This seminar will feature two presentations: an attempt to evaluate the impact of health policy under a decade of progressive governments in Korea; and an investigation into the health and economic well-being of the elderly in Korea. The presenters will be Dr. Byongho Tchoe, a 2008-09 visiting scholar at Stanford University, and Dr. Young Kyung Do, the inaugural postdoctoral fellow in the Asia Health Policy Program at Stanford.

Korea achieved universal health care coverage in 1989 only twelve years after the introduction of social health insurance under an authoritarian government. In 1992 a civil government won the presidential election. Consistent with a conservative ideology oriented toward market principles and globalization, that government emphasized competitive principles in health care policy. However, at the end of 1997 in the face of economic crisis, the progressive party won the Korean presidential election; their health emphasized strengthening equity, redistribution, and regulation of providers’ rent seeking behavior. Under successive progressive governments from 1998 to 2007, ambitious health policy reforms integrated insurers, separated prescribing from dispensing, reformed provider payment, expanded benefits coverage, increased medical-aid enrollees, and increased the role of government providers in the health care market. But in the election of 2007, they were defeated by a conservative party, which insists that competition among insurers and providers will enhance efficiency and quality in health care, and stresses consumer choice and responsibility.

Dr. Tchoe's talk will attempt to evaluate impact of health care policy under a decade of progressive governments in Korea. Although equity in both access to care and financial responsibility appear to be enhanced, there is controversy about whether the policies were cost-effective or improved health, and what will happen as the new government repeals regulations in the health care market. The return of economic crisis also brings renewed urgency to debates of economic and social policy.

Byongho Tchoe is a 2008-09 visiting scholar at Stanford University. After working at the Korea Development Institute from 1983 to 1995, he took up his current post with the Korea Institute for Health and Social Affairs. He has been influential in formulating health and social policy in Korea, having served as an advisor to the minister of health and social welfare and participated in many task forces and committees. In 2007, he was awarded a National Medal in honor of 30 years achievement related to Korea’s National Health Insurance. He has published many articles and books and served as president of the Korean Association of Health Economics and Policy and as vice president of the Korea Association of Social Security. He holds a master’s degree in public policy from Seoul National University and a Ph.D. in economics from the University of Georgia.

Young Kyung Do is the inaugural Postdoctoral Fellow in Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center. He completed his Ph.D. in health policy and administration at the University of North Carolina at Chapel Hill School of Public Health in August 2008. He has also earned M.D. and Master of Public Health degrees from Seoul National University (in 1997 and 2003, respectively). He earned board certification in preventive medicine from the Korean Medical Association in 2004. He received the First Prize Award in the Graduate Student Paper Competition in the Korea Labor and Income Panel Study Conference in 2007. He also is the recipient of the Harry T. Phillips Award for Outstanding Teaching by a Doctoral Student from the UNC Department of Health Policy and Administration in 2007. In May 2008, he was selected as a New Investigator in Global Health by the Global Health Council.

Why do community-based education and social persuasion programs for promoting healthy lifestyle and preventing chronic disease sometimes fall short of our expectations? Why are population effects so difficult to engineer and why are they so ephemeral? This research carried out at USC, the Claremont Graduate University, and collaborating institutions in China integrates across social, behavioral, and neurocognitive sciences to address those questions.

We conclude tentatively that the answer to each of the questions may lie in individual and context variability relative to program response, and that in order to more fully address the question of prevention program response variability requires engagement and integration across several levels of science to consider the roles of social groupings, environmental selection and design, social influence processes, and brain biology. What works in one social, cultural or organizational setting may not be so effective in another. What works for persons with certain genetic and experiential backgrounds may be totally ineffective for persons with different dispositional or personality characteristics. In a series of community/school based prevention trials carried out in markedly different southern California and central China settings, we have uncovered domains of consistent response, and other domains of substantial environment- and disposition-based response variability. A social influences based smoking prevention program framed in collectivist values and objectives worked to prevent smoking in one cultural setting but not another. And an individualist framed social influences program worked in the setting where the collectivist program did not. But the characteristics of the particular settings which defined program success or failure were different from what conventional (e.g., cultural psychology) wisdom would have led us to expect. Furthermore, both within and across cultural settings, the same individual dispositional characteristics moderated or determined program effectiveness, again in ways not predicted by the common cultural and behavioral science wisdom. In recent studies carried out both in China and the U.S. we have found affective decision deficits, with known neural underpinnings, to account for rapid progression to regular smoking and binge drinking. These deficits are akin to the dispositional characteristics found earlier to moderate prevention program effects. Subsequent brain imaging studies confirm the hypothesized regions of neural involvement. Together these findings hold promise for more effective – situation and phenotype specific – approaches to engendering and sustaining more optimal individual and population health behavior.

Seema Jayachandran is an assistant professor in the Department of Economics at Stanford University. She is also a Faculty Research Fellow at the National Bureau of Economic Research (NBER), and a Research Affiliate of the Bureau for Research and Economic Analysis of Development (BREAD), Centre for Economic Policy Research (CEPR), and Stanford Center for International Development (SCID).

Her research focuses on microeconomic issues in developing countries, including health, education, labor markets, and political economy. Her work has been published in the American Economic Review ("Odious Debt," on sovereign debt incurred by dictators), Journal of Political Economy ("Selling Labor Low," on labor market risk in India), and the Quarterly Journal of Economics ("Life Expectancy and Human Capital Investments," on increased education caused by declines in maternal mortality in Sri Lanka), and other journals.

Her current projects are based in India, Nepal, and Zimbabwe. She also works on social issues in the United States. Previously she was a Robert Wood Johnson Scholar in Health Policy Research at the University of California, Berkeley. She also worked as a management consultant with McKinsey & Company in San Francisco. She earned a PhD and master's degree from Harvard University, a master's degree from the University of Oxford where she was a Marshall Scholar, and a bachelor's degree from MIT.

Seminar summary:

Seema Jayachandran's presentation focused on the problem of what to do about "odious debt" -- that is, debt lent to rogue regimes that ultimately must be borne and paid by successive (legitimate) governments. She asks to what extent the status quo can change so that lenders will not want to lend to illegitimate governments. Her solution lies in increasing the costs of lending to rogue regimes through a policy of loan sanctions. Adopting an ex ante posture, Jayachandran argues that interests rates for loans would move toward infinity if banks knew that future legitimate governments would repudiate the debts of past regimes, particularly if new governments would have the blessing of the international community to do so. The loan-sanctions solution addresses a challenge faced by the debt relief movement, which focuses on debt "overhang," which weakens a poor country's economy. Instead, loan sanctions focus on the notion that some debt is, simply, illegitimate. And while trade sanctions pose problems (Jayachandran mentions that trade sanctions are often easy to evade and hurt people more than government), loan sanctions prevent a sanctioned government from borrowing. Loan sanctions are also self- enforcing (e.g., a lender would not lend if that lender knew it was unlikely to be repaid). The author raised questions for debate about who or what international body would implement loan sanctions or policy, the problem of banks making short-term loans to dictators who pay, and defining bad behaviors narrowly (or broadly) enough so as to target rogue or illegitimate regimes.