The increasing diversification of news media—from online versions of major newspapers to political bloggers, to 24-hour cable news to social media—plus the profession’s changing economics have caused the balance of power between political reporters and presidential candidates to change. Stephen Hess, senior fellow emeritus, says our very good, well-trained reporters are “almost dangerous” to presidential candidates who are trying to stay on message. Thus, says Hess, the way the press covers campaigns has changed as well, and not for the better.

Video

• Stephen Hess: The Changing Balance of Power in Presidential Campaign Reporting

Although advancements in medical science have greatly improved overall life expectancy and the ability for many to survive a cancer diagnosis, a recent study predicts that cancer care alone will cost the American health system $157 billion by 2020. It is well known that a major driver of these surmounting costs is the rising cost of chemotherapy and other treatments, in addition to the variation in how these treatments are used across the health care system.  However, there are several ways that providers, payers, and patients can work together to establish a more medically and financially effective cancer care model that also reduce costs and inefficiencies in the system.

Figure 1: Estimates of the national expenditures for cancer care in 2010 and estimated increase in cost in 2020

Source: Journal of the National Cancer Institute

Develop “Clinical Pathways” to Reduce Inappropriate Use
For many cancers, there are multiple drugs that can be equally effective in treating a patient’s condition, but the price of these treatments can differ in cost by tens of thousands of dollars. Currently, oncologists are responsible for purchasing their own chemotherapy drugs, processing and maintaining them in a specialized pharmacy-like set up, and then administering them to their patients. Insurers then reimburse the oncologists for the cost of the drugs plus a margin to defray the price of maintenance and administration. Since oncologists receive a share of their income from the margins on the drugs they prescribe, insurers assert that there is an incentive to prescribe the pricier drugs, even when lower cost options of equal effectiveness exist.

One mechanism for ensuring that the most evidence-based treatment is used in the care of cancer patients is to use a set of “clinical pathways.” These pathways are based on clinical guidelines available to the public, but tailored for a particular set of patients or a type of oncology practice. Many professional societies have contributed to these guidelines and are working on developing more advanced tools to manage a patient’s care. The American Society of Clinical Oncology (ASCO) is developing a system to rate drugs for advanced cancer based on a combination of benefit, side effects and price.

Several health plans and providers are already showing results. A Pennsylvania-based collaboration with the University of Pittsburgh Medical Center and commercial payers achieved savings of more than $1 million in only six months by controlling and reducing the use of Avastin through clinical pathways. A Washington-based health plan also achieved $1 million in cost savings through a partnership with 22 medical oncologists.[i] Most recently, one of the nation’s largest health plans announced a new clinical pathways program that provides oncologists with $350 per patient per month (PMPM) for adhering to specific chemotherapy regimens. The program will be rolled out in July across six states with potential for expansion after its first year.

Develop Appropriate Value-Based Incentives that Improve Care and Reduce Costs
It will also be essential to develop alternative payment models that move away from a volume-based fee-for-service model that only pay oncology practices for traditional face-to-face office visits and parenteral medications. Instead, payers should support the transition to value-based models that reward non-traditional care, such as telephone and e-mail clinician support, patient education, and counseling services with a social worker.

ASCO also released a comprehensive payment reform proposal to transition to an episode-based payment system. The proposal outlines five types of flexible, bundled payments built around (1) taking on new patients; (2) providing treatment during a given month; (3) actively monitoring patients when they are not being actively treated; (4) the progression or recurrence of a patient’s disease that requires significant treatment regimen changes; and (5) a patient’s participation in a clinical trial. Additional recommendations include adding penalties or bonuses of up to 10 percent based on the quality of care provided, and complementing other payment reforms such as primary care medical homes and accountable care organizations (ACOs). A number of potential methods of reforming the oncology payment system have been explored elsewhere, including implementation of the Community Oncology Alliance (COA) Oncology Medical Home.

Replicate value-based models across the private and public sectors. Even with momentum from private insurers, comprehensive change must involve the public sector. When Medicare, the largest health insurer in the country, changes policies, many commercial insurance companies follow suit. Cancer care would be an ideal arena to launch a program like Medicare’s Comprehensive Primary Care Initiative, a multi-payer public sector-private sector collaboration to strengthen primary care.

In many ways, insurers’ decisions to take direct action to minimize variations in care and excessive costs sets the stage for what is to come next in health care reform. Not only does this represent a step toward broad payment reform in oncology, but marks a trend toward exploring new methods of payment in other specialties, and to align those efforts with primary care payment reforms.

To learn more about the Engelberg Center's efforts to reform payment in the field of oncology, join us on July 9th from 10:30 AM to 12:30 PM EST for MEDTalk: Reinventing Patient-Centered Cancer Care.

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Earlier this month, the Trans-Pacific Partnership Agreement was signed by its 12 member states in New Zealand, bringing the trade deal one step closer to fruition. The member states must now work on resolving their respective domestic issues tied to TPP. For Japan, one of the major issue areas involving TPP is agriculture.

On February 24, the Center for East Asia Policy Studies hosted Kazuhito Yamashita for a presentation in which he discussed the impact of Japan’s market access commitment on agriculture, the TPP countermeasures that the Japanese government announced for agriculture, and the types of agricultural policy reform that are being considered in Japan.

Transcript

• Transcript of Kazuhito Yamashita Presentation (.pdf)

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• Yamashita Brookings presentation for website 022416
• Transcript Kazuhito Yamashita Presentation

Editors’ Note: In a recent interview with Foreign Policy Interrupted, Tamara Wittes was asked about how the situation in the Middle East has changed since she published her 2008 book Freedom’s Unsteady March. Five years after the Arab uprisings and the start of the Syrian civil war, and a year and a half after the Islamic State captured Mosul (along with the world’s attention), Tamara says that many of the same fundamental dynamics in the Middle East are still at work.

The situation in the region has changed so dramatically since then, but I think that the fundamental insights that informed that book remain true. The underlying drivers of change in the Middle East are still there in terms of the demographic drivers, the economic drivers, the technological drivers that I described in the book; they are all still present.

Although there’s a lot of disorder and a lot of violence, and that leads people on the ground to prioritize security and to search for security in different ways, that doesn’t mean that they’re going to be satisfied. It doesn’t mean that the, “well, at least it’s not ISIS” line is going to suffice for governments in the Middle East for very long.

The underlying drivers of change are still present, the pressure for change is still present, and a lot of those pressures are about the simple fact of individual empowerment. Expectations shifted, and people, individuals, have the ability to act in ways that they didn’t before. States and governments have to accommodate that. It’s affecting politics all over the world, and the Middle East is not immune.

So the question becomes: how are governments going to learn to accommodate that and turn it into a strength? I think that the United States does have a really important role to play there. There were mistakes that the Bush administration made—setting aside his vision of Iraq, which has of course been very thoroughly discussed and assessed. But even in terms of non-military intervention to try to advance reform, the critique I made in the book is that the Bush administration was overly focused on political process and elections in particular. I think that one of the other lessons that has come of recent years is that the United States and other Western countries get very focused on political institutions and think, well, if we set up a judicial system, and we set up a parliament, and a constitution, then the gears in the machine sort of start to turn, the states start to function. Look at the rebuilding efforts in Afghanistan, for example.

But what we see in the Middle East today is that formal institutions aren’t enough. People have to have trust in the institutions, and people and communities have to have sufficient agreement on the basic rules of the game to make those institutions legitimate and authoritative. And that’s what’s missing in a lot of places around the region right now, that there isn’t enough dialogue and debate and ultimately negotiated agreement on the basic rules of the game. So I think that the challenge for the United States and others who care about stability in the Middle East going forward is how to help cultivate platforms for that kind of dialogue, and how to help cultivate the skills and the mechanisms for resolving very fundamental questions about how government should be organized and what should be the role of religion and politics, and what’s the balance between individual rights and collective identity.

These are big, big, questions, and right now, in too many places, they are being fought over violently. But the questions still have to be answered, and so the challenge is helping develop ways to do that, to do it peacefully.

Real political change in Turkey has been hard to come by in recent years. Establishment parties in Turkey have, time and again, proven unable to change the political system. Now a new hope for reform has emerged in Turkey from an unlikely source: the Kurds.

During most of the Cold War—and particularly during the 1980s and 1990s—Turkey had, for lack of a better word, a Kemalist consensus: The military played a major role behind the scenes, and those outside the consensus, especially the Islamists and the Kurds, were essentially excluded from politics. 

The first wave of democratization in the post-Cold War era in Turkey came from the Islamists—specifically, from the Justice and Development Party (AKP). In 2002, when the AKP came to power, it decided that accession to the European Union should be its main goal and that effort could serve as tool to undermine the political power of the Turkish military that still lurked behind the scenes. So, incredibly, an Islamist party, the AKP, decided to bring about a post-Kemalist system by pushing for membership in the EU’s essentially liberal, democratic project. This strategy explains why Turkish liberals supported the AKP and could hope that the Islamists would push the system in a liberal direction.

But then something tragic happened. The AKP became the establishment. After the military was essentially defeated as a political force, the AKP ceased to be an anti-establishment party. Rather, it became a party that started to use the privileges of power, and itself began its own networks of patronage clientelism, and became a victim of this entity called the state. The AKP became the state. 

Now we're in a situation where the second wave of democratization may also come from an anti-establishment party, this one mostly representing the Kurds. The most democratic, the most liberal, the most progressive narrative that you hear in Turkish politics today is coming from Selahattin Demirtaş of the pro-Kurdish Peoples’ Democratic Party (HDP)—not the main opposition Republican People’s Party (CHP), not the far-right Nationalist Movement Party (MHP), and not the AKP.

There is reason to think that, in Turkey, only anti-establishment parties can actually improve the system. The old AKP was an anti-establishment party. What gives me hope about the HDP is that, even when it enters the parliament—and even if a miracle happens and it enters a coalition government—it will never become the state. 

By definition, the HDP is a Kurdish political party. The Islamists could become the state, because Turkey is 99 percent Muslim, and people could establish basically a sense of supremacy based on Muslim identity. The Kurds will never be able to represent the majority. They will never be able to become the state. They have vested and permanent interest in the rule of law—indeed their very survival depends on it. Their survival depends on minority rights and on checks and balances. This stark fact gives me hope about the HDP and its agenda.

What’s wrong with the rest of the Turkish opposition?

The real puzzle is the failure of establishment political parties to challenge the system. It would have been wonderful for a center-right party or a center-left party to have taken Turkey to the post-Kemalist phase, to a post-military, pro-E.U., pro-progressive phase. But the mainstream political parties have failed. The establishment of Turkey has failed. The Kemalist order in Turkey has failed.

The agent of change was first the Islamists, and now the agent of change has become the Kurds. 

What is it that creates this mental block of establishment political parties? Why did it take so many years for the CHP to understand that it can become an agent of change, too? In the absence of a left-wing movement in Turkey, there will never be balance. We need a progressive left. We need something that can challenge the strong coalition on the right. The HDP alone cannot be there.

One thing that is not being discussed in Turkey is the possibility of a CHP-HDP coalition, yet this is the most natural coalition. The CHP, if it's a progressive political party, it should be able to get rid of its Kemalist, neo-nationalist baggage and embrace the progress of liberal, democratic agenda of the HDP. 

One reason that the CHP voters and the CHP itself are unable to really embrace the HDP is because the CHP, deep down, is still the party of Atatürk, still the party of Kemalism, still the party of nationalism. And what the Kurds want in Turkey—make no mistake—what the Kurds want in Turkey is autonomy. They want nothing short of autonomy.

The days when you could basically solve the Kurdish question with some cosmetic cultural reforms are over. They want democratic decentralization. And to me, that translates into autonomy. And this is a very difficult step to digest for the CHP. Add to this the fact that the disgruntled CHP voters are voting for the HDP, the fact that people who usually could vote for a central-left progressive party are so disillusioned with the CHP that they're gravitating to the HDP. Therefore, there is also a tactical obstacle, in terms of cooperation between the HDP and the CHP right now. 

But down the line, I think the best reconciliation between Turkish nationalism and Kurdish nationalism would come from a CHP-HDP coalition. Turkish nationalism needs to reconcile itself to the fact that the Kurdish genie is out of the bottle. The good old days of assimilating the Kurds are over. The Kurds want autonomy. They will probably get it, hopefully in a bloodless way.

When Süleyman Demirel died last week I asked myself why such a permanent giant of Turkish politics failed to change the country during his 40 years of active politics. Why is it that genuine political change in Turkey proved to be so elusive during the long decades of Demirel's public service? The answer has partly to do with the fact that Demirel was synonymous with the establishment. Establishment parties in Turkey have, time and again, proven unable to change the political system.

During most of the Cold War—and particularly during the 1980s and 1990s—Turkey had, for lack of a better word, a Kemalist consensus, and those outside the consensus, especially the Islamists and the Kurds were essentially excluded from politics.

The first wave of democratization in the post-Cold War era in Turkey came from the Islamists—specifically, from the Justice and Development Party (AKP). In 2002, when the AKP came to power, it decided that accession to the European Union should be its main goal and that that effort could serve as tool to undermine the political power of the Turkish military, which still lurked behind the scenes. So, incredibly, the AKP, an Islamist party, decided to bring about a post-Kemalist system by pushing for membership in the EU's essentially liberal, democratic project. This strategy explains why Turkish liberals supported the AKP and could hope that the Islamists would push the system in a liberal direction.

But then something tragic happened. The AKP became the establishment. After the military was essentially defeated as a political force, the AKP ceased to be an anti-establishment party. Rather, it became a party that started to use the privileges of power, and itself began its own networks of patronage clientelism, and became a victim of this entity called the state. The AKP became the state.

I think similar dynamics were at play in Demirel's political career. Demirel, too, started his career by challenging the establishment but ended up becoming one of the most permanent politicians identified with the state. His ability to change the system vanished the minute he became the system. The real puzzle is the failure of establishment political parties to challenge the system. It would have been wonderful for a center-right party or a center-left party to have taken Turkey to the post-Kemalist phase, to a post-military, pro-EU and progressive phase. But the mainstream political parties have failed. The establishment of Turkey has failed. The Kemalist order in Turkey has failed. And together with that order, Demirel failed.

There is reason to think that, in Turkey, only anti-establishment parties can actually improve the system. The old AKP was an anti-establishment party. Now we're in a situation where the second wave of democratization may also come from an anti-establishment party, this one mostly representing the Kurds. The most democratic, the most liberal, the most progressive narrative heard in Turkish politics today comes from Selahattin Demirtaş, co-leader of the pro-Kurdish Peoples' Democratic Party (HDP) -- not the main opposition Republican People's Party (CHP), not the far-right Nationalist Movement Party (MHP), and not the AKP.

What gives me hope about the HDP is that, even when it enters Parliament—and even if a miracle happens and it enters a coalition government—it will never become the state. By definition, the HDP is a Kurdish political party. The Islamists were able to become the state because Turkey is 99 percent Muslim and people could basically establish a sense of supremacy based on Muslim identity. The Kurds will never be able to represent the majority. They will never be able to become the state. They have vested and permanent interest in the rule of law—indeed their very survival depends on it. Their survival depends on minority rights and on checks and balances. This stark fact gives me hope about the HDP and its agenda.

This piece was originally published by Today's Zaman.

So we’ve almost reached the end of the year 2015, which could go down in the history of global sustainable development efforts as one of the more significant years, with the trifecta of the approval of the Sustainable Development Goals (SDGs), the agreement on the Addis Agenda on Financing for Development (FfD) and the (shortly to be completed) Paris COP21 Climate Summit. Yet, all will depend on how the agreements with their ambitious targets are implemented on the ground.

Effective implementation will require a theory of change—a way to think about how we are to get from “here” in 2015 to “there” in 2030. The key problem is what has very appropriately been called by some “the missing middle,” i.e., the gap between the top-down global targets on the one hand and the bottom-up development initiatives, projects, and programs that are supported by governments, aid agencies, foundations, and social entrepreneurs.

One way to begin to close this gap is to aim for scaled-up global efforts in specific areas, as is pledged in the Addis Agenda, including efforts to fight global hunger and malnutrition, international tax cooperation and international cooperation to strengthen capacities of municipalities and other local authorities, investments and international coopera­tion to allow all children to complete free, equitable, inclusive and quality early childhood, primary and secondary education, and concessional and non-concessional financing.

Another way is to develop country-specific national targets and plans consistent with the SDG, Addis, and COP21 targets, as is currently being done with the assistance of the United Nations Development Program’s MAPS program. This can provide broad guidance on policy priorities and resource mobilization strategies to be pursued at the national level and can help national and international actors to prioritize their interventions in areas where a country’s needs are greatest.

However, calling for expanded global efforts in particular priority areas and defining national targets and plans is not enough. Individual development actors have to link their specific projects and programs with the national SDG, Addis, and COP21 targets. They systematically have to pursue a scaling-up strategy in their areas of engagement, i.e., to develop and pursue pathways from individual time-bound interventions to impact at a scale in a way that will help achieve the global and national targets. A recent paper I co-authored with Larry Cooley summarizes two complementary approaches of how one might design and implement such scaling-up pathways. The main point, however, is that only the pursuit of such scaling-up pathways constitutes a meaningful theory of change that offers hope for effective implementation of the new global sustainable development targets.

Fortunately, over the last decade, development analysts and agencies have increasingly focused on the question of how to scale up impact of successful development interventions. Leading the charge, the World Bank in 2004, under its president Jim Wolfensohn, organized a high-level international conference in Shanghai in cooperation with the Chinese authorities on the topic of scaling up development impact and published the associated analytical work. However, with changes in the leadership at the World Bank, the initiative passed to others in the mid-2000s, including the Brookings Institution, ExpandNet (a group of academics working with the World Health Organization), Management Systems International (MSI), and Stanford University. They developed analytical frameworks for systematically assessing scalability of development initiatives and innovations, analyzed the experience with more or less successful scaling-up initiatives, including in fragile and conflict-affected states, and established networks that bring together development experts and practitioners to share knowledge.

By now, many international development agencies (including GIZ, JICA, USAID, African Development Bank, IFAD and UNDP), foundations (including the Bill & Melinda Gates Foundation and Rockefeller Foundation) and leading development NGOs (including Heifer International, Save the Children and the World Resources Institute), among others, have focused on how best to scale up development impact, while the OECD recently introduced a prize for the most successful scaling-up development initiatives. The International Fund for Agricultural Development (IFAD) is perhaps the most advanced among the agencies, having developed a systematic operational approach to the innovation-learning-scaling-up cycle. In a collaborative effort with the Brookings Institution, IFAD reviewed its operational practices and experience and then prepared operational design and evaluation guidelines, which can serve as a good example for other development agencies. The World Bank, while yet to develop a systematic institution-wide approach to the scaling-up agenda, is exploring in specific areas how best to pursue scaled-up impact, such as in the areas of mother and child health, social enterprise innovation, and the “science of delivery.”

Now that the international community has agreed on the SDGs and the Addis Agenda, and is closing in on an agreement in Paris on how to respond to climate change, it is the right time to bridge the “missing middle” by linking the sustainable development and climate targets with effective scaling-up methodologies and practices among the development actors. In practical terms, this requires the following steps:

• Developing shared definitions, analytical frameworks, and operational approaches to scaling up among development experts;
• Developing sectoral and sub-sectoral strategies at country level that link short- and medium-term programs and interventions through scaling-up pathways with the longer-term SDG and climate targets;
• Introducing effective operational policies and practices in the development agencies in country strategies, project design, and monitoring and evaluation;
• Developing multi-stakeholder partnerships around key development interventions with the shared goal of pursuing well-identified scaling-up pathways focused on the achievement of the SDGs and climate targets;
• Developing incentive schemes based on the growing experience with “challenge funds” that focus not only on innovation, but also on scaling up, such as the recently established Global Innovation Fund; and
• Further building up expert and institutional networks to share experience and approaches, such as the Community of Practice on Scaling Up, recently set up by MSI and the Results for Development Institute.

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Technology unimaginable at the time of the nation’s founding now poses stark challenges to America’s core constitutional principles. Policymakers and legal scholars are closely examining how constitutional law is tested by technological change and how to preserve constitutional principles without hindering progress. In Constitution 3.0: Freedom and Technological Change (Brookings Institution Press, 2011), Governance Studies Senior Fellow Benjamin Wittes and Nonresident Senior Fellow Jeffrey Rosen asked a diverse group of leading scholars to imagine how technological developments plausible by the year 2025 could stress current constitutional law. The resulting essays explore scenarios involving information technology, genetic engineering, security, privacy and beyond.

On December 13, the Governance Studies program at Brookings hosted a Judicial Issues Forum examining the scenarios posed in Constitution 3.0 and the challenge of adapting our constitutional values to the technology of the near future. Wittes and Rosen offered key highlights and insights from the book and was joined by two key contributors, O. Carter Snead and Timothy Wu, who discussed their essays.

After the program, panelists took audience questions.

Video

• Constitution 3.0: Freedom, Technological Change and the Law

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• Constitution 3.0: Freedom, Technological Change and the Law

Transcript

• Uncorrected Transcript (.pdf)

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• 20111213_constitution_technology

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Change is a complicated thing in Cuba. On the one hand, many Cubans remain frustrated with limits on economic and political opportunity, and millennials are emigrating in ever rising numbers. On the other, there is more space for entrepreneurship, and Havana is full of energy and promise today.

The island’s emerging private sector is growing—and along with it, start-up investment costs. Three years ago, Yamina Vicente opened her events planning firm, Decorazón, with a mere $500 in cash. Today she estimates she would need $5,000 to compete. New upscale restaurants are opening: Mery Cabrera returned from Ecuador to invest her savings in Café Presidente, a sleek bistro located on the busy Avenue of the Presidents. And lively bars at establishments like 304 O’Reilly feature bright mixologists doing brisk business.

Photo credit: Richard Feinberg.

Havana’s hotels are fully booked through the current high season. The overflow of tourists is welcome news for the thousands of bed-and-breakfasts flowering throughout the city (many of which are now networked through AirBnB). While most bed-and-breakfasts used to be one or two rooms rented out of people’s homes, Cubans today are renovating entire buildings to rent out. These are the green shoots of what will become boutique hotels, and Cubans are quitting their low-paying jobs in the public sector to become managers of their family’s rental offerings.

Another new sign: real estate agencies! Most Cubans own their own homes—really own them, mortgage-free. But only recently did President Raúl Castro authorize the sales of homes, suddenly giving Cubans a valuable financial asset. Many sell them to get cash to open a new business. Others, to immigrate to Miami.

WiFi hot spots are also growing in number. Rejecting an offer from Google to provide Internet access to the entire island, the Cuban government instead set up some 700 public access locations. This includes 65 WiFi hot spots in parks, hotels, or major thoroughfares, where mostly young Cubans gather to message friends or chat with relatives overseas.

Economic swings

2015 was a good year for the Cuban economy, relatively speaking. Growth rose from the disappointing 2 percent in recent years to (by official measures) 4 percent. The Brazilian joint venture cigarette company, Brascuba, reported a 17 percent jump in sales, and announced a new $120 million investment in the Mariel Economic Development Zone. Shoppers crowded state-run malls over the holiday season, too. 

Photo credit: Richard Feinberg.

Consumers still report chronic shortages in many commodities, ranging from beer to soap, and complain of inflation in food prices. Alarmed by the chronic crisis of low productivity in agriculture, the government announced tax breaks for farmers in 2016. The government is already forecasting a slower growth rate for 2016, attributed to lower commodity prices and a faltering Venezuelan economy. It’s likely to fall back to the average 2 percent rate that has characterized the past decade.

Pick up the pace

Cuban officials are looking forward to the 7th Conference of the Cuban Communist Party (CCP) in mid-April. There is little public discussion of the agenda, however. Potential initiatives include a new electoral law permitting direct election of members of the national assembly (who are currently chosen indirectly by regional assemblies or by CCP-related mass organizations); a timetable for unification of the currency (Cubans today must deal with two forms of money); some measures to empower provincial governments; and the development of a more coherent, forward-looking economic development strategy.

[T]here are now two brain drains: an internal brain drain, as government officials abandon the public sector for higher incomes in the growing private sector; and emigration overseas.

But for many younger Cubans, the pace of change is way too slow. The talk of the town remains the exit option. Converse with any well-educated millennial and they’ll tell you that half or more of their classmates are now living abroad. Indeed, there are now two brain drains: an internal brain drain, as government officials abandon the public sector for higher incomes in the growing private sector; and emigration overseas to the United States, but also to Spain, Canada, Mexico.

The challenge for the governing CCP is to give young people hope in the future. The White House has signaled that President Obama may visit Cuba this year. Such a visit by Obama—who is immensely popular on the island—could help. But the main task is essentially a Cuban one.

Richard Feinberg’s forthcoming book, “Open for Business: Building the New Cuban Economy,” will be published by Brookings Press later this year.