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Oil Markets Provide a Glimpse of the Post-Pandemic Future

Henry Kissinger warns that many existing domestic and international institutions that have helped govern the past decades will not survive the Covid-19 crisis. He is surely correct.




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Oil Markets Provide a Glimpse of the Post-Pandemic Future

Henry Kissinger warns that many existing domestic and international institutions that have helped govern the past decades will not survive the Covid-19 crisis. He is surely correct.




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How Clean is the U.S. Steel Industry? An International Benchmarking of Energy and CO2 Intensities

In this report, the authors conduct a benchmarking analysis for energy and CO2 emissions intensity of the steel industry among the largest steel-producing countries.




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Geopolitical and Market Implications of Renewable Hydrogen: New Dependencies in a Low-Carbon Energy World

To accelerate the global transition to a low-carbon economy, all energy systems and sectors must be actively decarbonized. While hydrogen has been a staple in the energy and chemical industries for decades, renewable hydrogen is drawing increased attention today as a versatile and sustainable energy carrier with the potential to play an important piece in the carbon-free energy puzzle. Countries around the world are piloting new projects and policies, yet adopting hydrogen at scale will require innovating along the value chains; scaling technologies while significantly reducing costs; deploying enabling infrastructure; and defining appropriate national and international policies and market structures.

What are the general principles of how renewable hydrogen may reshape the structure of global energy markets? What are the likely geopolitical consequences such changes would cause? A deeper understanding of these nascent dynamics will allow policy makers and corporate investors to better navigate the challenges and maximize the opportunities that decarbonization will bring, without falling into the inefficient behaviors of the past.




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Illuminating Homes with LEDs in India: Rapid Market Creation Towards Low-carbon Technology Transition in a Developing Country

This paper examines a recent, rapid, and ongoing transition of India's lighting market to light emitting diode (LED) technology, from a negligible market share to LEDs becoming the dominant lighting products within five years, despite the country's otherwise limited visibility in the global solid-state lighting industry.




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Oil Markets Provide a Glimpse of the Post-Pandemic Future

Henry Kissinger warns that many existing domestic and international institutions that have helped govern the past decades will not survive the Covid-19 crisis. He is surely correct.




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How Clean is the U.S. Steel Industry? An International Benchmarking of Energy and CO2 Intensities

In this report, the authors conduct a benchmarking analysis for energy and CO2 emissions intensity of the steel industry among the largest steel-producing countries.




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Geopolitical and Market Implications of Renewable Hydrogen: New Dependencies in a Low-Carbon Energy World

To accelerate the global transition to a low-carbon economy, all energy systems and sectors must be actively decarbonized. While hydrogen has been a staple in the energy and chemical industries for decades, renewable hydrogen is drawing increased attention today as a versatile and sustainable energy carrier with the potential to play an important piece in the carbon-free energy puzzle. Countries around the world are piloting new projects and policies, yet adopting hydrogen at scale will require innovating along the value chains; scaling technologies while significantly reducing costs; deploying enabling infrastructure; and defining appropriate national and international policies and market structures.

What are the general principles of how renewable hydrogen may reshape the structure of global energy markets? What are the likely geopolitical consequences such changes would cause? A deeper understanding of these nascent dynamics will allow policy makers and corporate investors to better navigate the challenges and maximize the opportunities that decarbonization will bring, without falling into the inefficient behaviors of the past.




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Illuminating Homes with LEDs in India: Rapid Market Creation Towards Low-carbon Technology Transition in a Developing Country

This paper examines a recent, rapid, and ongoing transition of India's lighting market to light emitting diode (LED) technology, from a negligible market share to LEDs becoming the dominant lighting products within five years, despite the country's otherwise limited visibility in the global solid-state lighting industry.




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How Clean is the U.S. Steel Industry? An International Benchmarking of Energy and CO2 Intensities

In this report, the authors conduct a benchmarking analysis for energy and CO2 emissions intensity of the steel industry among the largest steel-producing countries.




mark

Geopolitical and Market Implications of Renewable Hydrogen: New Dependencies in a Low-Carbon Energy World

To accelerate the global transition to a low-carbon economy, all energy systems and sectors must be actively decarbonized. While hydrogen has been a staple in the energy and chemical industries for decades, renewable hydrogen is drawing increased attention today as a versatile and sustainable energy carrier with the potential to play an important piece in the carbon-free energy puzzle. Countries around the world are piloting new projects and policies, yet adopting hydrogen at scale will require innovating along the value chains; scaling technologies while significantly reducing costs; deploying enabling infrastructure; and defining appropriate national and international policies and market structures.

What are the general principles of how renewable hydrogen may reshape the structure of global energy markets? What are the likely geopolitical consequences such changes would cause? A deeper understanding of these nascent dynamics will allow policy makers and corporate investors to better navigate the challenges and maximize the opportunities that decarbonization will bring, without falling into the inefficient behaviors of the past.




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Illuminating Homes with LEDs in India: Rapid Market Creation Towards Low-carbon Technology Transition in a Developing Country

This paper examines a recent, rapid, and ongoing transition of India's lighting market to light emitting diode (LED) technology, from a negligible market share to LEDs becoming the dominant lighting products within five years, despite the country's otherwise limited visibility in the global solid-state lighting industry.




mark

How Clean is the U.S. Steel Industry? An International Benchmarking of Energy and CO2 Intensities

In this report, the authors conduct a benchmarking analysis for energy and CO2 emissions intensity of the steel industry among the largest steel-producing countries.




mark

Geopolitical and Market Implications of Renewable Hydrogen: New Dependencies in a Low-Carbon Energy World

To accelerate the global transition to a low-carbon economy, all energy systems and sectors must be actively decarbonized. While hydrogen has been a staple in the energy and chemical industries for decades, renewable hydrogen is drawing increased attention today as a versatile and sustainable energy carrier with the potential to play an important piece in the carbon-free energy puzzle. Countries around the world are piloting new projects and policies, yet adopting hydrogen at scale will require innovating along the value chains; scaling technologies while significantly reducing costs; deploying enabling infrastructure; and defining appropriate national and international policies and market structures.

What are the general principles of how renewable hydrogen may reshape the structure of global energy markets? What are the likely geopolitical consequences such changes would cause? A deeper understanding of these nascent dynamics will allow policy makers and corporate investors to better navigate the challenges and maximize the opportunities that decarbonization will bring, without falling into the inefficient behaviors of the past.




mark

Illuminating Homes with LEDs in India: Rapid Market Creation Towards Low-carbon Technology Transition in a Developing Country

This paper examines a recent, rapid, and ongoing transition of India's lighting market to light emitting diode (LED) technology, from a negligible market share to LEDs becoming the dominant lighting products within five years, despite the country's otherwise limited visibility in the global solid-state lighting industry.




mark

How Clean is the U.S. Steel Industry? An International Benchmarking of Energy and CO2 Intensities

In this report, the authors conduct a benchmarking analysis for energy and CO2 emissions intensity of the steel industry among the largest steel-producing countries.




mark

Geopolitical and Market Implications of Renewable Hydrogen: New Dependencies in a Low-Carbon Energy World

To accelerate the global transition to a low-carbon economy, all energy systems and sectors must be actively decarbonized. While hydrogen has been a staple in the energy and chemical industries for decades, renewable hydrogen is drawing increased attention today as a versatile and sustainable energy carrier with the potential to play an important piece in the carbon-free energy puzzle. Countries around the world are piloting new projects and policies, yet adopting hydrogen at scale will require innovating along the value chains; scaling technologies while significantly reducing costs; deploying enabling infrastructure; and defining appropriate national and international policies and market structures.

What are the general principles of how renewable hydrogen may reshape the structure of global energy markets? What are the likely geopolitical consequences such changes would cause? A deeper understanding of these nascent dynamics will allow policy makers and corporate investors to better navigate the challenges and maximize the opportunities that decarbonization will bring, without falling into the inefficient behaviors of the past.




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Illuminating Homes with LEDs in India: Rapid Market Creation Towards Low-carbon Technology Transition in a Developing Country

This paper examines a recent, rapid, and ongoing transition of India's lighting market to light emitting diode (LED) technology, from a negligible market share to LEDs becoming the dominant lighting products within five years, despite the country's otherwise limited visibility in the global solid-state lighting industry.




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Massa lowers benchmark as McLaren hits more trouble

Felipe Massa showed the first tangible proof of Williams' potential this year by topping the times on the opening day of the final pre-season test in Barcelona as McLaren experienced more problems and Mercedes also suffered a rare reliability issue




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Oil Markets Provide a Glimpse of the Post-Pandemic Future

Henry Kissinger warns that many existing domestic and international institutions that have helped govern the past decades will not survive the Covid-19 crisis. He is surely correct.




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Red Bull's Marko wins €400 Vettel bet in Malaysia

Red Bull motorsport advisor Helmut Marko left the Malaysian Grand Prix €400 richer after an astute bet - on former protégé Sebastian Vettel winning the race in his Ferrari




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How Clean is the U.S. Steel Industry? An International Benchmarking of Energy and CO2 Intensities

In this report, the authors conduct a benchmarking analysis for energy and CO2 emissions intensity of the steel industry among the largest steel-producing countries.




mark

Geopolitical and Market Implications of Renewable Hydrogen: New Dependencies in a Low-Carbon Energy World

To accelerate the global transition to a low-carbon economy, all energy systems and sectors must be actively decarbonized. While hydrogen has been a staple in the energy and chemical industries for decades, renewable hydrogen is drawing increased attention today as a versatile and sustainable energy carrier with the potential to play an important piece in the carbon-free energy puzzle. Countries around the world are piloting new projects and policies, yet adopting hydrogen at scale will require innovating along the value chains; scaling technologies while significantly reducing costs; deploying enabling infrastructure; and defining appropriate national and international policies and market structures.

What are the general principles of how renewable hydrogen may reshape the structure of global energy markets? What are the likely geopolitical consequences such changes would cause? A deeper understanding of these nascent dynamics will allow policy makers and corporate investors to better navigate the challenges and maximize the opportunities that decarbonization will bring, without falling into the inefficient behaviors of the past.




mark

Illuminating Homes with LEDs in India: Rapid Market Creation Towards Low-carbon Technology Transition in a Developing Country

This paper examines a recent, rapid, and ongoing transition of India's lighting market to light emitting diode (LED) technology, from a negligible market share to LEDs becoming the dominant lighting products within five years, despite the country's otherwise limited visibility in the global solid-state lighting industry.




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Abhijit Iyer-Mitra's arrested for 'derogatory' remarks: Many condemn Odisha govt's move

Arrest
Abhijit Iyer-Mitra was arrested for his alleged derogatory remarks against the Sun Temple and Odisha culture.
Security analyst and columnist Abhijit Iyer-Mitra was arrested on Tuesday for his alleged derogatory remarks against the Sun Temple and Odisha culture. The Commissionerate Police arrested Abhijit after hours of interrogation at an undisclosed location in Bhubaneswar. Police Commissioner Satyajit Mohanty said Abhijit was arrested in connection with a criminal case registered against him at Saheed Nagar Police Station on September 20. He has been booked under IP63C Sections 294, 295A, 153A, 500, 506 and Section 67 of the Information Technology Act. He also appeared before a House Committee of Odisha Assembly on Tuesday and tendered an unconditional apology for his derogatory remarks on legislators. The House panel, headed by leader of opposition Narasingh Mishra, asked Abhijit to re-appear on November 2 and submit an affidavit. "Abhijit Iyer-Mitra admitted to the charges levelled against him and offered an unconditional apology for his 'stupidity'. He has been directed to depose before the Committee and submit an affidavit in this regard," said Mishra. "After examining his affidavit, the panel will decide whether to accept his apology or not. Accordingly, the Committee will then recommend to the House to take action against him, if necessary," he said. Abhijit was questioned about the alleged breach of privilege. Many have condemned his arrest, terming it "a zone where freedom is in danger, and an "Orwellian nightmare". Dear Prime Minister @narendramodi, quite admirable that you are active on social media. So I am sure you are aware that in India one can get arrested, like my friend @Iyervval, for a tweet on the origin of Rasagola. That's the democracy & freedom we Indians enjoy under your govt. https://t.co/Hg9kd3pAAe — Aarti Tikoo Singh (@AartiTikoo) October 24, 2018 We're slipping into a zone where #freedom is in danger. It's outrageous that Abhijit Iyer-Mitra @Iyervval has been arrested by #Odisha Police on risible charges and denied bail. Please read and circulate my protest and appeal. Fight for your, his and everybody's liberty. #India pic.twitter.com/gbuHebzI8g — Kanchan Gupta (@KanchanGupta) October 24, 2018 Absurd, vindictive, to jail @iyervval for 14 days over a rosogolla-origin tweet. He's a shock-jock, but trawling through his year-old tweets to fuel specious outrage charges is an illustration of how much is wrong with India's FoE laws.https://t.co/TQZTh05PDW — Nilanjana Roy (@nilanjanaroy) October 24, 2018 .@Iyervval has been arrested by Odisha over a tweet about rasgolas. Read that again. Yes. Does this country have a reset button?https://t.co/wfBXqi5JgH — Kabir Taneja (@KabirTaneja) October 24, 2018 #AbhijitIyerMitra (@Iyervval) got arrested in Odisha for a conversation he had a year ago on SM about the origin of Rasogola! Yes, it's 2018 and you read it right, Rasagola. This is beyond bizarre!!https://t.co/ZGzeuI2fEy — Viju Cherian (@vijucherian) October 24, 2018 This is absurd, we are descending into some Orwellian nightmare. The man is known for his viciousness on social media but he can’t be targeted like this. https://t.co/nAkJqnwSpY — Rammanohar Reddy (@ramreddy) October 23, 2018 We are a banana republic. So much for India being a secular democracy . Shame ! #istandwithabhijit https://t.co/yhN95j5T4K — Naveen Suresh (@NavSuresh) October 24, 2018 This nonsense with @Iyervval has got to stop. His comments are often bigoted and silly and he knows it but mouthing off shouldn't be cause for arrest. Fighting over the origins of rasagola? How about over the success or otherwise of #MakeInIndia instead?https://t.co/EP4kxnYxmE — Jabin T Jacob 鄭嘉賓 (@jabinjacobt) October 25, 2018 He had earlier been summoned to appear before the panel on October 11, which he had skipped. He was summoned again to appear on October 23. Odisha Assembly Speaker Pradip Amat had on September 20 constituted a House Committee to probe the journalist's alleged derogatory remarks against the state and its lawmakers. Abhijit had on September 16 posted a video on Twitter criticising the Konark temple. Later, he went on to make the alleged derogatory remarks against Odisha and its culture. Two FIRs were registered against him at Konark and Saheed Nagar police stations for his remarks. Last month, the Odisha Police arrested the columnist in New Delhi for his anti-Odisha comments. However, he was given conditional bail by a local court in Delhi. Later, the Supreme Court rejected his bail plea saying his comments 'incited religious sentiments'. With IANS inputs




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Ferrari fans mark Schumacher's birthday with vigil

Ferrari fans have marked Michael Schumacher's birthday with a vigil outside the hospital where he is being treated in Grenoble




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How Clean is the U.S. Steel Industry? An International Benchmarking of Energy and CO2 Intensities

In this report, the authors conduct a benchmarking analysis for energy and CO2 emissions intensity of the steel industry among the largest steel-producing countries.




mark

Geopolitical and Market Implications of Renewable Hydrogen: New Dependencies in a Low-Carbon Energy World

To accelerate the global transition to a low-carbon economy, all energy systems and sectors must be actively decarbonized. While hydrogen has been a staple in the energy and chemical industries for decades, renewable hydrogen is drawing increased attention today as a versatile and sustainable energy carrier with the potential to play an important piece in the carbon-free energy puzzle. Countries around the world are piloting new projects and policies, yet adopting hydrogen at scale will require innovating along the value chains; scaling technologies while significantly reducing costs; deploying enabling infrastructure; and defining appropriate national and international policies and market structures.

What are the general principles of how renewable hydrogen may reshape the structure of global energy markets? What are the likely geopolitical consequences such changes would cause? A deeper understanding of these nascent dynamics will allow policy makers and corporate investors to better navigate the challenges and maximize the opportunities that decarbonization will bring, without falling into the inefficient behaviors of the past.




mark

Illuminating Homes with LEDs in India: Rapid Market Creation Towards Low-carbon Technology Transition in a Developing Country

This paper examines a recent, rapid, and ongoing transition of India's lighting market to light emitting diode (LED) technology, from a negligible market share to LEDs becoming the dominant lighting products within five years, despite the country's otherwise limited visibility in the global solid-state lighting industry.




mark

How did COVID-19 disrupt the market for U.S. Treasury debt?

The COVID-19 pandemic—in addition to posing a severe threat to public health—has disrupted the economy and financial markets, and prompted a strong desire among investors for safe and liquid securities. In that environment, one might expect U.S. Treasury securities to be the investment of choice, but for a while in March, the $18 trillion market…

       




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Oil Markets Provide a Glimpse of the Post-Pandemic Future

Henry Kissinger warns that many existing domestic and international institutions that have helped govern the past decades will not survive the Covid-19 crisis. He is surely correct.




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On April 13, 2020, Suzanne Maloney discussed “Why the Middle East Matters” via video conference with IHS Markit.  

On April 13, 2020, Suzanne Maloney discussed "Why the Middle East Matters" via video conference with IHS Markit.

       




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Webinar: A conversation with Secretary of Defense Mark T. Esper

The COVID-19 pandemic is among the most serious challenges confronting the globe since World War II. Its projected human and economic costs are devastating. While the armed forces of the United States will rise to this challenge as they have others, the Department of Defense will not stop planning for long-term threats to America's security,…

       




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Health care market consolidations: Impacts on costs, quality and access


Editor's note: On March 16, Paul B. Ginsburg testified before the California Senate Committee on Health on fostering competition in consolidated markets. Download the full testimony here.

Mr. Chairman, Madame Vice Chairman and Members of the Committee, I am honored to be invited to testify before this committee on this very important topic. I am a professor of health policy at the University of Southern California and director of public policy at the USC Schaeffer Center for Health Policy and Economics. I am also a Senior Fellow and the Leonard D. Schaeffer Chair in Health Policy Studies at The Brookings Institution, where I direct the Center for Health Policy. Much of my time is now devoted to leading the new Schaeffer Initiative for Innovation in Health Policy, which is a partnership between USC and the Brookings Institution. I am best known in California for the numerous community site visits over many years that I led in the state while I was president of the Center for Studying Health System Change; most of those studies were funded by the California HealthCare Foundation.

The key points in my testimony today are:

    • Health care markets are becoming more consolidated, causing price increases for purchasers of health services, and this trend will continue for the foreseeable future despite anti-trust enforcement; 
    • Government can still play an effective role in addressing higher prices that come from consolidation by pursuing policies that foster increased competition in health care markets. Many of these policies can be effective even in markets with high degrees of concentration, such as in Northern California.

Consolidation in health care has been increasing for some time and is now quite extensive in many markets. Some of this comes from mergers and acquisitions, but an important part also comes from larger organizations gaining market share from smaller competitors. The degree of consolidation varies by market. In California, most observers believe that metropolitan areas in the northern part of the state have provider markets that are far more consolidated than those in the southern part of the state. Insurer markets tend to be statewide and are less consolidated than those in many other states. The research literature on hospital mergers is now substantial and shows that mergers lead to higher prices, although without any measured impact on quality.[1]

The trend is accelerating for reasons that are apparent. For providers, it is becoming an increasingly challenging environment to be a small hospital or medical practice. There is more pressure on payment rates. New contracting models, such as Accountable Care Organizations (ACOs), tend to require more scale. The system is going through a challenging transition to electronic medical records, which is expensive and requires specialized expertise to avoid pitfalls. Lifestyle choices by younger physicians lead them to pursue employment in large organizations rather than solo ownerships or partnerships in small practices.

The environment is also challenging for small insurers. Multi-state employers prefer to contract with insurers that can serve all of their employees throughout the country. Scale economies are important in building the analytic capabilities that hold so much promise for effectively managing care. Insurer scale is important to make it worthwhile for providers to contract with them under alternative payment models. The implication of these trends is an expectation of increasing consolidation. There is need for both public and private sector initiatives in addition to anti-trust enforcement to foster greater competition on price and quality.

How can competition be fostered? For the insurance market, public exchanges created under the Affordable Care Act (ACA) and private insurance exchanges that serve employers can foster competition among insurers in a number of ways. Exchanges reduce entry barriers by reducing the fixed costs of getting an insurer’s products in front of potential customers. Building a brand is less important when your products will be presented to consumers on an exchange along with information on the benefit design, the actuarial value and the provider network. Exchanges make it easier for consumers to make informed choices across plans. This, in turn, makes the insurance market more competitive. Among public exchanges, Covered California has stood out for making this segment of the insurance market more competitive and helping consumers make choices that are better informed.

The rest of my statement is devoted to fostering competition among providers. I believe that fostering competition among providers is a higher priority because the consequences of lack of competition are potentially larger. In addition, a significant regulatory tool, minimum medical loss ratios, part of the ACA, is now in place and can limit the degree to which purchasers pay too much for health insurance in markets with insufficient competition.

Fostering competition in provider markets involves two prongs—broadened anti-trust policy and other policies to foster market forces. Anti-trust policy, at least at the federal level, to date has not addressed hospital acquisitions of physician practices. These acquisitions lead to higher prices to physicians because hospitals can negotiate higher prices for their employed physicians than the physicians were getting in small practices. Although not yet extensive, a developing research literature is measuring the price impact.[2] Hospital employment of physicians can also be a barrier to physicians steering patients to high-value providers (another hospital or a freestanding provider). To the degree that it reduces the chance of larger physician groups or independent practice associations forming, hospital employment of physicians reduces potential competitors in contracting under alternative payment models.

Another area not addressed by anti-trust policy is cross-market mergers. The concern is that a “must have” hospital in a multi-market system could lead to higher rates for system hospitals elsewhere. Anti-trust enforcement agencies have tended to look at markets separately, so this issue tends not to enter their analyses.

Many have seen price and quality transparency as a tool to foster competition among providers. Clearly, transparency has become a societal value and people increasingly expect more information about organizations that are important to them in both the public and private sector. But transparency is often oversold as a strategy to foster competition in health care provider markets. For one thing, many benefit designs have few incentives to favor providers with lower prices. Copays are the same for all providers and with coinsurance, the insurer covers most of the price difference. Even high deductibles are limited in their incentives because almost all in-patient stays exceed large deductibles and out-of-pocket maximums also come into play for many who are hospitalized. Another issue is that the complexity of comparing prices is a “heavy lift” for many consumers. Insurers and employers now have excellent web tools designed to make it easier for patients to compare prices, but indications are that the tools do not get a lot of use.

Network strategies have the potential to be more effective. The concept behind them is that the insurer is acting as a purchasing agent for enrollees. To the extent that they have the potential to shift volume from high-priced providers to low-priced providers, money can be saved in three distinct ways. The first is the higher proportion of services coming from lower-priced providers. The second is the additional discounts from providers seeking to become part of the limited or preferred network. Finally, if a large enough proportion of patients are enrolled in plans with these incentives, providers will likely increase the priority given to cost containment. In creating networks, insurers are increasingly using broader and more sophisticated measures of price as well as some measures of quality. Cost per patient per year or cost for all services involved in an episode is likely to have more relevance than unit prices. Using such measures to judge providers for networks has strong analytic parallels to reformed payment approaches, such as ACOs and bundled payments for episodes of care. Network strategies also create more opportunities for integration of care. For example, a limited network or a preferred tier in a broader network could be mostly limited to providers affiliated with a large health care system. Indeed, some health systems are developing their own health plan or partnering with an insurer to offer plans that favor their own providers.

In this testimony, I discuss two distinct network strategies. One is the limited network, which includes fewer providers than has been the norm in private insurance. The other is the tiered network, where the network is broad but a subset of providers are included in a preferred tier. Patients pay less in cost sharing when they use the preferred providers. Limited networks are a more powerful tool to obtain lower prices because patient incentives are stronger. If patients opt for a provider not in the limited network, they are subject to higher cost sharing and might have to pay the provider the difference between the charge and what the plan allows. Results of these stronger incentives are seen in a number of studies by McKinsey and Co. that have shown that on the public exchanges, limited network plans have premiums about 15 percent lower than plans with broader networks.

Public and private exchanges are an ideal environment for limited network plans. The fixed contributions or subsidies to purchase coverage mean that consumers’ incentives to choose a plan with a lower premium are not diluted—they save the full difference in premium. Exchanges do not have the “one size fits all” requirement that constrains many employers in using this strategy. If an employer is offering only one or two plans, it is important that an overwhelming majority of employees find the network acceptable. But a limited network on an exchange could appeal to fewer than half of those purchasing on the exchange and still be very successful. In addition, tools provided by exchanges to support consumers facilitate comparisons of plans by having each plan’s network accessible on a single web site.

In contrast, tiered networks have the potential to appeal to a larger consumer audience. Rather than making annual choices of which providers can be accessed in network, tiered networks allow these decisions on a point-of-service basis. So the consumer always has the option to draw on the full network. Considering the greater popularity of PPOs than HMOs and the fact that tiered formularies for prescription drugs are far more popular than closed formularies, the potential market for tiered networks might be much larger. But this has not happened. In many markets, dominant providers have blocked the offering of tiered networks by refusal to contract with insurers that do not place them in the preferred tier. This phenomenon was seen in Massachusetts, where 2010 legislation prohibiting this practice led to rapid growth in insurance products with tiered networks.

Some Californians are familiar with a related approach of reference pricing due to the pioneering work that CalPERS has done in this area for state and local employees. Reference pricing is really an “extra strength” version of the tiered network approach. An insurer sets a reference price and patients using providers that charge more are responsible for the difference (although providers sometimes do not charge patients in such plans any more than the reference price). So the incentive to avoid providers whose price exceeds the reference price is quite strong. While CalPERS has had success with joint replacements and some other procedures, a key question is what proportion of medical spending might be suitable to this approach. For reference pricing to be suitable, the services must be “shoppable,” meaning that they must be discretionary with the patient and can be planned in advance. One analysis estimates that only one third of health spending is “shoppable.”[3]

While network approaches have a lot of potential for fostering competition in health care markets, including those that are consolidated, they face a number of challenges that must be addressed. First, transparency about networks must be improved. Consumers need accurate information on which providers are in a network when they choose plans and when they choose providers for care. Accommodation is needed for patients under treatment if their provider should drop out of a network or be dropped from one. Network adequacy regulations are needed to protect consumers from networks that lack access to some specialties or do not have providers close enough to their residence. They are also important to preclude strategies that create networks unlikely to be attractive to patients with expensive, chronic diseases. But if network adequacy regulation is too aggressive, it risks seriously undermining a very promising tool for cost saving. So regulators must very carefully balance consumer protection with cost containment.

Some consider the problem of “surprise” balance bills, charges by out-of-network providers that patients do not choose, to be more significant in limited networks. This may be the case, but the problem is substantial in broader networks as well, and its policy response should apply throughout private insurance.

Another approach to foster competition in provider markets involves steps to foster independent medical practices. Medicare has taken steps to ease requirements for medical practices to contract as ACOs. It recently took some steps to limit the circumstances in which hospital-employed physicians get higher Medicare rates than those in office-based practice. Private insurers have provided support to some practices to incorporate electronic medical records into their practices. To the degree that independent practice can be made more attractive relative to hospital employment, competition in provider markets is likely to increase.

Additional restrictions on anti-competitive behavior by providers can also foster competition. These behaviors include “all or nothing” contracting requirements in which a hospital system requires insurers to contract with all hospitals in the system and “most favored nation” clauses in which insurers get providers to agree not to establish lower rates for other insurers.

Although the focus of discussion about policy in this testimony has been about fostering competition, regulatory alternatives that substitute for competition should not be ignored. At this time, two states—Maryland and West Virginia—regulate hospital rates. Some states, mostly in the Northeast, have been looking at this approach. Although I respect what some states have accomplished with this approach in the past, I need to point out that the current environment poses additional challenges for rate setting. The notion that rates would be the same for all payers, a longstanding component in Maryland, is unlikely to be practical today because rate differences between private insurance, Medicare and Medicaid are so large. So differences would likely have to be “grandfathered.” More practical would be to limit regulation to commercial rates, as West Virginia has done since the 1980s.

Another challenge is that with broad enthusiasm about the prospects for reformed payment, those contemplating rate setting need to make sure that the mechanism encourages payment reform rather than blocks it. Maryland has been quite careful about this and its recent initiative to broaden its program seems promising. But with the recent emphasis on multi-provider approaches to payment, such as ACOs and bundled payment, the limitation of regulatory authority to hospital rates could be a problem.

So what are my bottom lines for legislative priorities? I have two. States should address restrictions on anti-competitive practices such as anti-tiering restrictions, all-or-none contracting restrictions, and most favored nation clauses. My second is to regulate network adequacy wisely. It is a potent tool for fostering competition, even in consolidated markets. Network strategies do have problems that need to be addressed, but it must be done while preserving much of the potency of the approach.

A concluding thought involves acknowledging that provider payment reform approaches are likely to contribute to consolidation. Small hospitals and medical practices are not well positioned to participate, although virtual approaches can often be used in place of mergers, for example as California’s independent practice associations have enabled many small practices to participate. But I see payment reform as having major potential over time to reduce costs and increase quality. So my advice is to proceed with payment reform but also take steps to foster competition. Rate setting is best seen as a “stick in the closet” to use if market approaches should fail to control costs.


[1] Gaynor, M., and R. Town, The Impact of Hospital Consolidation – Update, Robert Wood Johnson Foundation Synthesis Report (June 2012).

[2] Baker, L. C., M.K Bundorf and D.P. Kessler, “Vertical Integration: Hospital Ownership Of Physician Practices Is Associated With Higher Prices And Spending,” Health Affairs, Vol. 35, No 5 (May 2014).

[3] Chapin White and Megan Egouchi, Reference Pricing: A Small Piece of the Health Care Pricing and Quality Puzzle. National Institute for Health Care Reform, Research Brief No. 18, October 2014.

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The market makers: Local innovation and federal evolution for impact investing


Announcements of new federal regulations on the use of program-related investments (PRIs) and the launch of a groundbreaking fund in Chicago are the latest signals that impact investing, once a marginal philanthropic and policy tool, is moving into the mainstream. They are also illustrative of two important and complementary paths to institutional change: fast-moving, collaborative local leadership creating innovative new instruments to meet funding demands; federal regulators updating policy to pave the way for change at scale.

Impact investing, referring to “investment strategies that generate financial returns while intentionally improving social and environmental conditions,” provides an important tier of higher-risk capital to fund socially beneficial projects with revenue-generating potential: affordable housing, early childhood and workforce development programs, and social enterprises. It is estimated that there are over $60 billion of impact investments globally and interest is growing—an annual JP Morgan study of impact investors from 2015 reports that the number of impact investing deals increased 13 percent between 2013 and 2014 following a 20 percent increase in the previous year.

Traditionally, foundations have split their impact investments into two pots, one for mission-related investments, designed to generate market-rate returns and maintain and grow the value of the endowment, and the other for program-related investments. PRIs can include loans, guarantees, or equity investments that advance a charitable purpose without expectation of market returns. PRIs are an attractive use of a foundation’s endowment as they allow foundations to recycle their limited grant funds and they count towards a foundation’s charitable distribution requirement of 5 percent of assets. However they have been underutilized to date due to perceived hurdles around their use–in fact among the thousands of foundations in the United States, currently only a few hundred make PRIs.

But this is changing, spurred on by both entrepreneurial local action and federal leadership. On April 21, the White House announced that the U.S. Department of the Treasury and Internal Revenue Service had finalized regulations that are expected to make it easier for private foundations to put their assets to work in innovative ways. While there is still room for improvement, by clarifying rules and signaling mainstream acceptance of impact investing practices these changes should lower the barriers to entry for some institutional investors.

This federal leadership is welcome, but is not by itself enough to meet the growing demand for capital investment in the civic sector. Local innovation, spurred by new philanthropic collaborations, can be transformative. On April 25 in Chicago, the Chicago Community Trust, the Calvert Foundation, and the John D. and Catherine T. MacArthur Foundation launched Benefit Chicago, a $100 million impact investment fund that aims to catalyze a new market by making it easier for individuals and institutions to put their dollars to work locally and help meet the estimated $100-400 million capital needs of the civic sector over the next five years.

A Next Street report found that the potential supply of patient capital from foundations and investors in the Chicago region was more than enough to meet the demand – if there were ways to more easily connect the two. Benefit Chicago addresses this market gap by making it possible for individuals to invest directly through a brokerage or a donor-advised fund and for the many foundations without dedicated impact investing programs to put their endowments to work at scale. All of the transactional details of deal flow, underwriting, and evaluation of results are handled by the intermediary, which should lead to greater efficiency and a significant increase in the size of the impact investing market in Chicago.

In the last few years, a new form of impact investing has made measurement of social return to investments even more concrete. Social impact bonds (SIBs), also known as pay for success (PFS) financing, are a way for private investors (including foundations) to provide capital to support social services with the promise of a return on their investment from a government agency if some agreed-upon social outcomes are achieved. These PFS transactions range from funding to support high-quality early childhood education programs in Chicago to reduction in chronic individual homelessness in the state of Massachusetts. Both the IRS and the Chicago announcements are bound to contribute to the growth of the impact bond market which to date represents a small segment of the impact investing market.

These examples illustrate a rare and wonderful convergence of leadership at the federal and local levels around an idea that makes sense. Beyond simply broadening the number of ways that foundations can deploy funds, growing the pool of impact investments can have a powerful market-making effect. Impact investments unlock other tiers of capital, reducing risk for private investors and making possible new types of deals with longer time horizons and lower expected market return.

In the near future, these federal and local moves together might radically change the philanthropic landscape. If every major city had a fund like Benefit Chicago, and all local investors had a simple on-ramp to impact investing, the pool of capital to help local organizations meet local needs could grow exponentially. This in turn could considerably improve funding for programs—like access to quality social services and affordable housing—that show impact over the long term.

Impact investing can be a bright spot in an otherwise somber fiscal environment if localities keep innovating and higher levels of government evolve to support, incentivize, and smooth its growth. These announcements from Washington and Chicago are examples of the multilevel leadership and creative institutional change we need to ensure that we tap every source of philanthropic capital, to feel some abundance in an era where scarcity is the dominant narrative.

Editor's Note: Alaina Harkness is a fellow at Brookings while on leave from the John D. and Catherine T. MacArthur Foundation, which is a donor to the Brookings Institution. The findings, interpretations and conclusions posted in this piece are solely those of the authors and not determined by any donation.

Image Source: © Jeff Haynes / Reuters
     
 
 




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The muni market in the post-Detroit and post-Puerto Rico bankruptcy era


Event Information

July 12, 2016
2:10 PM - 4:00 PM EDT

Online Only
Live Webcast

Puerto Rico is the latest, but probably not the last, case of a local government confronting financial strains that call into question its ability to meet its obligations to bondholders while providing services to its taxpaying constituents. Puerto Rico is, of course, a special case because it is a territory, not a state or municipality. Will Puerto Rico’s problems have ripple effects for the $3.7 trillion U.S. municipal bond market? What about the resolution of Detroit's bankruptcy? How will state and local governments and the courts weigh the interests of pensioners, employees, taxpayers and bondholders when there isn't enough money to go around?

On Tuesday, July 12, the Hutchins Center on Fiscal and Monetary Policy at Brookings webcasted the keynote address from the 5th annual Municipal Finance Conference, delivered by the sitting governor of Puerto Rico, Hon. Alejandro García Padilla. After Governor Padilla’s remarks on Puerto Rico’s future, Hutchins Center Director David Wessel moderated a panel on the politics and practice of municipal finance in the post-Detroit and post-Puerto Rico era.

Join the conversation and tweet questions for the panelists at #MuniFinance.

      

Video

Transcript

Event Materials

      
 
 




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How did COVID-19 disrupt the market for U.S. Treasury debt?

The COVID-19 pandemic—in addition to posing a severe threat to public health—has disrupted the economy and financial markets, and prompted a strong desire among investors for safe and liquid securities. In that environment, one might expect U.S. Treasury securities to be the investment of choice, but for a while in March, the $18 trillion market…

       




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Prices in Emissions Permit Markets

ABSTRACT

Of the many regulatory responses to climate change, cap-and-trade is the only one currently endorsed by large segments of the scientific, economic and political establishments. Under this type of system, regulators set the overall path of carbon dioxide (CO2) reductions, allocate or auction the appropriate number of emissions allowances to regulated entities and – through trading – allow the market to converge upon the least expensive set of abatement opportunities. As a result, the trading price of allowances is not set by the regulator as it would be under a tax system, but instead evolves over time to reflect the underlying supply and demand for allowances. In this paper, I develop a simple theory that relates the initial clearing price of CO2 allowances to the marginal cost premium of carbon-free technology, the maximum rate of energy capital replacement and the market interest rate. This theory suggests that the initial clearing price may be lower than the canonical range of CO2 prices found in static technology assessments. Consequently, these results have broad implications for the design of a comprehensive regulatory solution to the climate problem, providing, for example, some intuition about the proper value of a possible CO2 price trigger in a future cap-and-trade system.

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Fostering competition in consolidated markets

On March 16, Paul B. Ginsburg testified before the California Senate Committee on Health on fostering competition in consolidated markets.

      
 
 




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Identifying Areas With Inadequate Access to Supermarkets


When my wife and I relocated from D.C.’s Logan Circle to Capitol Hill five years ago, the most tumultuous change in our lifestyle (aside from my not being able to walk to Brookings every day) concerned the much farther distance we’d have to travel to the nearest supermarket. We had the luxury of shopping at a very nice, if spendy, grocery store about two blocks from our home, which meant that we often did “just-in-time” dinner shopping on the way home from work. Now we were moving to a house where the distance to the nearest supermarket was 1.5 miles, not so walkable at 7 pm.

Did we live in a “supermarket desert?” On the one hand, Capitol Hill is a pretty densely populated part of D.C., so 1.5 miles felt like a long way. And while the Hill is an economically diverse area, it’s large with significant pockets of affluence. On the other hand, like a lot of our neighbors, we own a car. So while nightly trips to the supermarket were out, it was hardly an onerous trip on the weekends.

There are, however, many communities nationwide in which that trip to the supermarket is a long one, and most have much lower incomes than the Hill. That’s the conclusion from new research we conducted with help from The Reinvestment Fund (TRF), a community development financial institution and research organization based in Philadelphia. TRF played a lead role in designing and implementing the Pennsylvania Fresh Food Financing Initiative, a program that provides grants and low-cost capital to facilitate the location of new supermarkets and fresh food retailers in that state’s underserved communities. That initiative is now the model for several other state and local programs, as well as the inspiration for a major new federal budget initiative that seeks to improve community health and economic development outcomes through supermarket attraction and expansion.

With TRF, we looked at 10 metro areas across the country, ranging in size from Jackson, Miss. to Los Angeles. Unlike a lot of previous research that attempted to identify “food deserts,” TRF’s analysis looks at factors beyond distance to a supermarket that matter for access, including a community’s population density and level of car ownership. And it uses household income and expenditure data to help pinpoint the communities that have a significant untapped local demand for supermarkets.

Across the 10 metro areas, about 1.7 million people (5 percent of total population) live in low- and moderate-income communities that are significantly underserved by supermarkets. African Americans, children, and very low-income families are over-represented in these areas. Greater Los Angeles alone accounts for half a million of the underserved; and in the Cleveland metro, more than one in nine residents lives in a low-supermarket-access community. Estimates suggest that upwards of $2.6 billion annually in grocery expenditures may “leak” out of these communities due to a lack of nearby supermarkets.

The real upside of this research project is that all of the results are viewable online, through TRF’s PolicyMap service. So local economic development officials, neighborhood-based organizations, retailers, and others can examine the location and characteristics of low-supermarket-access areas in their own communities. On Capitol Hill, the analysis suggests that we’re pretty well served. Lots of car owners, and it’s really not that far to the store. Cross the Anacostia River, however, and it’s another story altogether. Pinpointing and describing the untapped opportunities for supermarket development is hopefully a first step toward reducing market obstacles to higher-quality, lower-cost food options for residents of communities like Ward 7 and Ward 8 nationwide.

Authors

Publication: The Avenue, The New Republic
Image Source: © Sarah Conard / Reuters
     
 
 




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Supermarket Access in Low-Income Areas

The Brookings Metropolitan Policy Program and The Reinvestment Fund (TRF) performed a detailed analysis of supermarket access in 10 metropolitan areas, and the results are discussed in a new video, “Getting to Market."

Results from the analysis encourage users to view the locations of, and generate reports about, low-supermarket-access communities within the 10 metropolitan areas. This is highly useful data for those working at the national and local levels to tackle the problem of inadequate access through public policy and private investment. You can also access these data alongside any of PolicyMap’s 10,000 data indicators and full functionality at www.policymap.com

For those interested in other metropolitan areas, TRF has made available a nationwide analysis of low-supermarket-access communities at www.trfund.com.

Media Memo »


Profiles of 10 Metropolitan Areas (PDFs)

 Atlanta, GA  Little Rock, AR
 Baltimore, MD  Los Angeles, CA
 Cleveland, OH  Louisville, KY
 Jackson, MS  Phoenix, AZ
 Las Vegas, NV  San Francisco, CA

Below are samples of data found on our interactive map


Map of the San Francisco area showing Low Access Areas with the access score for the area. Access scores are the degree to which a low/moderate-income community's residents are underserved by supermarkets.


Map of Baltimore showing Low Access Areas against the estimated percentage of families that live in poverty.


Map of Cleveland showing Low Access Areas against the estimated population above the age of 65.

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The welfare effects of peer entry in the accommodation market: The case of Airbnb

The Internet has greatly reduced entry and advertising costs across a variety of industries. Peer-to-peer marketplaces such as Airbnb, Uber, and Etsy currently provide a platform for small and part-time peer providers to sell their goods and services. In this paper, Chiara Farronato of Harvard Business School and Andrey Fradkin of Boston University study the…

       




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Obama Criticized for 'Bitter' Blue-Collar Remarks

Ruy Teixeira joins NPR's Talk of the Nation host Neal Conan to discuss the Pennsylvania primary and the working-class vote.

NEAL CONAN: With us here in Studio 3A is Ruy Teixeira, a visiting fellow at Brookings Institution, co-author of the report "The Decline of the White Working Class and the Rise of a Mass Upper Middle Class." He's kind enough to be with us here. Thanks very much for coming in, nice to see you again.

RUY TEIXEIRA:
Great to be here.

NEAL CONAN: And, what are some of the common themes that we see around these working class voters that Sherry Linkon was talking to us about?

RUY TEIXEIRA: Well, I think Sherry touched on a number of them. I think one critical theme, obviously, for this election is their level of economic discontent and their sense that the economic ground has shifted underneath their feet, and they are sort of wondering where they are going to go in the future, where their kids are going to go, sort of, where their way of life is going to go.

This is a matter of great concern to these voters because the last, you know, actually the last several years, have not been kind to them. But more broadly, you can look back, you know, 35 years and say the last 35 years has not been very kind to them. This has been a period when America, by and large, has grown not as fast as it did and incomes have not risen as fast as they used to, but it's been particularly bad for these voters.

Anyone with less than a four-year college degree has really done rather poorly since about the middle 1970s. So, there's a real question in their minds of what America has in store for them in the future. And they are very interested to hear what politicians have to say about it. So far, it hasn't seemed to work out quite so well.

And the other side of it is really touched on by the controversy that you're referring to which is their sense of cultural traditionalism, their sense that, especially the Democrats, perhaps, seem out of touch with that at times. It seems like they don't respect their way of life. It seems like their social liberalism gets in the way of connecting to these voters and really hearing what they have to say and what their commitments and priorities really are and a sense of elitism on their part.

And that's really what, I think, Obama's getting slammed on this, you know, in general, and of course, obviously the McCain and Clinton campaigns have some interest in pushing this, but it did give them an opening to raise this issue and argue that, in fact, he is elitist. And Democrats, if they wish to get away from this, they have to adopt - I think it's a little bit unfair to the remark once you look at it in context.

But nevertheless, the perception was there particularly, I think the stuff about guns and about religion. I mean, can't you, like, own a gun and go to church and not be clinging to it? Because you know, your economic way of life is deteriorating. Again, I don't think that's what he meant. But that's how it's being interpreted. And that's where the discussion is.

Listen to the entire interview »

Authors

Publication: NPR Talk of the Nation
     
 
 




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Trends and Developments in African Frontier Bond Markets


Most sub-Saharan African countries have long had to rely on foreign assistance or loans from international financial institutions to supply part of their foreign currency needs and finance part of their domestic investment, given their low levels of domestic saving. But now many of them, for the first time, are able to borrow in international financial markets, selling so-called eurobonds, which are usually denominated in dollars or euros. 

The sudden surge in the demand for international sovereign bonds issued by countries in a region that contains some of the world’s poorest countries is due to a variety of factors—including rapid growth and better economic policies in the region, high commodity prices, and low global interest rates. Increased global liquidity as well as investors’ diversification needs, at a time when the correlation between many global assets has increased, has also helped increase the attractiveness of the so-called “frontier” markets, including those in sub-Saharan Africa. At the same time, the issuance of international sovereign bonds is part of a number of African countries’ strategies to restructure their debt, finance infrastructure investments, and establish sovereign benchmarks to help develop the sub-sovereign and corporate bond market. The development of the domestic sovereign bond market in many countries has also help strengthen the technical capacity of finance ministries and debt management offices to issue international debt.

Whether the rash of borrowing by sub-Saharan governments (as well as a handful of corporate entities in the region) is sustainable over the medium to long term, however, is open to question. The low interest rate environment is set to change at some point—both raising borrowing costs for the countries and reducing investor interest. In addition, oil prices are falling, which makes it harder for oil-producing countries to service or refinance their loans. In the medium term, heady economic growth may not continue if debt proceeds are only mostly used for current spending, and debt is not adequately managed.

Download the full paper (PDF) »

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Decoding Xi Jinping’s latest remarks on Taiwan


On March 5, Chinese President Xi Jinping spoke to the Shanghai delegates to the National People’s Congress (NPC) session in Beijing. China’s top leaders use these side meetings to convey policy guidance on a range of issues, and Xi used this particular one to offer his perspective on relations with Taiwan. There has been some nervousness in the wake of the January 16 elections, which swept the opposition Democratic Progressive Party (DPP) to power in both the executive and legislative branches. Because the Beijing government has always suspected that the fundamental objective of the DPP is to permanently separate Taiwan from China, observers were waiting expectantly to hear what Xi would have to say about Taiwan.

Well before the March 5 speech, of course, Xi’s subordinates responsible for Taiwan policy had already laid out what Taiwan President-elect Tsai Ing-wen and her party would have to do to prevent cross-Strait relations from deteriorating, and they continued to emphasize those conditions after Xi’s speech. But analysts believed that Xi’s own formulation would be the clearest indicator of Beijing’s policy. He is, after all, China’s paramount leader, and his words carry a far greater weight than those of other Chinese officials.

This is what Xi said to the Shanghai NPC delegation about Taiwan [translation by the author, emphasis added]:

Compatriots on the two sides of the Strait are blood brothers who share a common destiny, and are people for whom blood is thicker than water…Our policy towards Taiwan is correct and consistent, and will not change because of a change in [who heads] the Taiwan authorities. We will insist upon the political foundation of the “1992 consensus,” and continue to advance cross-Strait relations and peaceful development…If the historical fact of the “1992 consensus” is recognized and if its core connotation is acknowledged, then the two sides of the Strait will have a common political basis and positive interaction [virtuous circle] can be preserved. We will steadily push forward cross-Strait dialogue and cooperation in various fields, deepen cross-Strait economic, social, and financial development, and increase the familial attachment and welfare of compatriots [on both sides], close their spiritual gap, and strengthen their recognition that they share a common destiny. We will resolutely contain the separatist path of any form of Taiwan independence, protect state sovereignty and territorial integrity, and absolutely not allow a repetition of the historical tragedy of national separation. This is the common wish and firm intention of all Chinese sons and daughters, and is also our solemn pledge and obligation to history and to the people. The fruits of cross-Strait relations and peaceful development require the common support of compatriots on the two sides; creating a common and happy future requires the common effort of compatriots on the two sides; and realizing the great revival of the Chinese nation requires that compatriots on the two sides join hands to work with one heart.

The italicized sentences are key: They state what the new DPP government should do if it wishes to maintain healthy cross-Strait relations and affirms Beijing’s resolve to oppose any behavior it doesn’t like. Xi didn’t threaten specific actions, but he probably didn’t have to. As always, Beijing reserves the right to decide what DPP attitudes and actions constitute separatism and a quest for Taiwan independence. 

Xi didn’t threaten specific actions, but he probably didn’t have to.

Some background

There are two important points of reference contextualizing this statement from Xi. 

Xi on November 7, 2015. First, there are his reported remarks on the future of cross-Strait relations during his unprecedented meeting with current Taiwan president Ma Ying-jeou in Singapore last November 7. At that time, Xi first appealed to ethnic solidarity and national unity, as he did again on March 5. He asserted that the stakes to end the state of division between Mainland China and Taiwan were very high because it was a critical part of how he views rejuvenating the Chinese nation—a theme he repeated to the Shanghai delegation. 

Xi said Taiwan, under the new government, could either continue to follow the path it has walked for the last seven-plus years under the current Ma Ying-jeou administration (“peaceful development”), or it could take the path of renewed “confrontation,” “separation,” and zero-sum hostility. If Taiwan wished to follow the first path, Xi insisted, its leaders must adhere to the 1992 consensus and oppose “Taiwan independence.” Without this “magic compass that calms the sea,” Xi warned, “the ship of peaceful development will meet with great waves and even suffer total loss.” He was willing to overlook the DPP’s past positions and actions, but only if it identified with “the core connotation of the 1992 consensus” (a reference to the PRC view that the Mainland and Taiwan are both within the territorial scope of China, a view the DPP contests). Xi alluded to the “core connotation” on March 5 but did not re-state its content. Xi then made clear that if “disaster” occurred, it would be the DPP’s fault—it was therefore up to Tsai, he implied, to accommodate to Beijing’s conditions. 

In language and tone, Xi’s Singapore statement was far more strident and alarmist than what he said on March 5. He made that first statement more than two months before the election, when perhaps he thought that tough talk would weaken Tsai’s and the DPP’s appeal to voters. If that was his objective, he failed. The tone of his March 5 remarks was more modulated, but the substance was the same. Beijing would define the crossroads that Taiwan faced, and it was up to Tsai to take the right path—at least what it defined the right path.

Beijing would define the crossroads that Taiwan faced, and it was up to Tsai to take the right path—at least what it defined the right path.

Tsai on January 21, 2016. Second, there is an interview that Tsai gave to Liberty Times (Tzu-yu Shih Pao) on January 21—less than a week after the elections—in which she sought to meet Beijing partway. For the first time, she used the phrase “political foundation” and said it had four elements: 

  • “The first is that the SEF-ARATS discussions of 1992 are a historical fact and both sides had a common acknowledgment to set aside differences and seek common ground;” 
  • “The second is the Republic of China’s current constitutional order.”
  • “The third is the accumulated results of the more than 20 years of cross-strait negotiations, exchanges, and interactions;” and
  • “The fourth is Taiwan’s democratic principles and the will of the Taiwanese people to make sure that Taiwan voters understood the limits to his tolerance.”

So, Tsai accepts the 1992 meetings as a historical fact and acknowledges that the two sides did reach an agreement of sorts, but does not accept the 1992 consensus itself as a historical fact. She spoke more about process than content. The Republic of China’s “current constitutional order” is also part of the foundation, which some have read as Tsai’s acceptance that the Mainland and Taiwan are both parts of China’s territory (Beijing’s “core connotation”)—I, however, am not so sure. Tsai did not reject Xi’s requirements out of hand, but she framed them in her own way. 

So are ties growing friendlier?

Was Xi’s tonal moderation on March 5—relative to November 7—an indicator that mutual accommodation was going on? Perhaps. But the fact that the November meeting was ostensibly private while the March speech was public might explain the difference. 

Moreover, the stream of Chinese articles and statements since March 5 that explicitly restate Beijing’s long-standing preconditions are reason to doubt that much accommodation is actually occurring. The three basic scenarios I outlined last December—accommodation, limited Chinese punishment of the Tsai administration, and comprehensive punishment—are still in play, and the key variable remains whether Xi and his subordinates trust Tsai Ing-wen’s basic intentions. That is, will they accept her recent formulations as a good-faith effort to avoid deterioration? The next milestone will be May 20, when Tsai Ing-wen gives her inaugural address and may provide a more detailed formulation of her approach to China.

      
 
 




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Sizing the Clean Economy: Remarks by Bruce Katz


Editor's Note: During an event to launch a new report assessing the clean economy, Bruce Katz delivered a presentation highlighting the clean sector’s contribution to boosting exports and increasing manufacturing jobs. Katz's presentation also is featured in an iBook for the iPad.

Thank you, [Brookings Managing Director] Bill [Antholis] for that introduction, and for your leadership in this institution and more broadly in the national debate on climate change.

Before proceeding, I want to first thank my colleagues, Mark Muro, Jonathan Rothwell, Devashree Saha, and our friends at Battelle, particularly Mitch Horowitz and Marty Grueber for their creativity, collegiality, and painstaking attention to detail through a long and rigorous research effort. 

I’d also like to offer a special thanks to the Nathan Cummings Foundation, the General Electric Foundation, Living Cities, and the Surdna Foundation for their support and guidance of the program’s Clean Economy work, as well as the Rockefeller Foundation, who is supporting our policy and practice work around the clean economy in states and metropolitan areas.  

Today, we celebrate not just the release of a report, “Sizing the Clean Economy” but the unveiling of an interactive web site to spur further research, policy and practice, all freely available at www.brookings.edu/cleaneconomy.

We want today’s forum to be a participatory event and urge all of you in the audience and following on our webcast to engage online early and often. Please comment on Twitter via the hashtag created for this event (#cleanecon) and feel free to engage directly with me at @Bruce_Katz and Mark at @MarkMuro1 and send us any questions at MetroQ@brookings.edu.

 

The question before us: at a time of economic uncertainty and federal polarization, can America’s cities and metropolitan areas lead the nation to a clean economy—to create jobs in the near term and retool and restructure our economy for the long haul?

 

There is no doubt in our minds that moving to a clean economy is an environmental and energy imperative.  But consumers, companies, and cities are also sending an unequivocal signal: this is a market proposition and an economic transformation as profound as the information revolution.

Consumers around the globe are starting to demand lower carbon, energy efficient products and services: one in four drivers in the U.S., Europe, China, and Japan plans to buy electric vehicles when they are readily available. That would put about 50 million electric cars on the road in places from Baltimore to Beijing, Torino to Tokyo.

Companies see the clean economy as a growth sector: three quarters of major global corporations plan to increase “cleantech” budgets from 2012 to 2014. Global private investment in clean energy alone is up more than 6 fold since 2004, reaching $154 billion in 2010.

Cities and their metropolitan areas, early adapters of sustainable practice, are now competing to build out their special niches in the clean economy. I will provide details later on Greater Seattle’s bold strategy to be the global hub of clean IT. 

For two years, the Brookings Metro Program has hammered home the notion that the United States must pursue a different growth model post recession, a “next economy” that is driven by exports, powered by low carbon, fueled by innovation and rich with opportunity—and delivered by the large metropolitan areas that drive our economy.

Today, we will literally flip the dial and place the clean economy in the center of our macro vision and unveil the scale, scope and spatial geography of this promising growth engine. 

We have three sharp and timely findings.

First, the clean economy is a significant, diverse emerging market in the United States, already populated by some 2.7 million jobs. It is disproportionately manufacturing and export intensive—and offers better prospects for low and middle skilled workers than the national economy as a whole. This is exactly the kind of economy we want to build post-recession.

Second, metropolitan areas are on the vanguard of the clean economy due to their concentration of innovative drivers, as well as the built environment in which most people live, work and play. As in exports, metros specialize in different sectors of the clean economy—and the clustering of firms is catalyzing productive and sustainable growth.

Third, the U.S. must unleash the entrepreneurial energies and dynamism of our metropolitan engines to accelerate growth of the clean economy. That will require a strategic mix of private sector innovation and public policy that is stable, supportive, and predictable.  Given the nature and scale of global competition, U.S. governments, at all levels, must “get in the game” rather than “get out of the way.”  Smart public action can leverage private investment, create desperately needed jobs, and cement our position as the leading edge of innovative growth.

The stakes are very high. Make no mistake—we have a lot to do here and we are falling behind globally. Our competitors in mature and rising economies—Germany, Japan, and China—fully understand the potential of clean, and they are working at warp speed to set favorable conditions for rapid growth and grab their share of the next market revolution. We need to get our public-private act together—in cities and metros, in state capitals, at the now polarized federal level.

So let’s start with our first finding: the clean economy is a significant, diverse emerging market in the United States  

In total, we find there are 2.7 million clean economy jobs all across the United States. To put that number in perspective: the clean economy is nearly twice the size of the biosciences field and 60 percent of the 4.8 million strong IT sector. As you can tell, the clean economy also has more jobs than fossil fuel related industries.  

 Our definition of the clean economy is as follows:

“Any economic activity—measured in terms of establishments and jobs—that produces goods and services with an environmental benefit, or adds value to such products using skills or technologies that are uniquely applied to those products.”

This definition yields a broad and varied picture of economic activity: old and new, public and private, “green” and “blue.”

At the highest level, we find establishments and jobs grouping together in 5 discernible categories: Renewable Energy; Energy and Resource Efficiency; Greenhouse Gas Reduction; Environmental Management, and Recycling; Agricultural and Natural Resources Conservation; and Education and Compliance. Here we follow the categorization the Bureau of Labor Statistics is using for its own “green jobs” assessment due next year.

These categories then naturally break down into fine-grained segments, ultimately 39 in all.

Renewable Energy, for example, has nine segments, including Solar and Geothermal power, and Renewable Energy Services.

Energy and Resource Efficiency has 13 separate segments, from Electric Vehicle Technology to Water Efficient Products.

Greenhouse Gas Reduction, Environmental Management, and Recycling has 12 segments including Green Chemical Products and Professional Environmental Services.

And so on—you get the idea.

Each of the segments, in turn, has a distinct economic profile (cutting across multiple activities, occupations and skills) and a distinct spatial geography given the special assets and attributes of different places.

Let’s drill down a little so we all get on the same page.

Under renewable energy, let’s look at solar photovoltaic, a young rapidly innovating area. This segment employs more than 24,000 people in 555 establishments.

The list includes two major solar manufacturing firms, First Solar—with a major plant in Toledo—and BP Solar—with a facility in the Washington, DC metro, and Bombard Electric in Las Vegas, which helps businesses in that region—casinos, hotels, shopping centers—shift their energy use.

Under Greenhouse Gas Reduction, let’s take a look at Professional Environmental Services, an example of the role that expert services can play in domestic and global markets. This segment boasts some 140,000 workers in 5,400 establishments.

CH2M Hill in Denver provides environmental consulting services throughout the U.S. and the world, Ecology & Environment is a science and technical services firm with a large presence in Los Angeles, and Black & Veatch, out of Kansas City, is an engineering firm specializing in areas from environmental permitting to remediation.

One more definitional cut to consider: we have identified a group of young, super innovative “Cleantech” industries that cross multiple categories and show enormous growth potential. These industries are populated by companies with a median age of 15 years or less.

Most notably, this portfolio of segments—including wind power, battery technologies, bio fuels, and smart grid—grew about 8 percent a year since 2003, or twice as fast as the rest of the economy.

The clean economy, however, is not just broad and diverse, it is disproportionately productive.

The clean economy is export intensive, already taking advantage of the demand for clean goods and services coming from abroad.

In 2009, clean economy establishments exported almost $54 billion, including about $49.5 billion in goods and an additional $4.5 billion in services.

Significantly, clean economy establishments are by our calculations twice as export intensive as the national economy: over $20,000 worth of exports is sold for every job in the clean economy each year compared to just $10,400 worth of exports for the average U.S. job.

The export orientation of the clean economy today provides a platform for more exports tomorrow. With rising nations rapidly urbanizing, the demand for sustainable growth in all its dimensions will only grow, and the U.S. has the potential to serve that demand.

The clean economy also supports a production-driven innovation economy.

We find it employs a higher percentage of scientists than the national economy. Ten percent of clean economy jobs are in science and engineering, compared to 5 percent in U.S. economy generally.

As we now know, manufacturing and innovation are inextricably linked. This provides a stark challenge to the U.S.: we will innovate less unless we produce more.

By our account, the clean economy is a vehicle for production.

Twenty six percent of all clean economy jobs are involved in manufacturing, compared to just 9 percent of jobs in the economy as a whole.

Manufacturing accounts for a majority of the jobs in over half of the clean economy segments, with many sectors having a supermajority of production-oriented jobs.

Solar and wind energy, for example, have more than two thirds of their jobs in manufacturing. And some segments, including appliances, water efficient products, and electric vehicle technologies have over 90 percent of their jobs in manufacturing.

The good news: clean manufacturing is growing, even in the face of national declines in manufacturing employment. 

Finally, the clean economy is opportunity rich, providing prospects for a wide range of workers, and good wages up and down the skills ladder.

The clean economy is easy to enter, available to people of all skill levels: 45 percent of all clean jobs are held by workers with a high school diploma or less, compared to only 37 percent of U.S. jobs.

Once a worker enters the field, he or she is more likely to receive career-building training, as 41 percent of clean jobs offer medium to long-term training, compared to 23 percent of U.S. jobs.

The payoff is higher wages: the median wage in the clean economy is almost $44,000 for the average occupation, significantly higher than the national equivalent of $38,000 and change.

In summary, the clean economy is the kind of economy we want to build: export oriented, innovation fueled, opportunity rich, and balanced.

So here is our second major finding, metros are on the vanguard of the clean economy

Here is the heart of the American economy: 100 metropolitan areas that after decades of growth take up only 12 percent of our land mass, but harbor two-thirds of our population and generate 75 percent of our gross domestic product. 

These communities form a new economic geography, enveloping cities and suburbs, exurbs and rural towns.

Our research shows the extent to which these top 100 metros, in the aggregate, are driving growth in the Clean Economy.

In 2010, they constitute an increasing share of clean economy jobs, almost 64 percent.

And they include an outsized share, 74 percent, of jobs in cleantech industries, including extraordinarily high shares in solar photovoltaic, battery technologies, smart grid, and wind energy.

Innovative clean jobs are predominately in the top 100 metros because these places concentrate the assets that drive innovation, from initial research through commercialization through ultimate deployment

The major metros are also leading the growth of clean economy jobs around the built environment. They harbor 78 percent of jobs in public mass transit, and 90 percent of the jobs in green architecture, design and construction since moving people more efficiently and making buildings energy efficient will primarily be a metropolitan act, given where most people live and travel, and businesses locate.

Incredibly, metros also include a decent share of clean jobs that are traditionally rural, with at least 23 percent of jobs in resource-intensive activities like hydropower, sustainable forestry products, and biofuels, and more than half of organic food and farming jobs.

Metro economies, of course, do not exist in the aggregate; they have distinctive starting points and distinctive assets, attributes and advantages. 

Our research digs deep to profile the clean economy potential of each of the top 100 metro areas.

Four metro areas—New York, L.A., Chicago and Washington—are supersized job centers, with more than 70,000 jobs apiece in the clean economy in 2010. The New York metro alone has more than 152,000 clean economy jobs.

Other major metros—Philadelphia, San Francisco, Atlanta, Boston, Houston and Dallas—are also key players, with more than 38,000 jobs apiece as of that year.

Yet this is not just about the largest metros. As we see here, a different group of small and medium sized metros have more than 3.3 percent of their jobs situated in the clean economy. Albany leads the way, with an impressive 6.3 percent of its jobs in the clean economy.

The power of metros is the power of agglomeration, networks and clusters. 

Our report finds that clusters—the proximity of firms to businesses in related industries—boost metros’ growth performance in the clean economy, and metros facilitate clustering.

Examples include professional environmental services in Houston, solar photovoltaic in Los Angeles, fuel cells in Boston, wind in Chicago, water industries in Milwaukee, and energy efficiency in Philadelphia.

We can talk about clusters in the abstract, but its best to see them in practice from the ground up.

So let’s travel to the Philadelphia metropolis—the nation’s fifth largest—which includes the city of Philadelphia and surrounding counties.

Philadelphia is the fifth largest clean economy job center in the country.

Here we can find the advanced research engines of the University of Pennsylvania and Drexel in University City, who have partnered together on clean energy research and have provided a steady stream of talented workers to public, private and nonprofit firms and intermediaries.

These universities are part of the Greater Philadelphia Innovation Cluster, based at the Navy Yard, on the Delaware River.  This consortium received $129 million in federal funding from multiple agencies to demonstrate the efficacy of new building energy efficient components, systems and models.

The consortium includes strong support of City Hall, led by Mayor Michael Nutter, who has pioneered smart skills training in the energy efficient sector as well as the Philadelphia Industrial Development Corporation, which has been an investor in the Navy Yard.

And then, of course, there are firms and companies, the fuel of the economy, located throughout the Philadelphia metropolis.

Downtown we find Veridity Energy, a small smart grid firm with powerful technology tools. The density of Center City supports a healthy mix of highly skilled service firms. Just around the corner is Realwinwin, which provides finance services to companies making capital investments in energy efficiency.

But metropolitan economies cross city and county borders because different kinds of firms require different urban and suburban footprints—so if we look out to the suburb of Radnor, just past Bryn Mawr and I-476, we find Iberdrola, the second largest wind operator in the United States and a subsidiary of a major Spanish renewable energy company and an example of the wave of foreign direct investment that can help the U.S. build out the clean economy.   

The Philadelphia story reveals why cities and metro areas power our economy: they are hyper linked networks of private firms and public and nonprofit institutions that fertilize ideas, share workers, extend innovation, enhance competitiveness and catalyze growth.

Which leads to our final proposition: to build the next economy the U.S. must unleash the entrepreneurial energies and dynamism of our metropolitan engines.

We compete in a fiercely competitive world.

While America continues to debate the legitimacy of global warming research, our competitors in established nations like Germany, Japan and the U.K. and rising nations like China are taking transformative steps to grow their clean economies in the precise places—Munich, Tokyo, London, Shanghai—that drive their national economies. 

The United States can compete with these and other nations. No other nation can match us in domestic demand, advanced research, venture capital, the power of metro concentration.

But our potential will not be realized unless we provide a strong policy platform for the build out of the clean economy. 

Four steps are essential:  

Step one: scale-up markets by catalyzing demand for clean economy goods and services.  

Step two: drive innovation by investing in advanced R&D at scale, over a sustained period and via new distributed networks.

Step three: catalyze finance to produce and deploy more of what we invent. 

And step four: align with cities and metros to realize the synergies of clustering and place.  

Our competitors know that economy shaping of this magnitude should start at the national scale.

And so, in a perfect world, we would have our federal government create a framework for growth and success.

We have seen some of that leadership in the past few years, through: the procurement driven, market scaling efforts of the Department of Defense, the creation of new innovation vehicles like ARPA-E, some of the financial investments of the Department of Energy’s Loan Guarantee Program, and the metro-supporting investments in new energy regional innovation clusters—like the Greater Philadelphia example—supported by agencies with diverse sets of missions and resources, including DOE, Commerce, Labor, Education, and SBA. 

But with our global competitors continuously upping their goals and expanding their commitments, we desperately need our federal government to go further and act with vision and ambition and consistency.

To scale-up markets, Congress should enact a national clean energy standard (CES) that signals a long term, consistent commitment to alternative energy sources.

To drive innovation, Congress should embrace the call by the American Energy Innovation Council, led by corporate titans like Bill Gates and Jeff Immelt, to invest $16 billion annually in clean energy research and development through ARPA-E and networks of institutions that are multi-disciplinary and engage seamlessly with the private sector.

To catalyze finance, Congress should authorize a technology deployment finance entity—a Green Bank for short—to provide finance of the right scale and risk tolerance to ensure that ideas generated in America lead to products made in America.

Congress should also rationalize, reform, and selectively extend the myriad tax provisions and incentives that currently support the clean economy but which are now chaotic, unstable, inconsistent, and obtuse about evoking innovation and steady price declines from maturing clean technologies.

And to align with regions, Congress should more than double the number of energy innovation hubs and clusters that are seeded and funded.

Frankly, it is not difficult to lay out what reforms and investments are needed to grow the clean economy. Our competitors have given us clear guidance on that score. The only issue is whether our federal government, riven by excessive partisanship and ideological polarization, can muster the will to get anything done.  

Fortunately in the U.S. we have a default proposition when our national government falters, our states act as our “laboratories of democracy” and, as California Lt. Governor Gavin Newsom recently observed, our cities and metros act as the laboratories of innovation.

And so that’s how, for the time being, we will need to build our clean economy in the United States, the hard way, from the ground up.

The good news: there is no shortage of policy innovation and political commitment at the state and metro scale.

To scale up markets, California has set an aggressive renewable portfolio standard of 33 percent renewable energy by 2020. With this strong foundation, San Jose and other cities and counties are doing their part to facilitate consumer adoption: streamlining or even eliminating building permitting for solar panels.

To drive innovation, Wisconsin has created the School of Freshwater Sciences at the University of Wisconsin-Milwaukee to leverage that metro’s rising position in the blue economy. The Milwaukee Water Council is building on this, spearheading a network of scientists and companies to realize Milwaukee’s ambition to be a global hub for freshwater research, firm creation, and business expansion. 

To catalyze finance, Connecticut recently created the Connecticut Clean Energy Finance and Investment Authority. Capitalized with some $50 million annually, this Green Bank could accelerate the generation, transmission, and adoption of alternative energy.

At the municipal level, New York City has capitalized an Energy Efficiency Corporation to spur the financing of energy efficiency in the building sector.

And, finally, smart metros are now moving to build out their distinctive industry clusters.  In Greater Seattle, for example, the Puget Sound Regional Council has developed a business plan to cement that metro’s natural position as a global hub of energy efficient building technologies. This smart public-private initiative includes the establishment of a facility to test, integrate and verify promising energy efficient products and services before launching them to market.

Significantly, this metro vision is being supported by the State of Washington, which has committed to match any federal investment in the testing network.

Let me conclude with this vision: Let’s imagine a world in 20 years where the clean economy permeates every aspect of our economic and social fabric and, in the process, enhances productivity and competitiveness, lowers energy use, spurs further innovation, and provides quality work for a broad cross section of our citizenry. 

We believe today’s research—and the power of millions of consumers, tens of thousands of companies and hundreds of cities and metros—gives us the hope that this vision can become reality.

We have the data to set a platform for sustainable growth.

We have the roadmap to set the foundation for smart investment.

We have the entrepreneurs in all sectors to innovate and replicate. 

Let’s build the clean economy—worker by worker, firm by firm, metro by metro.

Thank you.

Authors

Image Source: © Larry Downing / Reuters
      
 
 




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Sizing the Green Economy: A Discussion with Mark Muro on Clean Sector Jobs


Editor's Note: During an appearance on the Platts Energy Week program, Mark Muro discussed jobs in the green sector, using findings from the "Sizing the Clean Economy" report.

Host BILL LOVELESS: Green jobs – what are they? And can they make much of a contribution to the economy? It’s an ongoing debate in Washington, and the rest of the U.S. for that matter, and it’s a knotty one because defining the term “green jobs” is difficult.

But now the Brookings Institution has taken a crack at it with a new report, “Sizing the Clean Economy.” One of the authors, Mark Muro, with the Brookings Metropolitan Policy Program, joins me now. Mark, do you think you’ve defined, once and for all, what the clean economy is?

MARK MURO: The answer to that is “no.” This has been an ongoing discussion for decades, really. On the other hand, I do think that we have done is tried to embrace good precedents, good sensible precedents from Europe. The European Statistical Agency comes at it similar to the way we did. But we’ve also anticipated where the Bureau of Labor Statistics, here in the U.S., will be next year when it offers our first U.S. official definition.

LOVELESS: A summer preview, maybe. I know the Bureau of Labor Statistics is working on that. Should this report ... tell me a little bit about this report — where the jobs are and should this in any way change the way we look at green jobs.

MURO: I think one thing that comes from this is that it’s a broad swath of, sometimes not very glamorous, industries that are very familiar. Wastewater, mass transit – those are properly viewed as green jobs because they take pressure off the environment. They keep our environment clean.

Watch Mark Muro's full interview with Platts Energy Week »

Authors

Publication: Platts Energy Week
Image Source: © Mike Segar / Reuters
      
 
 




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Unpredictable and uninsured: The challenging labor market experiences of nontraditional workers

As a result of the COVID-19 pandemic, the U.S. labor market has deteriorated from a position of relative strength into an extraordinarily weak condition in just a matter of weeks. Yet even in times of relative strength, millions of Americans struggle in the labor market, and although it is still early in the current downturn,…

       




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Antibiotic Development and Market Failure: No Quick Fix


The news Monday from the Centers for Disease Control and Prevention (CDC) on the incidence of resistant infections is disturbing but not surprising. CDC estimates that over two million Americans every year are affected by drug-resistant infections and of those, 23,000 die annually. The report notes that these figures are conservative and are likely an underestimate of the burden of resistant infections. While these numbers reflect domestic rates, antibiotic resistance is a global issue as well.

To further compound the issue, today’s antibiotic pipeline is nearly dry and has been for some time, with only a handful of large pharmaceutical companies and smaller biotech firms still engaged in antibiotic development. The threat of a so-called ‘post-antibiotic era’ – a time when there are no longer any effective antibiotic treatments – could become a reality without a concerted and comprehensive effort to combat this global threat. The evolution of drug resistance is an inherent risk of antibiotic use. The CDC report cited the development of new antibiotics and diagnostic tools, as well as programs and policies to support appropriate use of antibiotics, as being among the core strategies to combat resistance.

Clinical effectiveness and the relatively low cost of antibiotics have had the unintended consequence of contributing to overuse, accelerating the development of antibiotic resistance to all major classes of antibiotics. While there are some diagnostic tools available to support targeted treatment, it is often more time- and cost-effective for a physician to prescribe a relatively inexpensive, broad-spectrum antibiotic than to conduct a diagnostic test (if one exists at all). Antibiotic overuse can also be driven by patients who see antibiotics as safe and often low-cost cure-alls. Recognizing that these past patterns of overuse are dangerous, the clinical community is working diligently to curb inappropriate use and promote public health through stewardship and education programs. However, given the weakness of the current antibiotic development environment, it may be too little-too late; rates of resistance continue to rise globally while the number of effective therapies to treat many pathogens is dwindling. According to the CDC, resistance can be ”slowed but not stopped” – there will always be a need for novel antibiotics that can combat the evolution of these pathogens.

The current system for manufacturer return on investment for antibiotics, which are typically reimbursed at very low levels, is oriented towards volume sales. As a result, stewardship and educational programs geared toward limiting use of novel antibiotics create an ‘antibiotic development paradox.’ How can we incentivize investment in developing new effective antibiotics and also have successful programs that limit the use of these antibiotics in an effort to prevent or delay the development of resistance? Unless this fundamental conflict in the current business model is addressed, pharmaceutical firms are unlikely to expand development efforts.

How do we turn the tide?

There are several proposals that address aspects of the antibiotic development paradox with the goal of reinvigorating the antibiotic drug development ecosystem in a way that maximizes our ability to stay ahead of resistance. While none of these proposals alone will solve this problem, each could support the long-term goal of reinvigorating antibiotic discovery, development, and treatment.

Creating incentives for drug development

Antibiotic drug development has been a losing prospect for drug developers and has driven many of them to exit the antibiotic innovation space in the last few decades in favor of other therapeutic areas that have much larger markets and are easier areas to study. In order to make antibiotic development more attractive, various mechanisms have been proposed to stimulate or better reward successful clinical development. Incentives that can lower the financial risks associated with development include grants, tax credits, public-private partnerships, and intellectual property protections. Post-approval, prizes, advanced market commitments, and value-based pricing could all potentially provide additional incentives to invest in this research. Some potential incentives were discussed at the Incentives for Change: Addressing the Challenges in Antibacterial Drug Development workshop convened by Brookings in February 2013.

Balancing benefit and risk for severely-ill patients

Other incentives are related to the drug approval process. Novel mechanisms for expedited development and approval can speed time to market while still meeting traditional evidentiary requirements for safety and efficacy. In the last several years, a number of proposals – including from the Infectious Diseases Society of America and the President’s Council of Advisors on Science and Technology – have sought to reduce development time and cost and increase regulatory clarity through a more targeted clinical trial process directed at the highest-risk patients. A narrower study population would allow the U.S. Food and Drug Administration to make a more targeted assessment of the product’s safety, efficacy, and benefit-risk profile that could accelerate innovation for patients with serious drug-resistant infections. The need to steward these antibiotics, which was noted as a core action in the CDC report, would be especially important to both prevent the growth of resistance and to reduce the risk of adverse effects in less seriously-ill populations. Additional information on the proposed limited-use pathway and appropriate use is available on the Brookings website.

De-link reimbursement from return on investment

In order to attract investment for new antibiotic research, we must develop a business model that can support ongoing and expanding development without compromising the effectiveness of new therapies. Recognizing the need to “de-link” return on investment from the volume of antibiotics sold, efforts to move away from the volume-based reimbursement system could become an attractive path forward. Promising models, which were discussed at the Brookings workshop in February, included several guaranteed payment schemes supported by public funding. Taken to an extreme, such a system could even allow new antibiotics to be reserved indefinitely until needed, removing the developer’s incentive to sell any drugs in the years following approval. While such a program would likely be expensive (with sufficient returns estimated on the order of $1.75-2.5 billion over five years), government intervention is needed to fix this public health crisis and dangerous market failure. Its societal value in curtailing resistance and providing critical drugs would outweigh the cost to taxpayers.

The antibiotic development paradox will require a multi-pronged strategy that includes incentives to support front-end drug discovery and development, and new reimbursement policies that de-link unit volume sales from return on investment. However, this is by no means a quick fix. Even if this approach is successful, it will take decades for manufacturers to rebuild lost antibiotic development infrastructure and expertise, and to successfully develop and market new treatments. For the few drugs currently in development, even with expedited development and review pathways, they are still years from reaching the market.

Authors

Image Source: © Handout . / Reuters
       




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African Lions: A ‘new elite’ in the South African labor market?


While the South African labor market faces many large challenges, some more subtle trends might also be developing that undermine the country’s growth. Yes, the current level of unemployment stands at 24 percent. True, school dropout rates remain high: Only 50 percent of students will make it to the last year of high school, which means that the number of skilled workers in the country remains low. In addition, income inequality in South Africa is an overwhelming obstacle—with the country having one of the highest Gini coefficients (a statistical tool commonly used to measure inequality) in the world—and has been slowing its fight against poverty.

In their recent paper, Demographic, employment, and wage trends in South Africa, Haroon Bhorat, Karmen Naidoo, Morné Oosthuizen, and Kavisha Pillay examine important, perhaps precarious, trends in South African employment, such as the combination of South Africa’s weak educational system and labor demand biased toward skilled workers and the significant rise in temporary employment over full-time positions. However, the authors argue that perhaps the most interesting is the spike in public sector employment and the subsequent development of a new segment of the labor market, what they call a “new elite”: the unionized public sector employee.

The shift to services and the public sector

Like so many of sub-Saharan African countries, South Africa’s labor makeup (as well as contributions to GDP) has swiftly been shifting towards the services sector, especially since 2001. Table 1 clearly shows the dramatic shift in labor towards community, social, and personal (CSP) services and financial services: These two areas accounted for 73 percent of the shift in employment between 2001 and 2012 (Column 3). 

                                                            Employment Shares            Share of Change (ΔEi/ΔE) (a)   
   2001          2012   (2001-2012) 
Primary   0.15  0.07  -0.28
Agriculture   0.1  0.04  -0.2
Mining   0.05  0.02
 -0.08
Secondary   0.2  0.21
 0.21
Manufacturing   0.14  0.12
 0.04
Utilities   0.008  0.008
 0.004
Construction   0.05  0.07
 0.16
Tertiary   0.63  0.71
 1.08
Trade   0.21  0.21
 0.2
Transport   0.04  0.6  0.11
Financial  0.09  0.13  0.31
CSPS   0.17  0.22 0.42 
Private households   0.09  0.08  0.04
Total   1  1  1

Note: 1. CSPS stands for community, social, and personal services, which is predominantly made up of public sector employment.)

2.(a) The ratio of the percentage change in the share of employment to the overall change in employment over the period (share of change in employment). This measure shows, within each broad sector, where the sources of employment growth are. For example, employment in the tertiary sector is 1.08 times (or 108 percent of) the level of employment in 2001, which is the sum of the changes for all the industries within this sub-sector. CSPS then is the greatest contributor to employment growth in the tertiary sector.

Source: Bhorat et al. (2014) using PALMS dataset (2012).

Importantly, the authors emphasize, the CSP sector, which accounted for 42 percent of this shift, is mostly made up of public sector jobs—hinting that expansion of the public sector has contributed to this trend. The share of public sector employment rose to 17.5 percent by the end of 2014 from 14.2 percent in 2004. In addition, they note that the largest expansion of the public sector came in 2009, just after the global financial crisis, showing that the public sector was more capable of absorbing” excess unskilled and medium-skilled labor at times of economic and labor market distress.”

Another important trend the authors point to within the shift to the public sector between 2008 and 2014 is that a great number of jobs in which employment grew quickly involve unskilled workers (such as sweepers, farmhands and laborers, helpers and cleaners, construction and maintenance laborers, and garbage collectors) and medium-skilled workers (such as police and traffic officers, institution and home-based care workers, prison guards, cooks, and childcare workers) (Figure 1). For a deeper analysis of South African labor market’s skill needs, see the full paper.

Figure 1: Share of change in public sector jobs by detailed occupation (2008 Q1-2014 Q4)


Notes: These occupations are the largest 42 public sector occupations, making up 80 percent of total employment in the public sector in 2014, and 97 percent of the change in the number of public sector jobs over the 2008-14 period.

Source: StatsSA QLFS 2008Q1; StatsSA QLFS 2014Q4; own calculations.

From these trends, the authors infer that the South African government’s Expanded Public Works Program (EPWP)—which “creates jobs through government-funded infrastructure projects, through its non-profit organization and community work program, as well as through its public environment and culture programs”—has played a major part in the expansion of the public sector.

Interestingly, though, the authors also find that overall the public sector has a bigger proportion of high-skilled employees than the private sector), though, between 2008 and 2013 the public sector barely saw a change in its proportion of high-skilled workers. Rather, it experienced its largest growth in the medium- and low-skilled jobs, as noted in Figure 1. They note that this phenomenon suggests that “the state [is] able to absorb excess unskilled and medium-skilled labor at times of economic and labor market distress.” The private sector’s proportion of high-skilled workers, on the other hand, grew by 25 percent. There is then, they say, a “mismatch” between the supply and demand of South Africa’s labor market when it comes to high-skilled workers.

After exploring this trend, the authors also delve into the demographic differences between public and private sector workers. For example, they find that the average public sector worker is older (41 versus 38) and likely to have a higher educational level on average. There are more women in the public sector—52 percent compared to 44 percent. There are also more Africans—77 percent in the public sector (up from 72 percent in 2008) and 66 percent in the private sector (unchanged). The authors argue that these two statistics demonstrate that public sector has “transformed” its labor force at a faster pace since both are groups that historically have been marginalized in the South African labor market.

The impact of unions in the South African labor market

The public sector in South Africa also has a higher unionization rate: 69.2 percent compared to the private sector’s 24.4 percent rate in 2013). As public sector employment has grown, the authors say, so has its proportion of workers in unions. Unions in South Africa are influential, as the authors note, “Powerful labor unions are often associated with creating a wage premium for their members, given their ability to mobilize industrial action and negotiate in favor of their members during times of wage negotiations.”

Indeed, this seems to be the case. Past studies have found that bargaining power—as part of a bargaining council or a union—presents a wage premium.  The authors have similar results: The average public sector worker makes 11,668 rand ($1,209) per month compared to an average private sector employee (7,822 rand per month). Most importantly, though, when the authors disaggregate based on participation in a union, they actually find that, among non-unionized workers, the private sector employee actually receives a higher wage than the public sector worker, by about 952 rand per month. This finding, they say, suggests that the public sector premium might be tied to public sector union membership.

The authors admit a caveat: Public sector union workers tend to be white, older, and better educated than their non-unionized public sector counterparts. In fact, non-union public sector workers are 80 percent African and 10 percent colored[1] (two groups more likely to be under the EPWP). In addition, non-union occupations are usually less skilled (elementary occupations, service and sales occupations, and technical and associate professional occupations). However, they emphasize, “Ultimately though, the wage distributions above suggest that, at least in terms of earnings, a dual labor market may indeed be prevalent in the South African labor market.”  (For the authors’ full quantitative analysis, including an examination of how this trend interacts with state-owned enterprises and temporary workers, see the full paper.)

Thus, they argue, a “new labor elite” is forming.

Note: The African Lions project is a collaboration among United Nations University-World Institute for Development Economics Research (UNU-WIDER), the University of Cape Town’s Development Policy Research Unit (DPRU), and the Brookings Africa Growth Initiative, that provides an analytical basis for policy recommendations and value-added guidance to domestic policymakers in the fast-growing economies of Africa, as well as for the broader global community interested in the development of the region. The six papers, covering Mozambique, Kenya, Ghana, South Africa, Ethiopia, and Nigeria, explore the key constraints facing African economies as they attempt to maintain a long-run economic growth and development trajectory.


[1] In this paper, “African” is used to refer to people classified by the apartheid state as “native,” “Bantu,” or “black.” “Colored” refers mainly to people in the Western Cape province, and is an ethnic label for people of mixed ethnic origin who possess ancestry from Europe, Asia, and various Khoisan and Bantu tribes of Southern Africa.

Authors

  • Christina Golubski