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Global poverty and climate change are two of the most pressing challenges for global policymakers today, and require policy prescriptions that address their interrelated issues. Effective climate solutions must empower development by improving livelihoods, health and economic prospects while poverty alleviation must become a central strategy for both mitigating emissions and reducing the poor’s vulnerability to climate change.

In its fifth annual gathering, led by Lael Brainard and co-chaired by Strobe Talbott and Richard C. Blum, the Brookings Blum Roundtable addressed the challenges of climate change and development and convened leaders from both the development and climate change communities from August 1-3, 2008, to discuss and debate policy ideas that could benefit both fronts. By examining common challenges—accountability, effective deployment of resources, agenda-setting, mobilizing the public and financial resources, and achieving scale and sustainability—the Roundtable established a solid foundation for collaboration among the climate change and development communities and fostered ideas for policy action.

Keynote Sessions

Keynote Panel: “Noble Nobels: Solutions to Save the Planet”

• Steven Chu, University of California, Berkeley
• Al Gore, Generation Investment Management; 45^th Vice President of the United States

Keynote Panel: Legal Empowerment of the Poor

• Mary Robinson, Realizing Rights: The Ethical Globalization Initiative
• Madeline Albright, The Albright Group; Former U.S. Secretary of State

Keynote Panel: “How Do We Achieve Climate Justice?”

• Kumi Naidoo, CIVICUS and the Global Call to Action Against Poverty
• Mary Robinson, Realizing Rights: The Ethical Globalization Initiative
  
  

Choosing a health plan on one of the new public or private exchanges is no easy task. That’s especially true for those with medical conditions who want to be very sure the plan they enroll in will provide the services they need.

This challenge is not unique to buying health plans, however. It’s always hard for consumers to buy complex and technical services or products when they have little or no expertise in the field. Health insurance can be especially daunting, with so many factors to consider, and even the terminology can be confusing.

Standardizing choices and terms can be helpful to a point. Grouping health plans according to premiums and out-of-pocket costs – bronze, silver, gold and platinum plans – has worked well in the public exchanges. But standardization will always be in tension with innovation, and the reality is that most exchanges will carry a larger inventory of plans than what the typical consumer wants to scroll through. So the question of “choice architecture” – how the plans are filtered or screened – will come to the fore. 

Consumers will have many questions.  What is the price? How do I assess the trade-off between lower premiums and higher cost sharing? Is my doctor in the plan’s network? Are the drugs I take in the formulary (whatever that is)? Things can get real complicated real fast, and it can feel like there are too many, not too few, choices. No wonder some call that “choice anxiety”.

But that view overlooks how technology is likely to reduce choice anxiety in health care, just as it has for other complicated searches.  It used to take a librarian to find an obscure article or a travel agent to plan a vacation. Today a few keystrokes on Google locates the article, and Travelocity makes vacation planning a cakewalk, with everything from on-time flight arrival data to pictures of hotel rooms and customer reviews arranged by star ratings.

Expect technology to have the same dramatic impact on buying health coverage in the near future. There are several reasons for this:

The presentation of consumer information will get better. When large new markets for products and services are created and the demand for buyers’ information rises sharply, the incentive for entrepreneurs – both for-profit and nonprofit – to provide customer-friendly information also rises. We’ve already seen this in parts of the health care market where there has been plenty of choice. Millions of federal employees have for many years been able choose among a wide range of plans with differing benefits.  Many have turned to the highly regarded Consumers’ Checkbook to help them understand and readily compare plans in the federal program.

Checkbook has launched a similar comparison tool for the  Illinois exchange and recently won the Robert Wood Johnson Foundation’s (RWJF) first "Plan Choice Challenge," a nationwide competition to design a technology application that helps people choose their best health plan options.

Navigation technology will make searches simple and quick.  Most consumers don’t want to spend a lot of time comparing plans; they want to find the best buy for their situation as quickly as possible.  That’s why brokers have traditionally encouraged employers to offer their employees a carefully limited set of shopping choices, but we expect plan navigation technology to constantly improve the shopping experience in ways that will help customers search a larger inventory and still make choices more easily.   Stride Health, a San Francisco startup and finalist in the RWJF Challenge, has developed a recommendation technology that searches massive data sets on networks and formularies in seconds to help consumers find a “match” that fits their budget and health care needs.  (Full disclosure – author Joel Ario is an investor).  

Stride is one of more than 40 “web brokers” that has met federal consumer protection and privacy standards enabling it to work with the federal exchange to enroll subsidy-eligible individuals in coverage.  Expect increasing collaboration between public exchanges and private vendors, with a surge of apps and gadgets to make navigation easier and easier in health exchanges.

Technology will allow choices to be tailored to medical history.  Advances in technology won’t just make it technically easier to pick and choose by price and reputation. These advances will also empower Americans to base their choices on their likely medical needs. Today, tailoring your coverage to your medical condition usually means trying to get a doctor– or several doctors– to help you figure out what you should look for in a plan. Even with that help, for the average person it’s still a hit-or-miss proposition. But new forms of choice technology are beginning to utilize questions about medical history to guide buyers towards the plans that are most suited to their condition.  

Checkbook and Stride already allow consumers to enter more detailed health histories and get more sophisticated assistance, and this will only improve as exchanges publish more data in machine readable formats.   Expect more and increasingly sophisticated customized navigators, especially as patients get more access to their electronic medical records.  Also expect sellers to respond with products than bundle services to meet the new demand.

Does this mean that an iPhone app will be all that’s needed to ensure that every consumer can find his or her perfect plan? Not quite.  Health insurance marketplaces will continue to present thorny regulatory challenges.  Insurance regulators will need to guard against unfair practices, such as insurers’ designing benefit plans to drive away applicants with certain health conditions; privacy concerns will be raised whenever apps ask for medical history; and new forms of provider integration will test antitrust doctrine.

But one thing is clear. Improving technology will soon make picking the right health plan a far more precise and simple process – easy enough for many of our children to do on their smart phones or whatever gadget comes next.

Event Information

The Metropolitan Policy Program at Brookings, hosted The Political Geography of America's Purple States: Five Trends That Will Decide the 2008 Election, a briefing on a new series of reports on the political demography of "purple" states in the 2008 election.

Purple states-or states where the current balance of political forces does not decisively favor one party or the other-will play an undeniably pivotal role in the upcoming election and include: Virginia and Florida in the South; the Intermountain West states of Colorado, New Mexico, Nevada, and Arizona; Michigan, Missouri, and Ohio in the Heartland; and Pennsylvania.

On October 10, 2008 at the National Press Club in Washington DC, authors William Frey and Ruy Teixeira highlighted the political and demographic trends in these 10 battleground states, focusing not only on their role in the 2008 election, but their position as toss-ups in years to come.

The session opened with an overview of the demographic shifts shaping all the contested states studied, and evolved into a detailed presentation of the trends that are testing and reshaping the balance of their voting populations, focusing particularly on five trends that Frey and Teixeira believe will decide the 2008 election. Feedback from James Barnes, political correspondent for the National Journal, helped shape the conversation.

Event Materials

• Agenda
• Presentation
• Biographies

For the last several years, the US government has been negotiating a free-trade agreement known as the Trans-Pacific Partnership (TPP) with 11 other countries across the Asia-Pacific and Latin American regions, which could have major impact on the pharmaceutical market.  When finalized it will be the largest free-trade agreement in history, impacting up to one-third of world trade and roughly 40 percent of the global gross domestic product. The deal has attracted a fair share of criticism from a wide range of groups, including concerns over proposed regulations for biologic drugs in participating countries. Specifically, critics are concerned about the length of data exclusivity granted to the companies that hold the patents on these drugs. Below is a primer on biologics and how they are being addressed in the TPP.

Biologic drugs include any therapy derived from a biological source; a group which includes vaccines, anti-toxins, proteins, and monoclonal antibodies. Because they are typically much larger and more structurally complex than traditional ‘small-molecule’ drugs, they are also more difficult—and much more costly—to develop and manufacture. Biologics are also among the most expensive drugs on the market, costing an average of 22 times more than nonbiologic drugs. Avastin, a cancer drug, can cost more than $50,000 a year, while the rheumatoid arthritis drug Remicade can cost up to $2,500 per injection.

Given these high costs, there is substantial interest in encouraging the development of biosimilars, a term used to describe follow-on versions of an original biologic. Estimates of the potential cost savings vary substantially, but some have predicted that competition from biosimilars could reduce US spending on biologics by $44 to $66 billion over the next ten years.  In the European Union, biosimilars have been on the market since 2006, and a 2013 analysis found that, for the 14 biosimilars on the market, the average price discount was about 25 percent. By 2020, the overall cost savings are projected to total $16-$43 billion.

After the Affordable Care Act (ACA) was passed in 2010, the US Food and Drug Administration (FDA) developed an accelerated approval pathway for biosimilars, modeled after the pathway used for the approval of small-molecule generics. In order to meet the criteria for biosimilarity, the drug must share the same mechanism of action for the approved condition of use, and there must be no clinically significant differences between the two drugs in terms of purity, safety, or potency. FDA recently approved its first biosimilar, Zarxio, which is a copy of the oncology drug Neupogen.

Under current FDA regulations, biologic drugs are granted 12 years of data exclusivity following approval. During this period of exclusivity, the FDA may not approve a biosimilar application that relies on the data submitted as part of the original biologic application. This form of temporary monopoly is distinct from patent protection, which is granted well before approval and is not related to clinical data.  Data exclusivity does not prevent another company from generating the data independently, but drug companies are unlikely to go to the considerable (and costly) effort of replicating a full course of clinical trials for a drug that is already on the market. (Though biosimilars may need to undergo some additional clinical testing under current FDA regulations, the amount of data required to support approval would certainly be less than what is required for an original biologic approval.)

The 12-year exclusivity period for biologics was established in the ACA following intense debate, and has continued to attract criticism. (By contrast, the period of data exclusivity is just five years for small-molecule drugs.) Supporters argue that given the greater cost and difficulty of bringing a biologic to market a longer period of exclusivity is necessary to incentivize innovation. Others argue that the resulting restrictions on competition keep drug prices unnecessarily high, inevitably putting a strain on the health system and keeping potentially life-saving drugs out of reach for many patients.

For the 11 countries besides the U.S. that are involved in the TPP, current data exclusivity protections range from zero (Brunei) to eight years (Japan). Under the Obama Administration’s current proposal, participating countries would increase those periods to match the US standard of 12 years. Curiously, this proposal directly contradicts the administration’s ongoing domestic efforts to lower the period of data exclusivity. Since the ACA passed, the Obama administration has repeatedly proposed reducing it to seven, arguing that this would save Medicare $4.4 billion over the next decade. Some have noted that, once the 12-year period is enshrined in the TPP, it will become significantly more difficult to change it through the US legislative process. Furthermore, imposing US standards on the 11 member countries would inevitably restrict competition at the global level, and many patient advocacy and international humanitarian organizations have argued that doing so would undermine the efforts of US global health initiatives like the Vaccine Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria, which rely on price competition to manage program costs.

It is unclear whether the US will be successful in its efforts. There have been reports that the issue of data exclusivity has become a significant point of contention, and the US delegation may seek to compromise on its demands. It may, for example, negotiate exceptions for the poorer countries involved in the negotiation, as the Washington Post notes. However, the details of the negotiations are largely confidential, which makes it challenging to assess the possibilities, their relative advantages, or how the US Trade Representative (which is leading the US negotiations) is balancing the need to ensure adequate incentives for innovation with the need to control drug costs and facilitate patient access to potentially life-saving therapies.

Editor's note: Elizabeth Richardson, a research associate in the Center for Health Policy, contributed to the research and writing of this post. 

If current economic growth trends persist, the “great divergence” between Western Europe and East and South Asia in per capita income that commenced 200 years ago will close sometime this century. Key to the closing will be greater accessibility to technology, higher education in East and South Asia, and the relentless diffusion of knowledge including in the biosciences. Advances in the biosciences are poised to contribute in a major way to English economist Thomas Malthus’s four necessities of human life–food, fiber, fuel, and building materials–as well as to human and animal health, biodiversity conservation, and environmental remediation and sustainability.

As my coauthor Leo Furcht and I recently wrote in “Divergence, Convergence, and Innovation: East-West Bioscience in an Anxious Age”, 21st century history will describe the great economic and technological convergence between East and West. It will also further entwine the economic and ecological storylines of the human experience as the vast populations of China and India strive to enter the middle class. Environmentally sustainable economic growth will require putting knowledge of life code, cellular processes, biosynthesis, and biological regeneration to practical use. That prospect is at hand because the biosciences are in the midst of their own convergence–with information technology, nanotechnology, microelectronics, materials, artificial intelligence, robotics, architecture, and design.

From William Hoffman and Leo Furcht, "The Biologist’s Imagination: Innovation in the Biosciences" (Oxford University Press, 2014)

Biomolecules, brainpower, and Malthusian limits

Products arising from molecular biology constitute a growing share of the global economy with each passing year as technologies evolve, production processes improve, and markets expand. In recent years industrial biotechnology has grown faster than the biologic drugs and agricultural biotech sectors in the U.S.

U.S. biotech revenue in billions of U.S. dollars.
Source: Robert Carlson, "Nature Biotechnology", In press

Industrial biotechnology employs greener and cleaner technologies to make chemicals, solvents, fuels, and materials such as biocomposites and bioplastics. Growth in this sector can weaken the link between economic growth, environmental pollution, and greenhouse gas emissions. Genomics, synthetic biology and metabolic engineering are poised to accelerate growth in the design and manufacture of industrial enzymes and renewable bio-based products. East and South Asian production and consumption of industrial enzymes are on the rise as the Asian middle class expands.

Bioscience is enabling major cereal crops such as wheat, rice, and corn to adapt to a changing climate. Cereal crop yields need to grow by an estimated 70 percent by mid-century to feed the projected nine billion people expected to then inhabit our planet. The challenge of feeding nine billion people without further deforestation and environmental degradation has resurrected the specter of Malthusian limits to our planet’s ecological carrying capacity. These limits are expressed in food and water shortages, forced migrations, political instability, armed conflict, abatement and cleanup activities, and health care related to pollution and climate change. Even with the powerful tools of food crop bioscience–marker-assisted selection, targeted mutation-selection, genetic modification, and others–maintaining crop production levels at expected higher temperatures and with less water is highly questionable.

Precise genomic editing of cereal grains could equip rice, wheat, and corn with nitrogen fixation capabilities, thus reducing the need for synthetic fertilizers with their environmental and atmospheric costs. East and South Asia, facing major food production challenges, ecological limits, pollution from fertilizer use, and drought from climate change, may take the lead over the West in adopting innovative food crop technologies.

Meanwhile, hundreds of thousands of human beings of many ethnicities have had their genomes decoded over the past decade, with the number expected to increase exponentially as sequencing technologies grow in productivity and decline in price. Genomic information coupled with precise genomic editing and bioregenerative tools give us unprecedented power to shape the course of evolution, including our own.

Cost trend of sequencing a human-sized genome and Moore’s Law 2001 – 2015.
Source: Kris A. Wetterstrand, DNA Sequencing Costs: Data from the NHGRI Genome Sequencing Program.

The practice of technological innovation in the industrial era – the systematic application of ideas, inventions and technology to markets, trade, and social systems–is now being joined with the code of life, DNA, and the basic unit of life, the cell. Even as the economic gap between East and West narrows, no other convergence has such profound implications for our future and the future health of living systems and ecosystems. That makes the task for policymakers a daunting one.

During his presentation at the University of Michigan/Urban Land Institute Real Estate Forum, Christopher B. Leinberger discusses the impact walkable urbane places has and will have on metropolitan development patterns, the market reasons for this change and how to strategically manage it.

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On Thursday, when former Secretary of State Hillary Rodham Clinton appears before the Senate Benghazi Committee for a new round of hearings, reporters with vivid historical imaginations will be pining for an epic battle. Melodramatic journalists may recall the 1950-1951 Kefauver Committee investigating organized crime, which introduced politicized television dramas to millions of Americans. They may evoke the 1954 Army-McCarthy hearings, when the aristocratic Boston lawyer Joseph Welch cold-cocked the anti-communist Senator Joe McCarthy by asking: “Have you no sense of decency, sir, at long last? Have you left no sense of decency?” They will yearn for the constitutional grandeur of the 1973 Senate Watergate hearings, which exposed Richard Nixon’s corruption. Alas, most likely, we will endure yet another round of the 1990s’ tawdry Clinton follies, which diminished both parties and helped trigger our current political depression.

Although Hillary Clinton often performs well under pressure and probably has rehearsed a dramatic soundbite or two to rile her partisan base, these hearings are bad news for her campaign. The email server scandal has gotten more traction than the Clintonites would have expected. It stirs fears that both Hillary and Bill Clinton are so convinced of their own goodness, their own idealism, their own contributions to the public good, that they exempt themselves from the rules ordinary Americans must follow. The scandal also reminds many of the Clintons’ moral blindspot, their ethical sloppiness that led them into the cozy, overlapping, ambiguities, and occasional lies behind the Whitewater mess, the Travelgate coverup, the Paula Jones sexual harassment, the Monica Lewinsky obstruction of justice, and a host of lesser Clinton catastrophes.

Many Americans had Clinton fatigue by 2000, despite Clinton’s record high approval ratings. And with our Canadian neighbors just having voted in Justin Trudeau due to Stephen Harper fatigue, Hillary Clinton should remember that American voters want a fresh start after enduring a decade and a half of terrorist fears and economic woes, preceded by a scadal-plagued, hyper-partisan period of peace and prosperity in the 1990s.

Democrats also should worry that Hillary Clinton’s best defense is pretty offensive. She will play the partisan card. In the final question of the Democratic debate, Anderson Cooper asked “Which enemy are you most proud of?” Hillary Clinton answered: “Well, in addition to the NRA, the health insurance companies, the drug companies, the Iranians. Probably the Republicans.” In his presidential announcement-esque I’m-not-running speech Vice President Joe Biden pointedly said: “I don’t think we should look at Republicans as our enemies.” How does a candidate who compares Republicans to Iranians woo centrist voters in crucial swing states? And you can imagine the general campaign commercials asking: How does a president who demonizes her rivals work with them after Election Day?

Republicans should not be too cocky about these hearings either. The male senators pounding away at millions of American women’s best chance at a female president should beware the Anita Hill effect. During the 1991 fight over the sexual harassment allegations during Clarence Thomas’s Supreme Court nomination hearings, hostile senators interrogating Thomas’s female accuser looked like bullies who, in the parlance of the time, “just didn’t get it.” For the last six years, the Democrats have cleverly cast the Republicans as the party of no. In the 1990s, the Clintons cleverly cast the Republicans as a party of Ken Starrs, prosecutorial prigs abusing congressional and federal powers to subvert the political process and undermine the Constitution.

Moreover, Hillary Clinton’s defense during the last set of hearings more accurately reflects the public mood. Four brave Americans died. Their Islamist terrorist murderers are the guilty ones, not whatever mistaken spin the Obama administration may or may not have put on it subsequently.

Since the 1990s, gotcha journalism and politics have ruined politicians’ reputations and soured Americans on politics. Unlike the Watergate scandal, which produced heroes defending the Constitution like Judge John Sirica and Senator Sam Ervin, the Clinton scandals, and especially the Monica Lewinsky debacle, tarnished everyone involved. Journalists and Republicans looked like bullies, invading people’s privacy, treating personal indiscretions as high crimes not even misdemeanors. Feminists and Democrats sounded like hypocrites, excusing sexual harassment and the White House as a hostile workplace for women as long as the perpetrator was a pro-choice liberal. The people’s business suffered. In post Watergate America, the Pig-Pen-like cloud shrouding the Clintons, and their supporters’ “everybody does it” defense, had once naïve Americans now cynically grumbling, “they’re all guilty of something.”

Inevitably, after the Thursday hearings, too many Republicans and Democrats will assess the results based on quickie polls suggesting who “won” or “lost” the exchange, and whether Hillary Clinton’s popularity rises or falls. Washington should start tracking a different set of poll results. Back in the 1950s and the 1960s, the vast majority of Americans trusted their government. The most recent Gallup poll has only 19 percent of Americans surveyed agreeing that “you can trust government to do what is right.” Those metrics suggested that both Democrats and Republicans, all the presidential candidates, the president, Congress, and the Supreme Court, have disappointed the American people. A healthy democracy needs citizens with more faith in their government, we don’t need more recriminations, the criminalizing of politics, or more partisan clashes. Perhaps it is time for Senate Republicans to join Democrats in creating a bipartsan committee to investigate that problem, and begin by inviting all presidential candidates to testify about what they will do to make Americans believe in Washington again.

It’s easy to imagine a future in a decade or less when most people will have a smartphone. In our recent paper Pathways to Smarter Digital Financial Inclusion, we explore the benefits of extending financial services to the mass of lower-income people in developing countries who are currently dubious of the value that financial services can bring to them, distrustful of formal financial institutions, or uncomfortable with the treatment they expect to receive.

The report analyzes six inherent characteristics of smartphones that have the potential to change market dynamics relative to the status quo of simple mobile phones and cards. 

Customer-Facing Changes:

1. The graphical user interface.
2. The ability to attach a variety of peripheral devices to it (such as a card reader or a small printer issuing receipts).
3. The lower marginal cost of mobile data communications relative to traditional mobile channels (such as SMS or USSD).

Service Provider Changes:

4. Greater freedom to program services without requiring the acquiescence or active participation of the telco.
5. Greater flexibility to distribute service logic between the handset (apps) and the network (servers).
6. More opportunities to capture more customer data with which to enhance customer value and stickiness.

Taken together, these changes may lower the costs of designing for lower-income people dramatically, and the designs ought to take advantage of continuous feedback from users. This should give low-end customers a stronger sense of choice over the services that are relevant to them, and voice over how they wish to be served and treated.

Traditionally poor people have been invisible to service providers because so little was known about their preferences that it was not possible build a service proposition or business case around them. The paper describes three pathways that will allow providers to design services on smartphones that will enable an increasingly granular understanding of their customers. Each of the three pathways offers providers a different approach to discover what they need to know about prospective customers in order to begin engaging with them. 

Pathway One: Through Big Data

Providers will piece together information on potential low-income customers directly, by assembling available data from disparate sources (e.g. history of airtime top-ups and bill payment, activity on online social networks, neighborhood or village-level socio-demographic data, etc.) and by accelerating data acquisition cycles (e.g. inferring behavior from granting of small loans in rapid succession, administering selected psychometric questions, or conducting A/B tests with special offers). There is a growing number of data analytics companies that are applying big data in this way to benefit the poor.

Pathway Two: Through local Businesses

Smartphones will have a special impact on micro and small enterprises, which will see increasing business benefits from recording and transacting more of their business digitally. As their business data becomes more visible to financial institutions, local firms will increasingly channel financial services, and particularly credit, to their customers, employees, and suppliers. Financial institutions will backstop their credit, which in effect turns smaller businesses into front-line distribution partners into local communities.

Pathway Three: Through Socio-Financial Networks

Firms view individuals primarily as managers of a web of socio-financial relationships that may or may not allow them access to formal financial services. Beyond providing loans to “creditworthy” people, financial institutions can provide transactional engines, similar to the crowdfunding platforms that enable all people to locate potential funding sources within their existing social networks. A provider equipped with appropriate network analysis tools could then promote rather than displace people´s own funding relationships and activities. This would provide financial service firms valuable insight into how people manage their financial needs.

The pathways are intended as an exploration of how smartphones could support the development of a healthier and more inclusive digital financial service ecosystem, by addressing the two critical deficiencies of the current mass-market digital finance systems. Smartphones could enable stronger customer value propositions, leading to much higher levels of customer engagement, leading to more revelation of customer data and more robust business cases for the providers involved. Mobile technology could also lead to a broader diversity of players coming into the space, each playing to their specific interests and contributing their specific set of skills, but together delivering customer value through the right combination of collaboration and competition.

Politicians and scholars often lament the persistence of poverty across generations. But affluence persists, too. In the U.S. especially, the top of the income distribution is just as “sticky”, in intergenerational terms, as the bottom. The American upper middle class is reproducing itself quite effectively.

Class reproduction is of course driven by a whole range of factors, from parenting and family structure through formal education, informal learning, the use of social networks, and so on. Some are unfair: playing the legacy card in college admissions, securing internships via closed social networks, zoning out lower-income families from our neighborhoods and school catchment areas. (These “opportunity hoarding” mechanisms are the focus of my forthcoming book, Dream Hoarders.)

It is natural and laudable for parents to want their children to prosper. It is also understandable that they’ll use the resources and means at their disposal to try to reduce the chances of their children being downwardly mobile. They are likely to try even harder if the drop looks big, in economic terms.

There is a significant earnings gap between those at the top and those in the middle. But this gap is much bigger in the U.S. than in other nations, and is getting bigger over time:

The cost of falling reflects the particular way in which income inequality has risen in recent years: namely, at the top of the distribution. The relationship between income inequality and intergenerational mobility is a much-disputed one, as regular readers of this blog know well. Overall, the evidence for a “Great Gatsby Curve” is quite weak.

But at the top of the distribution, there could be some incentive effects linking inequality and immobility. As the income gap has widened at the top, the consequences of falling out of the upper middle class have worsened. So the incentives of the upper middle class to keep themselves, and their children, up at the top have strengthened. It looks like a long drop, because it is.

Upper middle class Americans do seem worried. In 2011, while around half of American adults making less than $30,000 per year agreed that “today’s children will lead a better life than their parents,” only 37 percent of those making $75,000 or more were as optimistic.

The greater spending of upper middle class parents on “enrichment activities” is well known; recent evidence suggests the Great Recession did nothing to reduce it. American upper middle class parents are desperate to secure their children a high position on the earnings ladder. This makes sense, given the consequences of downward mobility for their economic fortunes. Inequality incentivizes opportunity hoarding, which reduces social mobility. Time, perhaps, to lower the stakes a little?

ABSTRACT

This study analyzes the willingness to pay for health insurance and hence the potential market for new low-cost health insurance product in Namibia, using the double bounded contingent valuation (DBCV) method. The findings suggest that 87 percent of the uninsured respondents are willing to join the proposed health insurance scheme and on average are willing to insure 3.2 individuals (around 90 percent of the average family size). On average respondents are willing to pay NAD 48 per capita per month and respondents in the poorest income quintile are willing to pay up to 11.4 percent of their income. This implies that private voluntary health insurance schemes, in addition to the potential for protecting the poor against the negative financial shock of illness, may be able to serve as a reliable income flow for health care providers in this setting.

Read the full paper on ScienceDirect »

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.