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.

In July 2023, Professor Rozelle joined a group of ten academics from the US, including both professors and think tank professionals, and traveled to China where they met with 12 scholars from China. The group spent three days at Peking University in discussion and went on several site visits around Beijing (to the Foreign Ministry; Xinhua New Agency; American Chamber of Commerce in Beijing; the US Embassy) where they furthered dialogue on the current state of scholarly exchange and how to improve it.

There were several key takeaways from the meetings:

Scholarly exchange is still occurring but at a much lower level compared with 5 to 10 years ago. 
Scholarly exchange is suffering collateral damage from the deteriorating US-China relations.

Challenges to scholarly exchange exist within both countries.
Rozelle remarked, “when we [the 10 academics from the US] got together with our academic colleagues from China, we immediately bonded and opened up with a sense of camaraderie, we almost immediately knew we were facing the same challenges on both sides of the Pacific.”

Through discussion, Rozelle documented 15 different issues that are inhibiting research efforts within China, (such as increased privacy laws, shutting off access to public databases, putting strict limits on access to archives, and more,) and 10 things in the US hindering research (such as, not issuing visas to engineering/biomedicine/science Ph.D students and post-docs from China). 

The biggest issue both sides face is the perception that scholarly exchange may compromise national security.
A small fraction of scholarly exchange is related to national security issues, the other share of scholarly exchange is much more related to positive outcomes in research, technology, and national growth. A secular decline of scholarly exchange is going to have large negative impacts on growth, equity and happiness in both countries as well as around the world.

Leaders in both countries need to define what types of scholarly exchange concern national security.
What can be done to improve scholarly exchange? Both countries have stated that scholarly exchange is related to national security, which is what has led to the decline (and prohibition, in some cases,) of scholarly exchange.

The challenge is that there has been no definition or clarification given of what types of scholarly exchange are sensitive to this matter. As a result, lower-level bureaucrats both in the United States and in China have taken risk-averse approaches in implementing these efforts by making it difficult to do almost all research. The two groups of scholars almost unanimously agreed that what is urgently needed is for upper-level leaders in the two countries to officially define what specific topic areas are national security concerns, and which are not.

In early October 2023 the delegation from China will join the US delegation in Washington DC to continue the conversation and strategize on how to foster more scholarly exchange between the two nations.

Rozelle is currently working on producing a brief that will seek to demonstrate both the benefits of US-China scholarly exchange as well as the cost of the disruption. Once published, the brief will be part of the overall effort as well as being linked here.
 

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.

What does this poll show about the American public and our political and civic discourse that the headlines miss?

Diamond: Over and over (this is now our third "America in One Room"), we find that ordinary Americans are hungry for thoughtful and civil discussions with their fellow citizens about the issues we face. And it is possible to have these discussions if you set good conditions and ensure that everyone has access to the same body of balanced and objective information, with a fair presentation of the pro and con arguments for each proposal. Americans do narrow their differences when they can deliberate in this way. But more than that — and quite stunning to us — they also became more hopeful about American democracy. The percentage of Americans who say they are satisfied with the way democracy is working in the US increased from 27% before deliberation to 45% after. And satisfaction among Republicans doubled — from 24% to 50%.

Siu: Headlines often lead with how polarized our society is, but what they fail to tell us is that if people had the opportunity to engage with diverse others, people are capable of having respectful conversations. In fact, after deliberation, agreement with the statement 'I respect their point of view though it is different from mine' increased from 57 to 75%. Among Democrats, this percentage increased from 49 to 73%, and among Republicans, this increased from 73 to 84%. The headlines amplify the perceived polarization in our society, but what it misses is how deliberation can bring our society together in a respectful way.

Fishkin: Dialogue across differences can activate the fundamental values of our democracy and show the way for constructive solutions. The increased support for ranked choice voting and for non-partisan redistricting commissions was particularly noteworthy.

What implications might this installment of A1R have for the 2024 U.S. presidential election and democratic reform initiatives on the ballot?

Fishkin: This project identifies practical reforms that have a claim on the values and concerns of the American public if they focus on the issues. I think it can be invoked for non-partisan redistricting commissions, for ranked-choice voting in various contexts, for ethics reform of the Supreme Court, and a host of other issues.

Diamond: It may not have much impact on the 2024 presidential election, but it will give momentum to reformers who are working to expand voting rights, ensure a more transparent non-partisan administration of elections, and institute Ranked Choice Voting and related electoral reforms. I think our results show that people can be persuaded, even across party lines, and it points to certain types of reforms that are more broadly appealing than others. As we analyze the transcripts of the discussions, we will also learn what kinds of arguments resonated with voters and which did not.

Siu: One of the striking results from this installment of A1R is people's concerns about voting accessibility. From restoring voting rights to citizens with felony convictions to strengthening federal standards for election machines and requirements for reporting security incidents, we hope that policymakers see the priorities that registered voters have for ensuring that our elections are fair and transparent.

How can this research be used to help reduce polarization moving forward and create meaningful change in our public dialogues?

Siu: This installment of A1R, along with the previous A1R Deliberative Polls, have shown that deliberation can, in fact, reduce political and affective polarization. We must all understand that for our society and for any society around the world, listening to each other, whether we agree or disagree, is really not an option. 

Diamond: We now have a second major demonstration in the US of the dramatic utility of the Stanford Online Deliberation Platform, developed by Stanford Professor Ashish Goel and his Crowdsourced Democracy Team. This was the second "America in One Room" to deploy this platform very successfully. When people can deliberate online, it cuts costs dramatically, and yet still, it brings about reductions in polarization and constructive changes in public opinion on many issues. Now the challenge is to figure out how we can scale up deliberation to much larger numbers of Americans and apply the tool to a wider range of issues in jurisdictions across the US as well as globally. International demand for the framework and tools of the Deliberative Democracy Lab keeps growing.

Fishkin: With our technology, we have hopes of spreading this kind of dialogue. I was struck that Republicans, Democrats, and Independents all supported fostering deliberation on contentious topics.

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.”
 

Below is a transcript of remarks by Miku Yamada, MIP '23, at the diploma ceremony for Ford Dorsey Master's in International Policy graduates on June 18, 2023.
 

At Stanford, this MIP cohort quickly became my family. We became a family, not only because we had classes together every single day for the first quarter, but because despite all of our differences, we shared a collective desire to make the world, with all of its imperfections and inequalities, a better place for all to live in. 

When I think back to the first quarter, most of my memories are being in the MIP studio, or one of the study rooms in the dorms, either trying to flip probability trees, or struggling to understand how to calculate the Balance of Payments. But these are now fond memories, because through all these grueling work sessions, I developed a support system that carried me throughout my Stanford experience. 

While I learned a great deal from the classes I took, I learned equally as much, if not more, from my classmates. At the Friday discussions hosted by Taimur, we exchanged opinions on a broad range of topics, from cryptocurrency to critical race theory, encouraging each other to look at these issues from multiple lenses. We challenged the assumptions we had each internalized, and together, we boldly envisioned what we could do once we stepped out of our comfort zones. It was these discussions that inspired me to take classes I would not have considered otherwise, on topics ranging from energy to tech platform policy. 

We mastered our specializations and delved into new interests. Some of us, like Tanvi and Daniel, started out focusing on issues in development and governance, but fell in love with the exciting intersection of technology and policy. Angela immersed herself in the innovation ecosystem at Stanford as the first non-STEM Threshold Venture Fellow. Munashe and Dulguun took the opportunity to study at the Diplomatic Academy of Vienna to further broaden their perspective on policy issues. Omar and Corinna pursued their passions in space policy and food systems, unearthing amazing opportunities.

Not only were these two years a time of learning, many of us dedicated our time to creating social impact. Arden’s work on helping resettle high-risk Afghan refugees, and Francesca’s work with the Stanford’s Jail and Prison Education Project are two prime examples of this. Shiro was awarded the Stanford Impact Founder Fellowship to build human capital for climate-adaptive farms in sub-Saharan Africa. The 20+ units of cyber policy electives were not enough for Caroline and Ilari, and so they devoted their time out of class to tackle online safety challenges at the Stanford Internet Observatory.

Throughout our journey, we experienced many joyous moments, which we celebrated together. We welcomed Brian’s beautiful daughter Lena. Joyce hosted us to celebrate the Lunar New Year, as we welcomed the year of the tiger, and then the year of the rabbit. I will never forget listening to Jasdeep read us his beautiful poem, and the harmonies of Caroline, Corinna, and Ben among the flickering flames at campfire night. We cheered on as Rosie performed in the Law School musical two years in a row, even as an expecting mom. We travelled around the world to conduct fieldwork for our capstone projects. I had the pleasure of witnessing Jonathan and Omar fall in love with the food in Tokyo and Hanoi, and especially the wonder that is Japanese 7-11s. We also celebrated the 40th anniversary of the IPS/ MIP program, together with our inspiring alumni.

However, these past two years have not always been easy. As much as grad school is an immensely rewarding time, it is also a challenging time. It is challenging because we are constantly tackling questions to which there are no answers to. It is challenging because it is a time of uncertainty, and it is difficult to measure how much we have grown. Throughout these two years, many of us have suffered personal losses, and wished we were closer to home. As policy students, it is especially devastating to see the ideals we strive for being destroyed by anger, fear, and greed. We watched in horror and disbelief as Russia invaded Ukraine, and many innocent civilians lost their lives. We saw Covid-19 continuing its rampage, impacting communities and people dear to us. 

Even so, we made it through. We supported each other through the lows. Here I was constantly surrounded by friends who gave me more kindness and love than I could ever return. I was struck so many times at how beautiful and powerful it is when we choose to be selfless, and choose to empower others. 

Now it is time for us to each embark on our separate journeys. Some of us, Chubing, Joyce, Suman, Anna and Luis will further expand their interdisciplinary learning at Stanford. Others, like Jonathan and Ben, will start their careers applying their policy skills in consulting. Yet others, including myself, will work in government to develop policies from the public sector.

We will continue to face challenges. As we learned from the Problem-Solving Framework, making changes is not an easy task, and it is not something we can do on our own. It takes time and hard work- but now we are equipped with the tools we need and a community of caring and inspiring friends all around the world. 

The most important lesson I have learned through Stanford, is to truly care about the problems we aim to solve, and to approach them with love. Sometimes it seems easier not to care, when caring too much about things that never seem to get better breaks your heart. Sometimes it is difficult to love, because it is too painful to watch the people and the things we love being hurt. Still, I hope we have the strength to always choose empathy and love. When we believe in a cause, and when we love a community, we can make an impact, deeper and larger than we could even imagine. Knowing each and every one of you, I am confident that we are ready to go out and tackle even the most difficult obstacles, with hope, compassion, and love. 

I want to end by sharing one of my favorite Japanese phrases: 「一期一会」(ichigo ichie). It roughly translates into “one chance in a lifetime”, and means that we should treasure each encounter and each moment in our life, because no moment is repeatable. Let us cherish all the encounters we make in our life. Let us never take a moment or an opportunity for granted. I especially hope that you will all remember this very moment as a time of joy and gratitude.

Now, please join me in congratulating the graduates of the MIP Class of 2023!