Editor's note: This article appears in the April 2015 issue of Global Forum. Click here to view the full publication.

Since passage of the Affordable Care Act in 2010, the last several years have seen a groundswell in physician payment and delivery reforms designed to achieve higher value health care through incentivizing higher quality care and lower overall costs. Accountable care models, for example, are achieving marked progress by realigning provider incentives toward greater risk-sharing and increased payments and shared savings with measured improvements in quality and cost containment. Medical homes are introducing greater care coordination and team-based care management, while the use of episode-based or bundled payments is removing perverse incentives that reward volume and intensity.

These reforms are coming just as the number of highly targeted, highly priced treatments continues to expand. The U.S. Food and Drug Administration (FDA) approved a decade-high 41 novel new drugs in 2014, many of them targeted therapies approved on the basis of increasingly sophisticated progress in genomics and the understanding of disease progression. In areas like oncology, such targeted treatments have grown as a percentage of global oncology market size from 11% in 2003 to 46% in 2013. New brand specialty drug spending in the U.S. is estimated to have been $7.5 billion in 2013, or 69% of total new drug spending. The growing prevalence of these drugs and their cost to the health system are setting the stage for significant flashpoints between industry, payers, and providers, seen most clearly in the debate over hepatitis C treatment costs that roiled stakeholder interactions for most of the past year. 

More of these targeted treatments are in the development pipeline, and a growing number of public policy efforts taking shape in 2015 are focused on accelerating their availability. The House of Representatives' 21st Century Cures Initiative, for example, has released a slew of legislative proposals aimed at promoting breakthrough innovation by increasing the efficiency of drug development and regulatory review. These efforts have significant downstream implications for the pace at which targeted and specialty therapies will become available, their associated costs, and the growing importance of demonstrating value in the postmarket setting.

As payers and providers continue their push toward increased value-based care, more innovative models for connecting such reforms to drug development are needed. Earlier collaboration with industry could enable more efficient identification of unmet need, opportunities to add value through drug development, and clearer input on the value proposition and evidentiary thresholds needed for coverage. Equally important will be unique public-private collaborations that invest in developing a better postmarket data infrastructure that can more effectively identify high value uses of new treatments and support achieving value through new payment reforms.

Stronger collaboration could also improve evidence development and the coverage determination process after a targeted  treatment has gained regulatory approval. Facilitated drug access programs like those proposed by the Medicare Administrative Contractor Palmetto GBA create access points for patients to receive targeted anti-cancer agents off-label while payers and industry gather important additional outcomes data in patient registries. More systematic and efficient use of policies like Medicare's Coverage with Evidence Development (CED), which allows for provisional coverage for promising technologies or treatments while evidence continues to be collected, could enable industry and payers to work together to learn about a medical product's performance in patient populations not typically represented in clinical studies. A CED-type model could be especially useful for certain specialty drugs: data collected as a condition of payment could help payers and providers develop evidence from actual practice to improve treatment algorithms, increase adherence, and improve outcomes. 

Finally, collaborations that support stronger postmarket data collection can also support novel drug payment models that further reward value. Bundled payments that include physician-administered drugs, for example, could encourage providers to increase quality while also incentivizing manufacturers to help promote evidence-based drug use and lower costs for uses that generate low value. Outcomes-based purchasing contracts that tie price paid to a medical product's performance could be another promising approach for high-expense treatment with clearly defined and feasibly measured outcomes.

Many of these ideas are not new, but as manufacturers, payers, providers, and patients move into an increasingly value-focused era of health care, it is clear that they must work together to find new ways to both promote development of promising new treatments while also making good on the promise of value-based health care reforms.

The confluence of the agreement on 17 Sustainable Development Goals (SDGs, or Global Goals) in 2015, and the increased attention being paid to the role of non-traditional actors in contributing to shared prosperity, provide a unique opportunity to focus attention on attempts to identify promising new solutions to the barriers that impede the full development of the world’s youngest citizens. Current estimates indicate that 200 million children globally under the age of 5 are at risk of not reaching their development potential. With these goals, the global community has a tremendous opportunity to change the course of history. There is evidence that certain early childhood development (ECD) interventions—spanning the nutrition, health, water and sanitation, education, social protection, and governance sectors from conception to age 5—have high potential to help to achieve the SDGs related to child development. Furthermore, early childhood interventions have been found to improve adult health and education levels, reduce crime, and raise employment rates, which will be paramount to achieving global economic, climate, and physical security.

Impact bonds have the potential to address some of the main financing and delivery constraints faced in ECD. By providing upfront private capital, impact bonds could help to address service provider liquidity constraints and leverage public capital by allowing the government to connect preventive programs with future benefits to individuals, society, and the economy. Impact bonds also have the potential to drive performance management, support monitoring and evaluation, and create accountability, which all help to address quality and capacity constraints. By fostering innovation, experimentation and adaptive learning in service delivery, cost-effective solutions could be identified through impact bonds. By producing evidence of outcome achievement, impact bonds could shift the focus toward effective ECD programs. Finally, collaboration across stakeholders—a necessary component of impact bonds—has the potential to allow for alignment of interests and a win-win situation for investors, outcome funders, and program beneficiaries alike.

The high participation of non-state actors and potentially significant returns in ECD make it a promising sector for impact bonds. Unlike other services that may have entrenched interests, the multitude of agencies and non-state entities financing and providing ECD services potentially allows for more experimentation. The preventive nature of ECD programs also fits well with the core feature of SIBs, which is that preventive investments will result in valuable short- and potentially long-term outcomes. There is evidence that ECD interventions can have immense effects on later-life outcomes. For example, a longitudinal study of a program in Jamaica, in which participants received weekly visits from community health workers over a 2-year period, was found to increase the earnings of participants by 25 percent, 20 years later.

There may, however, be some particular challenges associated with applying impact bonds in the ECD sector. Impact bonds (and other Payment by Results mechanisms tied to outcomes) require meaningful outcomes that are measureable within a timeframe that is reasonable to the outcome funder (and investors in the case of an impact bond). Meaningful outcomes are outcomes that are intrinsically or extrinsically valuable. Intrinsically valuable outcomes that are measureable within a reasonable timeframe could be extrinsically valuable if they are proxies for long-term benefits to individuals, society, or the economy. The delay between ECD interventions and later-life results may prove an impediment in some cases. By identifying appropriate interim measures such as language development, socioemotional development, and schooling outcomes that may proxy for desirable longer-term outcomes, the issue of delay could be mitigated. For example, there is evidence that early stimulation and health programs can have statistically significant effects on schooling outcomes in the short-run. An increase in focus on the intrinsic value of short-term outcomes that result from ECD interventions, such as child survival, is also important.

As the global community moves beyond the Millennium Development Goals to a set of Global Goals and associated targets linked to measurable outcomes, there is an opportunity to demonstrate a commitment to invest in future generations. Leveraging upfront funding, focusing on outcomes through adaptive learning and testing new ways to deliver early childhood interventions more effectively are all means of achieving the ECD-related goals. Despite the hype around all of the new financing mechanisms, the keys to creating high-quality, locally appropriate programs remains simple—real-time collection of outcome data, the freedom to fail, and the flexibility to course-adjust. In some circumstances social service provision based on outcomes and adaptive learning may require mechanisms like impact bonds or other Payment by Results mechanisms. In other circumstances it may not. As this very nascent field continues to grow, more research will be needed to capture lessons learned, contextualize them within the larger landscape of ECD financing and service provision, and apply them to real-world social challenges with the world’s youngest and most disadvantaged populations at the forefront of the conversation. 

Read the previous report on the landscape of impact bonds across sectors and geography »

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On Wednesday, June 2, the Center for Universal Education at Brookings hosted a discussion on the need to refocus the international education dialogue from school enrollment to learning achieved in developing countries. Participants, who included education experts from academia, international organizations and government, assessed the current state of systematic efforts at the global level to measure learning outcomes.

Center for Universal Education Co-Director and Senior Fellow Jacques van der Gaag opened the event by charting the landscape of learning, including education outside the primary school classroom, during early childhood development and the importance of acquiring both cognitive and non-cognitive skills for ensuring learning outcomes.

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As the recent primary in Delaware attests, this year's midterm elections continue to offer unexpected twists and raise large questions. Will the Republicans take over the House and possibly the Senate? Or has the Republican wave ebbed? What role will President Obama play in rallying seemingly dispirited Democrats -- and what effect will reaction to the sluggish economy play in rallying Republicans? Is the Tea Party more an asset or a liability to the G.O.P.'s hopes? What effect will the inevitably narrowed partisan majorities have in the last two year's of Obama's first term? And how will contests for governorships and state legislatures around the nation affect redistricting and the shape of politics to come?

On October 4, a panel of Brookings Governance Studies scholars, moderated by Senior Fellow E.J. Dionne, Jr., attempted to answer these questions. Senior Fellow Thomas Mann provided an overview. Senior Fellow Sarah Binder discussed congressional dynamics under shrunken majorities or divided government. Senior Fellow William Galston offered his views on the administration’s policy prospects during the 112th Congress. Nonresident Senior Fellow Michael McDonald addressed electoral reapportionment and redistricting around the country.

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• Partisan Gridlock post-Elections?
• GOP Influence over Redistricting, Reapportionment
• Working Within Divided Government
• Good Conditions for GOP in 2010 Midterms

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• Midterm Elections 2010: Driving Forces, Likely Outcomes, Possible Consequences

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• Uncorrected Transcript (.pdf)

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Editors Note: This post is an extended version of a previous post.

Cozzens, Susan and Dhanaraj Thakur (Eds). 2014. Innovation and Inequality: Emerging technologies in an unequal world. Northampton, Massachusetts: Edward Elgar.

Historically, the debate on innovation has focused on the determinants of the pace of innovation—on the premise that innovation is the driver of long-term economic growth. Analysts and policymakers have taken less interest on how innovation-based growth affects income distribution. Less attention even has received the question of how innovation affects other forms of inequality such as economic opportunity, social mobility, access to education, healthcare, and legal representation, or inequalities in exposure to insalubrious environments, be these physical (through exposure to polluted air, water, food or harmful work conditions) or social (neighborhoods ridden with violence and crime). The relation between innovation, equal political representation and the right for people to have a say in the collective decisions that affect their lives can also be added to the list of neglect.

But neglect has not been universal. A small but growing group of analysts have been working for at least three decades to produce a more careful picture of the relationship between innovation and the economy. A distinguished vanguard of this group has recently published a collection of case studies that illuminates our understanding of innovation and inequality—which is the title of the book. The book is edited by Susan Cozzens and Dhanaraj Thakur. Cozzens is a professor in the School of Public Policy and Vice Provost of Academic Affairs at Georgia Tech. She has studied innovation and inequality long before inequality was a hot topic and led the group that collaborated on this book. Thakur is a faculty member of the school College of Public Service and Urban Affairs at Tennessee State University (while writing the book he taught at the University of West Indies in Jamaica). He is an original and sensible voice in the study of social dimensions of communication technologies.

We’d like to highlight here three aspects of the book: the research design, the empirical focus, and the conceptual framework developed from the case studies in the book.

Edited volumes are all too often a collection of disparate papers, but not in this case. This book is patently the product of a research design that probes the evolution of a set of technologies across a wide variety of national settings and, at the same time, it examines the different reactions to new technologies within specific countries. The second part of the book devotes five chapters to study five emerging technologies—recombinant insulin, genetically modified corn, mobile phones, open-source software, and tissue culture—observing the contrasts and similarities of their evolution in different national environments. In turn, part three considers the experience of eight countries, four of high income—Canada, Germany, Malta, and the U.S.—and four of medium or low income—Argentina, Costa Rica, Jamaica, and Mozambique. The stories in part three tell how these countries assimilated these diverse technologies into to their economies and policy environments.

The second aspect to highlight is the deliberate choice of elements for empirical focus. First, the object of inquiry is not all of technology but a discreet set of emerging technologies gaining a specificity that would otherwise be negated if they were to handle the unwieldy concept of “technology” broadly construed. At the same time, this choice reveals the policy orientation of the book because these new entrants have just started to shape the socio-technical spaces they inhabit while the spaces of older technologies have likely ossified. Second, the study offers ample variance in terms of jurisdictions under study, i.e. countries of all income levels; a decision that makes at the same time theory construction more difficult and the test of general premises more robust.[i] We can add that the book avoids sweeping generalizations. Third, they focus on technological projects and their champions, a choice that increases the rigor of the empirical analysis. This choice, naturally, narrows the space of generality but the lessons are more precise and the conjectures are presented with according modesty. The combination of a solid design and clear empirical focus allow the reader to obtain a sense of general insight from the cases taken together that could not be derived from any individual case standing alone.

Economic and technology historians have tackled the effects of technological advancement, from the steam engine to the Internet, but those lessons are not easily applicable to the present because emerging technologies intimate at a different kind of reconfiguration of economic and social structures. It is still too early to know the long-term effects of new technologies like genetically modified crops or mobile phone cash-transfers, but this book does a good job providing useful concepts that begin to form an analytical framework. In addition, the mix of country case studies subverts the disciplinary separation between the economics of innovation (devoted mostly to high-income countries) and development studies (interested in middle and low income economies). As a consequence of these selections, the reader can draw lessons that are likely to apply to technologies and countries other than the ones discussed in this book.

The third aspect we would like to underscore in this review is the conceptual framework. Cozzens, Thakur and their colleagues have done a service to anyone interested in pursuing the empirical and theoretical analysis of innovation and inequality.

For these authors, income distribution is only one part of the puzzle. They observe that inequalities are also part of social, ethnic, and gender cleavages in society. Frances Stewart, from Oxford University, introduced the notion of horizontal inequalities or inequalities at the social group level (for instance, across ethnic groups or genders). She developed the concept to contrast vertical inequalities or inequalities operating at the individual level (such as household income or wealth). The authors of this book borrow Stewart’s concept and pay attention to horizontal inequalities in the technologies they examine and observe that new technologies enter marketplaces that are already configured under historical forms of exclusion. A dramatic example is the lack of access to recombinant insulin in the U.S., because it is expensive and minorities are less likely to have health insurance (see Table 3.1 in p. 80).[ii] Another example is how innovation opens opportunities for entrepreneurs but closes them for women in cultures that systematically exclude women from entrepreneurial activities.

Another key concept is that of complementary assets. A poignant example is the failure of recombinant insulin to reach poor patients in Mozambique who are sent home with old medicine even though insulin is subsidized by the government. The reason why doctors deny the poor the new treatment is that they don’t have the literacy and household resources (e.g. a refrigerator, a clock) necessary to preserve the shots, inject themselves periodically, and read sugar blood levels. Technologies aimed at fighting poverty require complementary assets to be already in place and in the absence of them, they fail to mitigate suffering and ultimately ameliorate inequality. Another illustration of the importance of complementary assets is given by the case of Open Source Software. This technology has a nominal price of zero; however, only individuals who have computers and the time, disposition, and resources to learn how to use open source operative systems benefit. Likewise, companies without the internal resources to adapt open software will not adopt it and remain economically tied to proprietary software.

These observations lead to two critical concepts elaborated in the book: distributional boundaries and the inequalities across technological transitions. Distributional boundaries refer to the reach of the benefits of new technologies, boundaries that could be geographic (as in urban/suburban or center/periphery) or across social cleavages or incomes levels. Standard models of technological diffusion assume the entire population will gradually adopt a new technology, but in reality the authors observe several factors intervene in limiting the scope of diffusion to certain groups. The most insidious factors are monopolies that exercise sufficient control over markets to levy high prices. In these markets, the price becomes an exclusionary barrier to diffusion. This is quite evident in the case of mobile phones (see table 5.1, p. 128) where monopolies (or oligopolies) have market power to create and maintain a distributional boundary between post-pay and high-quality for middle and high income clients and pre-pay and low-quality for poor customers. This boundary renders pre-pay plans doubly regressive because the per-minute rates are higher than post-pay and phone expenses represent a far larger percentage in poor people’s income. Another example of exclusion happens in GMOs because in some countries subsistence farmers cannot afford the prices for engineering seeds; a disadvantage that compounds to their cost and health problems as they have to use more and stronger pesticides.

A technological transition, as used here, is an inflection point in the adoption of a technology that re-shapes its distributional boundaries. When smart phones were introduced, a new market for second-hand or hand-down phones was created in Maputo; people who could not access the top technology get stuck with a sub-par system. By looking at tissue culture they find that “whether it provides benefits to small farmers as well as large ones depends crucially on public interventions in the lower-income countries in our study” (p. 190). In fact, farmers in Costa Rica enjoy much better protections compare to those in Jamaica and Mozambique because the governmental program created to support banana tissue culture was designed and implemented as an extension program aimed at disseminating know-how among small-farmers and not exclusively to large multinational-owned farms. When introducing the same technology, because of this different policy environment, the distributional boundaries were made much more extensive in Costa Rica.

This is a book devoted to present the complexity of the innovation-inequality link. The authors are generous in their descriptions, punctilious in the analysis of their case studies, and cautious and measured in their conclusions. Readers who seek an overarching theory of inequality, a simple story, or a test of causality, are bound to be disappointed. But those readers may find the highest reward from carefully reading all the case studies presented in this book, not only because of the edifying richness of the detail herein but also because they will be invited to rethink the proper way to understand and address the problem of inequality.[iii]