing to cooperate more than before with the Association of Southeast Asian Nations (ASEAN). Part of that is simply “showing up”—a willingness to attend ASEAN regional meetings. Another part of the pivot, however, involves raising the American security profile in the region, which has so far strengthened ASEAN’s diplomatic hand in dealing with China’s sweeping claim to the South China Sea.

How has the pivot been received and interpreted in Asia?

Generally speaking, the pivot has been welcomed in Southeast Asia, despite worries that if it becomes an effort to contain China, a Sino-American cold war could result. The specific responses of Southeast Asian governments have differed, however, on a spectrum from passive acquiescence to active support.

In Japan, the rotation of prime ministers in and out of office has understandably focused that country’s politics more on domestic concerns, and the still not fully resolved disposition of U.S. forces on Okinawa has drawn energy from the bilateral relationship.

As a “middle power,” South Korea has been supportive of multilateral frameworks and solutions. Seoul is pleased to see a renewed American interest in working with Asians in multilateral settings such as ASEAN and the East Asia Summit.

China’s response has varied between cool and hostile. The foreign ministry has treated the pivot with some equanimity compared with the hostility of those in the People’s Liberation Army who view increased American involvement in Asia as a threat to Chinese aims and claims, especially regarding the South China Sea. China’s foreign policy is the outcome of contestation between various groups inside the country that do not necessarily see eye to eye on how best to handle the United States.

What do you see as the main implications, repercussions, and complications of the pivot?

The pivot, as Hillary Clinton advertised it in her Foreign Policy article, signals a shift in U.S. priorities away from Iraq and Afghanistan. For a time following the 9/11 attacks on America in 2001, the United States tended either to neglect Southeast Asia or to treat it as a second front in the “war on terror.” Economically, the pivot implies an acknowledgment that if America is to prosper in this century it will have to pay closer attention to Asia as an engine of global economic growth. Diplomatically, the pivot implies that with regard to Asian states, Washington cannot merely manage its relations bilaterally as the hub where their spokes meet, but must cultivate multilateral diplomacy as well. Militarily, the pivot implies that even while the American global force posture is drawn down in some parts of the world, it needs to be upgraded in Asia in response to Asian and American concerns over the terms on which China’s rise will take place.

A major constructive repercussion of the pivot has been the evolution of China’s own diplomacy in Southeast Asia. Previously China had disavowed multilateral diplomacy with Southeast Asians over claims to the South China Sea—a bilateralist strategy that in Southeast Asian eyes resembled an effort to “divide and rule.” America’s willingness to reach out to ASEAN and take part in ASEAN events has helped diplomats in any one Southeast Asian country to resist having to face China alone. Multilateral discussions, involving China and meant to prepare the way toward an eventual Code of Conduct, are now underway.

But as we saw recently during Hillary Clinton’s visit to the Philippines, it is important for Washington to maintain its independence and impartiality while facilitating peace in the region.

Complications? Yes, there is a danger that Washington could be dragged into supporting, or appearing to support, the claims of one of the Southeast Asian parties to the dispute. The Obama administration is aware of this risk, however, and I strongly doubt that an American official will again refer to the “West Philippine Sea.” 

A more serious complication in the longer run may arise from the pivot’s emphasis to date on Asian-Pacific security, and its relative lack of attention to creating and cultivating American economic opportunities in Asia.

China’s economic footprint in Asia is large and growing. It has moved up to become the main trading partner of many countries that used to trade proportionally more with the United States. An unbalanced relationship in which China saves and lends what Americans borrow and spend is unhealthy for both countries, and it cannot last. The pivot should forestall an invidious division of labor whereby Washington through the Seventh Fleet subsidizes the regional peace that enables Asians to prosper doing business with China. A higher priority needs to be placed on promoting American trade and investment in Asia, including China.

The Obama administration is hoping to persuade more Asian economies to join an arrangement called the Trans-Pacific Strategic Economic Partnership (TPP), but the bar that it sets is high. The TPP’s strict protections for the environment, labor, and intellectual property rights and its comprehensive cuts in both tariff and non-tariff barriers to trade have raised its quality but lowered its appeal, especially to the region’s larger economies. Meanwhile, anticipated cuts in American budgets for defense will only intensify the need to refocus the pivot on economic as well as military access to Asia.

Related Resources

Foreign Policy: “America’s Pacific Century”
November 2011 article by Hillary Clinton introducing the concept of the "Asia pivot."

Stanford Daily: "Obama pivots policy toward Asia"
Summary of Donald K. Emmerson's May 1, 2012 talk.

LinkAsia: "Treat Scarborough Shoal Incident as a 'Wake Up Call'"

A revelatory story emerged in China this spring: Bo Xilai, Chongqing’s powerful Communist Party head, was stripped of both his post and party membership and accused of shocking abuses of power, including covering up his wife’s alleged involvement in the death of a shadowy British businessman.

On May 2, the Shorenstein Asia-Pacific Research Center held a special seminar to make sense of what this unusual high-level scandal could mean for the future of China’s current political system, erupting just months ahead of a once-in-a-generation leadership transition.

Minxin Pei, director of the Keck Center for International and Strategic Studies at Claremont McKenna College, said the scandal is a severe test for the Chinese Communist Party (CCP), which balances on a knife’s edge as it prepares to replace the majority of its Politburo members—the highest CCP echelon. The Bo affair has exposed the existence of serious corruption at a very high level of government, calling into question the party’s image and credibility.

“This is the biggest threat to party unity since 1989,” he said.

More potentially damaging still, however, is the negative light it has cast on China’s overall political system. The scandal has revealed weaknesses and loopholes in the power structure, and the government’s poor crisis management skills.

“The Bo Xilai affair is the beginning of the end of the Tiananmen era,” Pei said. “Twenty years from now, historians will make this point.”

Xueguang Zhou, a professor of sociology and Freeman Spogli Institute senior fellow, agreed with Pei’s analysis that Bo’s fall from power has tarnished the party’s image and deeply disrupted the cohesiveness of its upper leadership.He spoke also of the outpouring of criticism on social media sites for the government’s inability to reign in corruption—so much so that censors have not been able to keep up.

“These voices have been so fierce in criticizing the top leadership that it has huge implications for the emergence of China’s civil society,” Zhou said. 

He expressed his concern for the future of local politics after the smoke from the Bo affair has cleared. Although it is widely acknowledged in China that shady political dealings go hand-in-hand with local-level politics, positive innovations in governance also frequently occur at the city and county level.

“I hope that local governments will still have the power to experiment,” he said.

After all is said and done, China’s top leadership is at a major turning point. Only time will tell the full impact of the fall of Bo Xilai, both during this year’s power transition and the evolution of China’s government structure in the coming decades.

China’s demographic landscape is rapidly changing, and the government has responded by launching ambitious social and health service reforms to meet the changing needs of the country’s 1.3 billion people. This week, officials approved a five-year plan to develop a comprehensive nationwide social security network.

Karen Eggleston, the Asia Health Policy Program (AHPP) director and a Stanford Health Policy fellow, discusses the success of China’s health care reforms—including its recently established universal health care system—and the long road still ahead.

Why is the overall health and wellbeing of China’s population important globally?

There are many reasons why the health of China’s citizens matters within a larger global context. On the most basic level, China represents almost 20 percent of humanity. But it is also a major player in the world economy and it depends on having a healthy workforce, especially now that its population is aging more. The government’s ability to meet the needs of its underserved citizens contributes to a more productive and stable China, and works towards closing the huge gaps we see in human wellbeing across the world.

China also potentially offers a model for other developing countries, such as India, that may want to figure out how to make universal health coverage work at a tenth of the income of most of the countries that have put it into place before.

What are some of the biggest changes in China’s health care system since 1949?

One of the most significant changes is that China has achieved very basic universal health insurance coverage in a relatively short period of time.  

Throughout the Mao period (1949–1978) there was a health care system linked to the centrally planned economy, which provided a basic level of coverage via government providers with a lot of regional variation. When economic reform came in 1980, large parts of the system—particularly financing for insurance—collapsed. The majority of China’s citizens were uninsured during the past few decades of very rapid social and economic development.

China’s overall population is changing quite dramatically, which means it has different health care needs, such as treating chronic disease and caring for an increasingly elderly population. The central government is trying to establish a system of accessible primary care—a concept that China’s barefoot doctors helped to pioneer but that fell into disarray—and health services that fit these new needs. 

How does China’s basic health care system work? Are there segments of the population still not receiving adequate coverage and care?

China has had a system where people can select their own doctors. Patients usually want to go to clinics attached to the highest-reputation hospitals, but of course, when you are not insured you almost always by default go to where you can afford the care. “It is difficult to see the doctor, and it is expensive” has been the lament of patients in China, so an explicit goal of the health care reforms has been to address this.

The term “universal coverage” has different definitions. China initially put in place a form of insurance that only covers 20 or 30 percent of medical costs for the previously uninsured population, especially in rural areas. Benefits have expanded, but remain limited. As with the previous system, disparities in coverage still exist across the population. China not only has a huge population with huge economic differences, but within that there is a large migrant worker population. It is a challenge to figure out how to cover these citizens and how to provide them with access to better care. The government is quite aware there are segments of the population not receiving equal coverage, and it continues to strive to resolve the issue.  

What are the greatest innovations in China’s health care system in recent years?

One of the most remarkable things China has achieved is really its new health insurance system. Even if the current coverage is not particularly generous it is nearly universal, and mechanisms are put in place each year to provide more generous coverage. China is also working on strengthening its primary care and population health services, infusing a huge sum of government money into these efforts. It is the only developing country of its per-capita income that has achieved such results so far.

Interestingly, a lot of people assume China achieved its universal coverage by mandate, while in fact the central government did so by subsidizing the cost for local governments and individuals. This reduces the burden, for example, on poorer rural governments and residents, and is one innovative way China is trying to eliminate the disparity in access to care.

Eggleston has recently published a working paper on China’s health care reforms since the Mao era on the AHPP website, as well as an article in the Milken Institute Review.

Gordon Liu, a Chinese government advisor on health care and the executive director of Peking University’s Health Economics and Management Institute, spoke at Stanford on May 29 on the future of China’s health care system.