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Lebanon has formed a controversial new government in a polarised, charged atmosphere, and protesters are not going to be easily pacified by its promises, explains Rami Khoury.

The fourth consecutive month of Lebanon's unprecedented political and economic crisis kicked off this week with three dramatic developments that will interplay in the coming months to define the country's direction for years to come: Escalating protests on the streets, heightened security measures by an increasingly militarising state, and now, a new cabinet of controversial so-called "independent technocrats" led by Prime Minister-designate Hassan Diab.

Seeking to increase pressure on the political elite to act responsibly amid inaction vis-a-vis the slow collapse of the economy, the protesters had launched the fourth month of their protest movement, which had begun on 17 October last year, with a 'Week of Anger', stepping up their tactics and targeting banks and government institutions.





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Will the New Oil Pact Open a Broader Dialogue Between Trump and Putin?

Since President Trump moved into the White House, he has been eager for a dramatic initiative with Russian President Vladimir Putin, and he may finally have found one in Sunday’s announcement of a joint American-Russian-Saudi effort to stabilize world oil prices.




pac

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




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Micro-Multilateralism and the Impact of Urban Diplomacy on Global Diplomacy

Director of the Project on Europe and the Transatlantic Relationship and the Future of Diplomacy Project, Cathryn Clüver Ashbrook speaks to WDR 5 on micro-multilateralism and the impact of urban diplomacy global diplomacy, particularly on climate change.




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COVID-19 Impact Could Be As ‘Serious As a World War,’ Former Amb Says

European capitals are taking a variety of steps individually to try to beat back the outbreak. But few countries are working together to combat the spread of COVID-19, the disease caused by the novel coronavirus. 




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Asia Whole and Free? Assessing the Viability and Practicality of a Pacific NATO

This report will address four questions in the Pacific NATO debate. First, is there a historical precedent for a Pacific NATO? This report does find a precedent in the Southeast Asia Treaty Organization (SEATO), though it was largely unsuccessful due to its lack of regional adoption, weak mutual defense provisions, and ultimately became tainted by the Vietnam War.

Second, would such an alliance be necessary given the plethora of existing multilateral partnerships in the region? While there is a broad multilateral landscape in the Indo-Pacific, there is currently no agreement that combines both the wide reach and deep obligations of a hypothetical Pacific NATO. However, the Quad and RIMPAC do bring together many of the key Indo-Pacific powers and serve as an important foundation for U.S.-oriented multilateral regional security.

Third, how could such an alliance be structured? This report examines three options: expanding NATO’s mandate beyond Europe, building on its Enhanced Opportunity Partner (EOP) program, and creating a new alliance system. It also uses the case of Montenegro’s NATO accession to generate a broad set of criteria for future membership.

And fourth, how would Indo-Pacific nations, including China, respond to such an alliance? This would be exceedingly difficult. China has significant economic leverage over even our closest allies, like Australia and Japan.

Intractable internal disputes abound, particularly between South Korea and Japan and four nations—Malaysia, the Philippines, Taiwan, and Vietnam—with competing claims in the South China Sea. Two of the United States’ most important partners in the region, India and Singapore, have a longstanding aversion to exactly this type of alliance system. And for newer partners, like Malaysia and Indonesia, the value proposition is even less clear. The Chinese are likely to respond to any attempts at a multilateral military alliance in its backyard with a whole-of-government effort to stop it. If that alliance includes Taiwan, it could result in even more aggressive action.




pac

Lebanon has formed a controversial new government in a polarised, charged atmosphere, and protesters are not going to be easily pacified by its promises, explains Rami Khoury.

The fourth consecutive month of Lebanon's unprecedented political and economic crisis kicked off this week with three dramatic developments that will interplay in the coming months to define the country's direction for years to come: Escalating protests on the streets, heightened security measures by an increasingly militarising state, and now, a new cabinet of controversial so-called "independent technocrats" led by Prime Minister-designate Hassan Diab.

Seeking to increase pressure on the political elite to act responsibly amid inaction vis-a-vis the slow collapse of the economy, the protesters had launched the fourth month of their protest movement, which had begun on 17 October last year, with a 'Week of Anger', stepping up their tactics and targeting banks and government institutions.




pac

Lebanon has formed a controversial new government in a polarised, charged atmosphere, and protesters are not going to be easily pacified by its promises, explains Rami Khoury.

The fourth consecutive month of Lebanon's unprecedented political and economic crisis kicked off this week with three dramatic developments that will interplay in the coming months to define the country's direction for years to come: Escalating protests on the streets, heightened security measures by an increasingly militarising state, and now, a new cabinet of controversial so-called "independent technocrats" led by Prime Minister-designate Hassan Diab.

Seeking to increase pressure on the political elite to act responsibly amid inaction vis-a-vis the slow collapse of the economy, the protesters had launched the fourth month of their protest movement, which had begun on 17 October last year, with a 'Week of Anger', stepping up their tactics and targeting banks and government institutions.




pac

Will the New Oil Pact Open a Broader Dialogue Between Trump and Putin?

Since President Trump moved into the White House, he has been eager for a dramatic initiative with Russian President Vladimir Putin, and he may finally have found one in Sunday’s announcement of a joint American-Russian-Saudi effort to stabilize world oil prices.




pac

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




pac

Africa in the news: New EU-Africa strategy, impacts of the oil price crash, and spread of coronavirus

The European Union unveils its new Africa strategy On Monday, March 9, the European Union unveiled its new Africa engagement strategy, which the EU hopes will shift the relationship to one of more equal partnership. The new “Strategy with Africa” will focus on six areas of partnership: energy (especially green energy) access; digital transformation; sustainable…

       




pac

Africa in the news: COVID-19 impacts African economies and daily lives; clashes in the Sahel

African governments begin borrowing from IMF, World Bank to soften hit from COVID-19 This week, several countries and multilateral organizations announced additional measures to combat the economic fallout from COVID-19 in Africa. Among the actions taken by countries, Uganda’s central bank cut its benchmark interest rate by 1 percentage point to 8 percent and directed…

       




pac

NATO and outer space: Now what?

At the North Atlantic Treaty Organization’s (NATO) December 2019 Leader’s Summit in London, leaders acknowledged that technology is rapidly changing the international security environment, stating: “To stay secure, we must look to the future together. We are addressing the breadth and scale of new technologies to maintain our technological edge.”  Leaders also identified outer space…

       




pac

Webinar: Space junk—Addressing the orbital debris challenge

Decades of space activity have littered Earth’s orbit with orbital debris, popularly known as space junk. Objects in orbit include spent rocket bodies, inactive satellites, a wrench, and even a toothbrush. The current quantity and density of man-made debris significantly increases the odds of future collisions either as debris damages space systems or as colliding…

       




pac

Will the New Oil Pact Open a Broader Dialogue Between Trump and Putin?

Since President Trump moved into the White House, he has been eager for a dramatic initiative with Russian President Vladimir Putin, and he may finally have found one in Sunday’s announcement of a joint American-Russian-Saudi effort to stabilize world oil prices.




pac

COVID’s Broader Impacts: Risks and Recommendations

While the world’s health and economy are the clearest victims of COVID-19, the pandemic has impacted nearly every aspect of society – from national security to international relationships. We asked several of our experts to share their thoughts on risks and/or recommendations that policymakers and the public should consider in the coming weeks and months.




pac

Lebanon has formed a controversial new government in a polarised, charged atmosphere, and protesters are not going to be easily pacified by its promises, explains Rami Khoury.

The fourth consecutive month of Lebanon's unprecedented political and economic crisis kicked off this week with three dramatic developments that will interplay in the coming months to define the country's direction for years to come: Escalating protests on the streets, heightened security measures by an increasingly militarising state, and now, a new cabinet of controversial so-called "independent technocrats" led by Prime Minister-designate Hassan Diab.

Seeking to increase pressure on the political elite to act responsibly amid inaction vis-a-vis the slow collapse of the economy, the protesters had launched the fourth month of their protest movement, which had begun on 17 October last year, with a 'Week of Anger', stepping up their tactics and targeting banks and government institutions.




pac

The Impact of AI and Digitalization on Social Cohesion

February 24th, 2020, in Cambridge, Massachusetts, Dr. Gesche Joost, Professor of Design Research at the Berlin University of the Arts and head of the Design Research Lab since 2005, discussed the digital divide and how it will shape social connectivity in an event moderated by Cathryn Clüver Ashbrook, Executive Director of the Future of Diplomacy Project and the Project on Europe and the Transatlantic Relationship, and Lauren Zabierek, Executive Director of the Cyber Project.




pac

Hamilton unable to explain lack of Q3 pace

Lewis Hamilton could not explain his inability to perform in the final session of qualifying in China, which will see him start the race from sixth on the grid




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Alonso banking on Ferrari race pace

Fernando Alonso is banking on a strong performance in the race, after he claimed to have extracted everything possible from his Ferrari to take third in qualifying for the Chinese Grand Prix




pac

Hamilton: Ferrari pace a surprise

Lewis Hamilton admits he is surprised about Ferrari's competitive lap times in Friday practice but thinks he left plenty of time on the table from his own qualifying simulation




pac

Lebanon has formed a controversial new government in a polarised, charged atmosphere, and protesters are not going to be easily pacified by its promises, explains Rami Khoury.

The fourth consecutive month of Lebanon's unprecedented political and economic crisis kicked off this week with three dramatic developments that will interplay in the coming months to define the country's direction for years to come: Escalating protests on the streets, heightened security measures by an increasingly militarising state, and now, a new cabinet of controversial so-called "independent technocrats" led by Prime Minister-designate Hassan Diab.

Seeking to increase pressure on the political elite to act responsibly amid inaction vis-a-vis the slow collapse of the economy, the protesters had launched the fourth month of their protest movement, which had begun on 17 October last year, with a 'Week of Anger', stepping up their tactics and targeting banks and government institutions.




pac

Webinar: The impact of COVID-19 on prisons

Across America, incarcerated people are being hit hard by COVID-19. The infection rate in Washington, D.C., jails is 14 times higher than the general population of the city. In one Michigan correctional facility, more than 600 incarcerated people have tested positive — almost 50% of the prison's total population. In Arkansas, about 40% of the…

       




pac

Lebanon has formed a controversial new government in a polarised, charged atmosphere, and protesters are not going to be easily pacified by its promises, explains Rami Khoury.

The fourth consecutive month of Lebanon's unprecedented political and economic crisis kicked off this week with three dramatic developments that will interplay in the coming months to define the country's direction for years to come: Escalating protests on the streets, heightened security measures by an increasingly militarising state, and now, a new cabinet of controversial so-called "independent technocrats" led by Prime Minister-designate Hassan Diab.

Seeking to increase pressure on the political elite to act responsibly amid inaction vis-a-vis the slow collapse of the economy, the protesters had launched the fourth month of their protest movement, which had begun on 17 October last year, with a 'Week of Anger', stepping up their tactics and targeting banks and government institutions.




pac

McLaren needs a 'bucket load' of pace - Button

Jenson Button says McLaren needs a "bucket load" of both pace and reliability to get anywhere close to being competitive at the Australian Grand Prix this weekend




pac

Lebanon has formed a controversial new government in a polarised, charged atmosphere, and protesters are not going to be easily pacified by its promises, explains Rami Khoury.

The fourth consecutive month of Lebanon's unprecedented political and economic crisis kicked off this week with three dramatic developments that will interplay in the coming months to define the country's direction for years to come: Escalating protests on the streets, heightened security measures by an increasingly militarising state, and now, a new cabinet of controversial so-called "independent technocrats" led by Prime Minister-designate Hassan Diab.

Seeking to increase pressure on the political elite to act responsibly amid inaction vis-a-vis the slow collapse of the economy, the protesters had launched the fourth month of their protest movement, which had begun on 17 October last year, with a 'Week of Anger', stepping up their tactics and targeting banks and government institutions.




pac

COVID in the Maghreb: Responses and impacts

       




pac

A Crime Wave in Cyberspace

Listen to the chatter from top officials, and you’d think that World War III was about to break out on the Internet. The defense secretary is warning about a digital “Pearl Harbor.” Former director of national intelligence Mike McConnell declares that the United States is “fighting a cyber war, and we’re losing.” Every new hack brings more pronouncements of network doom.

The scare talk, however, is misplaced. Yes, we’re facing enormous cybersecurity problems — just look at the high-profile penetrations of such companies as Sony and Lockheed or the millions of Americans whose personal information has been stolen online.

But these aren’t signs of some impending cataclysmic showdown as I explain in my new cybersecurity paper for The Brookings Institution. They’re markers of a rising tide of online crime that, in its own way, could be more dangerous than a cyberwar. According to the British government, online thieves, scammers and industrial spies cost U.K. businesses an estimated $43.5 billion in the past year alone. Crooks-for-hire will infect a thousand computers for $7 — that’s how simple it’s become. Sixty thousand new malicious software variants are detected every day. Forget “Pearl Harbor”; if we’re not careful, the Internet could be in danger of looking like the South Bronx circa 1989 – a place where crooks hold such sway that honest people find it hard to live or work there.

Could there be some online conflict in the future? Maybe. But crooks are draining billions from the legitimate global economy right now. Even the Pentagon’s specialists are worried, noting in their new cybersecurity strategy that “the tools and techniques developed by cyber criminals are increasing in sophistication at an incredible rate.”

Those tools also are becoming easier to use. The latest crimeware makes stealing passwords about as simple as setting up Web pages. One gang, recently arrested, used it to drain $9.5 million in just three months.

Read the full article at washingtonpost.com >>

Authors

Publication: The Washington Post
      
 
 




pac

NATO and outer space: Now what?

At the North Atlantic Treaty Organization’s (NATO) December 2019 Leader’s Summit in London, leaders acknowledged that technology is rapidly changing the international security environment, stating: “To stay secure, we must look to the future together. We are addressing the breadth and scale of new technologies to maintain our technological edge.”  Leaders also identified outer space…

       




pac

Webinar: Space junk—Addressing the orbital debris challenge

Decades of space activity have littered Earth’s orbit with orbital debris, popularly known as space junk. Objects in orbit include spent rocket bodies, inactive satellites, a wrench, and even a toothbrush. The current quantity and density of man-made debris significantly increases the odds of future collisions either as debris damages space systems or as colliding…

       




pac

Turning back the Poverty Clock: How will COVID-19 impact the world’s poorest people?

The release of the IMF’s World Economic Outlook provides an initial country-by-country assessment of what might happen to the world economy in 2020 and 2021. Using the methods described in the World Poverty Clock, we ask what will happen to the number of poor people in the world—those living in households with less than $1.90…

       




pac

Webinar: The impact of COVID-19 on prisons

Across America, incarcerated people are being hit hard by COVID-19. The infection rate in Washington, D.C., jails is 14 times higher than the general population of the city. In one Michigan correctional facility, more than 600 incarcerated people have tested positive — almost 50% of the prison's total population. In Arkansas, about 40% of the…

       




pac

Impacts and implications of the 2020 Taiwan general elections

Taiwan held elections for the president and all the members of the Legislative Yuan on January 11. Although President Tsai Ing-wen had maintained a strong lead in the polls, there were questions about the reliability of some polls. Moreover, the outcome of the legislative elections was very uncertain. China, which has long made clear its…

       




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The fight for geopolitical supremacy in the Asia-Pacific

      
 
 




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Hutchins Center Fiscal Impact Measure

The Hutchins Center Fiscal Impact Measure shows how much local, state, and federal tax and spending policy adds to or subtracts from overall economic growth, and provides a near-term forecast of fiscal policies’ effects on economic activity. Editor’s Note: Due to significant uncertainty about the effect of the COVID-19 pandemic on the outlook for GDP…

       




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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.

Downloads

Authors

      




pac

On April 9, 2020, Vanda Felbab-Brown discussed “Is the War in Afghanistan Really Over?” via teleconference with the Pacific Council on International Policy.

On April 9, 2020, Vanda Felbab-Brown discussed "Is the War in Afghanistan Really Over?" via teleconference with the Pacific Council on International Policy.

       




pac

Africa in the news: COVID-19 impacts African economies and daily lives; clashes in the Sahel

African governments begin borrowing from IMF, World Bank to soften hit from COVID-19 This week, several countries and multilateral organizations announced additional measures to combat the economic fallout from COVID-19 in Africa. Among the actions taken by countries, Uganda’s central bank cut its benchmark interest rate by 1 percentage point to 8 percent and directed…

       




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On April 30, 2020, Vanda Felbab-Brown participated in an event with the Middle East Institute on the “Pandemic in Pakistan and Afghanistan: The Potential Social, Political and Economic Impact.”

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AdiEU: The impact of Brexit on UK cities

How will the U.K.'s cities be affected by Brexit? A new report from Metro Dynamics explores the significant impact Brexit will have on U.K. cities and shows why it is critical they have a seat at the table during exit negotiations with Brussels and in the creation of a new national budget.

      
 
 




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Perceived Impacts of International Service on Volunteers

International volunteer service is defined as an organized period of engagement and contribution to society by individuals who volunteer across an international border. There is growing interest in the potential of international service to foster international understanding between peoples and nations and to promote global citizenship and intercultural cooperation. Studies suggest that international service develops skills, mindsets, behaviors and networks that prepare volunteers for living and working in a knowledge-based global economy. Many believe that even short-term experiences abroad can begin to prepare participants for longer-term engagement and future international service.

International service may be growing in prevalence worldwide. In the United States, more than one million Americans reported volunteering abroad in 2008. Despite the scale of international service, its impacts are not well understood. Although there is a growing body of descriptive evidence about the various models and intended outcomes of international service, the overwhelming majority of research is based on case and cross-sectional studies, which do not permit conclusions about the impacts of international service. Scholars and practitioners in the field have called for rigorous research that documents impacts.

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Authors

  • Amanda Moore McBride
  • Benjamin J. Lough
  • Margaret Sherrard Sherraden
     
 
 




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Impacts of Malaria Interventions and their Potential Additional Humanitarian Benefits in Sub-Saharan Africa


INTRODUCTION

Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts.

National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being.

There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike.

The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts). Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts. However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits.

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Authors

Image Source: © Handout . / Reuters
      
 
 




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Youth and Civil Society Action on Sustainable Development Goals: New Multi-Stakeholder Framework Advanced at UN Asia-Pacific Hosted Forum


In late October at the United Nations Economic and Social Commission for Asia and the Pacific (UN ESCAP) headquarters in Bangkok, a multi-stakeholder coalition was launched to promote the role of youth and civil society in advancing post-2015 United Nations Sustainable Development Goals (SDGs). The youth initiatives, fostering regional integration and youth service impact in the Association of Southeast Asian Nations (ASEAN) and counterpart regions of Northeast and South Asia, will be furthered through a new Asia-Pacific Peace Service Alliance. The alliance is comprised of youth leaders, foundations, civil society entities, multilateral partners and U.N. agencies. Together, their initiatives illustrate the potential of youth and multi-stakeholder coalitions to scale impacts to meet SDG development targets through youth service and social media campaigns, and partnerships with multilateral agencies, nongovernmental organizations, corporations and research institutes.

The “Asia-Pacific Forum on Youth Volunteerism to Promote Participation in Development and Peace” at UN ESCAP featured a new joint partnership of the U.S. Peace Corps and the Korea International Cooperation Agency (KOICA) as well as USAID support for the ASEAN Youth Volunteering Program. With key leadership from ASEAN youth entitles, sponsor FK Norway, Youth Corps Singapore and Peace Corps’ innovative program in Thailand, the forum also furthered President Obama’s goal of Americans serving “side by side” with other nations’ volunteers. The multi-stakeholder Asia-Pacific alliance will be powered by creative youth action and a broad array of private and public partners from Thailand, Malaysia, Myanmar, Indonesia, Singapore, the Philippines, Australia, Korea, China, Mongolia, Japan, India, Nepal, Pakistan, the U.S. and other nations.

During the event, Dr. Shamshad Akhtar, ESCAP executive secretary, pointed out that “tapping youth potential is critical to shape our shared destiny, as they are a source of new ideas, talent and inspiration. For ESCAP and the United Nations, a dynamic youth agenda is vital to ensure the success of post-2015 sustainable development.”

Dr. Surin Pitsuwan, former ASEAN secretary-general, called for a new Asia-wide multilateralism engaging youth and civil society.  In his remarks, he drew from his experience in mobilizing Asian relief and recovery efforts after Cyclone Nargis devastated the delta region of Myanmar in May 2008. Surin, honorary Alliance chairman and this year’s recipient of the Harris Wofford Global Citizenship Award, also noted the necessity of a “spiritual evolution” to a common sense of well-being to redress the “present course of possible extinction” caused by global conflicts and climate challenges. He summoned Asia-Pacific youth, representing 60 percent of the world’s young population, to “be the change you want to see” and to “commit our youth to a useful cause for humanity.”

The potential for similar upscaled service efforts in Africa, weaving regional integration and youth volunteering impact, has been assessed in Brookings research and policy recommendations being implemented in the Common Market of Eastern and Southern Africa (COMESA). Recommendations, many of which COMESA and ASEAN are undertaking, include enabling youth entrepreneurship and service contributions to livelihoods in regional economic integration schemes, and commissioning third-party support for impact evidence research.

A good example of successful voluntary service contributions from which regional economic communities like ASEAN can learn a lot is the current Omnimed pilot research intervention in Uganda. In eastern Ugandan villages, 1,200 village health workers supported by volunteer medical doctors, Uganda’s Health Ministry, Peace Corps volunteers and Global Peace Women are addressing lifesaving maternal and child health outcomes furthering UNICEF’s campaign on “integrated health” addressing malaria, diarrheal disease and indoor cooking pollution. The effort has included construction of 15 secure water sources and 1,200 clean cook stoves along with randomized controlled trials.

Last week, the young leaders from more than 40 nations produced a “Bangkok Statement” outlining their policy guidance and practical steps to guide volunteering work plans for the new Asia-Pacific alliance. Youth service initiatives undertaken in “collective impact” clusters will focus on the environment (including clean water and solar villages), health service, entrepreneurship, youth roles in disaster preparedness and positive peace. The forum was co-convened by ESCAP, UNESCO, the Global Peace Foundation and the Global Young Leaders Academy.

      
 
 




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Reforming the Senate at a Snail’s Pace


As the clock runs out on the dysfunctional 112th Congress, few have been impressed by its paltry record and balky performance. But pardon my glee: December has been a great month for students of Congress. First, the House leadership was handed a blistering defeat on its “Plan B” to resolve the fiscal cliff. Next, while their leaders were meeting to negotiate an 11th hour of the 12th month fiscal cliff deal, eight senators unveiled a bipartisan proposal to head off a Democratic threat to change the rules by majority vote. When it rains, it pours!

The reform package—addressing “talking filibusters” and filibusters on procedural motions – deserves a bit more attention. And it deserves an appropriate historical illustration: To the right, a 1928 Chicago Tribune cartoon that features not the talking filibuster…but a sleeping one. Seems that talking filibusters might have been few and far between even back then.

Ezra Klein and Jon Bernstein have detailed the proposed changes and weighed in here and here, as has Steve Smith by tweet here and here. Since then, a coalition of nearly fifty liberal groups has rejected the proposal out of hand as watered down reform. To these several perspectives on the McCain-Levin plan, I would add the following thoughts:

First, these are at best incremental reforms. The majority leader would essentially gain the right to set the Senate’s agenda by majority vote, as a four-hour debate limit would be imposed on the motion to proceed. But the majority leader would pay a price for that new power: He would lose his power to block amendments (by “filling the tree”) and the minority bill manager and leader would be newly guaranteed an amendment each upon consideration of a legislative measure. (The majority leader, it seems, might still be able to fill the tree after the guaranteed amendments are dispensed with.) This change leaves untouched the sixty-vote threshold for invoking cloture on the measure or other amendments, similar to the plans of Democratic reformers. In short, the change tries to address the grievances of both the majority (by circumventing filibusters of the motion to proceed) and the minority (by creating and guaranteeing amendment opportunities).

Second, the incremental nature of the reforms is not accidental. Ezra has a point when he argues that this is “filibuster reform for people who don’t want to reform the filibuster.” Still, the incremental nature of the proposal strikes me as the price of negotiating procedural change in a legislative body whose rules already advantage the minority party: The majority gets a little only by giving a little. The barrier to reform is entrenched in the Senate’s cloture rule, given the supermajority required for ending filibusters of proposals that curtail minority rights. A Senate majority could circumvent that barrier by going nuclear with 51 votes, but that strategy is not cost-free. To be sure, reformers claim to have 51 votes for a reform-by-ruling move. But it’s not clear to me yet that the majority would be willing to pay the accompanying costs of weathering the minority’s response to going nuclear.

Third, the rules address leaders’ interests more so than those of the rank and file. Some of the proposed changes are aimed at time management. For example, with the consent of the majority and minority leaders and a bipartisan handful of senators , the cloture process is sped up markedly. Similarly, the three debatable steps required to get to conference are condensed to a single motion (albeit one still subject to sixty votes if the minority objects). Other proposed changes alleviate the minority leader from objecting on his colleagues’ behalf, undermining individual senators’ ability to threaten to filibuster without actually showing up. Then again, there’s no enforcement mechanism in the proposal: Senators would be counting on the minority leader to play by the new rules and to abandon his practice of lodging objections on behalf of his absent colleagues. It’s fair to be skeptical that such informal reforms would ever stick.

Fourth, I think there’s promise in the proposal’s directive to the presiding officer to put questions to a (majority) vote when opponents no longer seek to debate a bill. I share skeptics’ views that majorities might rarely want to hold the minority’s feet to the fire to wear down the opposition and that minorities might at times relish the spotlight while holding the floor. But the proposal strikes me as a potentially valuable chance to see if the change would make a difference. If approved, the McCain-Levin proposal would be adopted as a standing order of the Senate for just the upcoming Congress, providing a testing ground for this version of the talking filibuster. (Standing orders are typically approved opening day by unanimous consent; would there be such consent for McCain-Levin or another negotiated proposal?)

Finally, it may be that incremental procedural change is all that a polarized Senate can agree on—especially if some Democrats are skittish about changing the rules by majority vote. Granted, majority senators won’t agree to the plan if it’s perceived as empowering the minority, not the majority, as Senator Harkin has suggested. Nor should they. In that case, an incremental package may be more than a polarized Senate can agree on—leaving the nuclear option as the only avenue for Democrats seeking to rein in the excesses of the Senate minority’s parliamentary rights.

Authors

Publication: The Monkey Cage
Image Source: © Jason Reed / Reuters
     
 
 




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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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Making the Rescue Package Work: Asset and Equity Purchases

Executive Summary

If the main purpose of the Emergency Economic Stabilization Act of 2008 is to give banks confidence in each other, then enabling Treasury directly to bolster the capital positions of banks that need more capital may be an even more effective way to restoring confidence to the inter-bank market than the purchased of troubled assets. Whatever Congress may have intended about the pricing of the distressed assets, it also authorized a much more direct way to recapitalize the financial system and weak banks in particular: direct purchases by Treasury of securities that individual institutions may wish to issue to bolster their capital. At this writing, Treasury reportedly is considering ways do this. In this essay, we outline a specific bank recapitalization plan for Treasury to consider.

In particular, Treasury could announce its willingness to entertain applications for capital injections, using a set pricing formula. For publicly traded banks, Treasury could buy at the price as of a given date, such as the price one or more days before its plan was announced. For privately-owned banks, Treasury could use a price based on the average price-to-book value for publicly traded banks as of that date. To prevent government intrusion into the affairs of the banks, the stock should be non-voting. Treasury would make clear that it only would take minority positions. There should be no takeovers of more companies—AIG, Fannie and Freddie are quite enough. Treasury also should announce that it will dispose (or sell back to the bank) any stock acquired through these actions as soon as the financial system has stabilized and the bank is in sound financial condition (perhaps a time limit, such as three years, should be a working presumption).

We believe Treasury can accommodate a systematic recapitalization plan within the funding it has been given – initially $350 billion and another $350 billion later upon request to Congress (unless it disapproves) – by using the required disclosures about its asset purchases as a way of jump starting private sector pricing and trading of these securities. This should conserve Treasury’s resources it might otherwise use for asset purchases, and thus free up funds to recapitalize weak banks directly, but in an orderly fashion.

Treasury will have to be careful when it buys distressed assets to guard against the possibility that banks will just dump their worst stuff on taxpayers. The Department will also have to be careful when buying equity in banks. There cannot be an open invitation for bank owners to move assets out of the bank and then, in effect, say: “We don’t want this bank, you buy it.” To avoid this problem, Treasury should work closely with the FDIC and other regulators to determine whether or not a particular bank is eligible for an equity injection. The Department also may need to limit the scope of the recapitalization program to larger national banks, if it becomes infeasible to allow smaller banks to participate.

Making the Rescue Package Work: Asset and Equity Purchases [1]

The unprecedented financial rescue plan – technically the Emergency Economic Stabilization Act of 2008 (“EESA,” the “Act”, or the “plan”) -- has now been enacted by the Congress. One of the goals of the plan is to end the immediate panic in inter-bank lending markets, and on this basis several omens are not encouraging.

The Dow Jones stock index has been dropping daily, by large amounts, since EESA was enacted. The TED spread measures the difference between the interest rate on short term Treasury bills and the interest rate banks pay to borrow from each other (the LIBOR) and is a widely accepted measure of perceived risk in the financial sector. For several years this spread had hovered around 50 basis points or half a percentage point, reflecting the fact that lending to other financial institutions was considered almost as safe as buying Treasury bills. However, the spread shot up to 2.4 percentage points in July 2007 as the financial crisis hit, and it fluctuated widely in subsequent months. Following passage of the plan it remains even more elevated than it was last July—it was 3.8 percentage points as of October 7 and broke 4 percent on October 8. Financial institutions simply do not trust each other’s credit worthiness. Some of the market worries, of course, reflect the fragile state of the U.S. and global economies, but clearly the passage of the rescue plan itself has not calmed markets.

A second and related goal for the plan, according to media accounts, is to facilitate the recapitalization of the financial system, but the language of the bill is surprisingly coy about this. While the Act aims to “restore liquidity and stability to the financial system” it also directs the Treasury Secretary to prevent “unjust enrichment of financial institutions participating” in the asset purchase program. It is not yet clear whether Treasury will choose to recapitalize banks through its asset purchases – by buying them at prices above the values to which banks and other sellers have already written them down – or whether Treasury will simply use its purchases to stabilize prices for these securities and thus provide liquidity to the market, even if it may result in additional write-downs of their values (and thus additional reductions in capital).

Whatever Congress may have intended about the pricing of the distressed assets, it also authorized a much more direct way to recapitalize the financial system and weak banks in particular: direct purchases by Treasury of securities that individual institutions may wish to issue to bolster their capital. Of course, in normal times, such authority would be unnecessary because financial institutions would seek to tap private sources of capital first. But these are not normal times, to say the least.

If the main purpose of the plan is to give banks confidence in each other, then enabling Treasury directly to bolster the capital positions of banks that need more capital may be an even more effective way to restoring confidence to the inter-bank market. Accordingly, we outline here a possible supplementary bank recapitalization plan that we believe Treasury should pursue, at the same time it purchases distressed assets. As this paper is being completed on October 9, 2008, The New York Times reports that the Treasury is now considering such a move. We are encouraged by this and in this essay we provide both a rationale for doing so and some concrete suggestions for how such a direct recapitalization program might work. We do not support further nationalization of the banking system beyond what has already been done but we believe that the crisis has become so severe that the asset purchase plan on its own will not be enough to turn the current situation around. Additional capital is urgently needed and could be supplied by Treasury purchases of minority, non-voting equity stakes, or by warrants.

We believe Treasury can accommodate a systematic recapitalization plan within the funding it has been given – initially $350 billion and another $350 billion later upon request to Congress (unless it disapproves) – by using the required disclosures about its asset purchases as a way of jump starting private sector pricing and trading of these securities. This should conserve Treasury’s resources it might otherwise use for asset purchases, and thus free up funds to recapitalize weak banks directly, but in an orderly fashion, as we describe below.

Why Do Banks Need More Capital?

Financial institutions make money by borrowing money on favorable terms, that is, at low interest rates, and then lending it out at higher rates or by buying assets that yield higher returns. They may make money in other ways too, but the state of their balance sheets of assets and liabilities is crucial. In order to create a viable financial institution that can accommodate requests by depositors to take money out, someone has to put up capital and typically this comes from the equity in the company. The owners of the company have an incentive to keep this equity capital low and to build a large volume of borrowing and lending off a small base of capital—to increase leverage. This is because the profits earned are divided among the equity owners and the less capital there is, the higher the return on equity.

Governments for many years and in almost all countries have regulations in place setting capital requirements for banks in particular to stop them from taking too much risk in the pursuit of high returns and also protect any fund that insures their deposits against loss (the FDIC in this country). But some of our larger banks in recent years found a way around these rules by establishing “off-balance sheet” entities – Structured Investment Vehicles (“SIVs”) – to purchase mortgage-related and other asset-backed securities that the banks were issuing. In addition, large investment banks significantly increased their leverage in the years running up to the recent crisis, and were able to do so without mandated capital requirements. As a result, when the mortgage crisis hit, our financial system was weaker than was widely believed, and in the case of large banks in particular, than was officially reported.[2]

The mortgage crisis, which first surfaced in 2006 and has escalated rapidly since then, has hit bank balance sheets severely. As banks were forced to recognize losses on the mortgages they held in their portfolio, and especially to write down the values of their mortgage securities to their “market values” (even though the prices in those “markets” reflected relatively few “fire-sale” trades), they suffered reductions of their capital. Furthermore, the large banks that had created SIVs to escape such events found they could not hide from them when the SIVs could no longer roll over the commercial paper they had issued to finance their holdings of mortgage securities. To avoid dumping these securities on the market to satisfy their creditors, the banks took the SIVs back on their balance sheets, only to suffer further losses to their capital.

As we have seen, some of our largest banks – Washington Mutual and Wachovia, to name two – have not been able to survive all of this, and have been forced or are or being forced into the hands of stronger survivors. Other banks have been doing their best to shore up their capital bases by issuing new equity to replace the losses they have absorbed on delinquent loans and declining prices of their asset-backed securities. According to media reports, financial institutions (largely banks) worldwide have suffered over $700 billion in such losses to date, of which they replaced approximately $500 billion by issuing new equity.

But more losses are sure to come; indeed Secretary Paulson has said to expect further bank failures. Earlier this year, the International Monetary Fund projected that losses due to the credit crisis worldwide could hit $1 trillion. The IMF has recently upped that forecast to $1.4 trillion. If anything close to this latest forecast is realized, then many banks – here and abroad – will need to raise even more equity, but in a capital market that is now highly more risk averse than only a few months ago.

It is in this environment that banks have grown much less comfortable dealing with each other, even though they must to keep the financial system running. Every day, some banks have more cash on hand, or reserves, than they need to meet reserve requirements and ordinary demands for liquidity, while others are short of such funds. In the United States, banks thus trade with each other in the Federal Funds market while global banks borrow and lend to each other through the London Interbank market using the LIBOR rate of interest. The Federal Reserve’s main objective of monetary policy is to stabilize the “Fed funds” rate around a target, now just lowered to 1.5%, down from 2% where it has been for some months (and down from 5.25% before subprime mortgage crisis). To do so, the Fed has added a huge amount of liquidity to the financial system, even going so far this week as to buy up commercial paper issued by corporations, an unprecedented step. But the Fed does not and probably cannot control the longer term inter-bank market, in which banks lend to each other typically over a 3-month period.

The steep jump in the 3-month inter-bank lending rate – well over 4 percent – reflects two fundamental facts that EESA is designed to address. One is that banks don’t trust each others’ valuations of the mortgage and possibly other asset-backed securities they are all holding, precisely because the “markets” in those securities are so thin and thus not generating reliable prices. The second problem is that banks either are short of capital themselves, or fear that their counterparties are. No wonder that banks are so unwilling to lend to each other for a period even as short as three months – which in this environment, can seem like an eternity.

The capital shortage in the banking system, in particular, has severe implications for the rest of the economy. An institution that is short of capital is forced to cut back on its lending and this shows up in denials of lines of credit to companies and reductions in credit limits for consumers. Households cut back on spending; it is difficult to get a mortgage or a car loan; and companies reduce investment and curtail operations. And as we learn in any college course on banking, the impact of a loss of capital on bank lending can be multiplied. Each dollar of bank capital supports roughly ten dollars of overall lending in the economy. Each dollar of lost capital thus can result in ten dollars of lending contraction. The impact of an economy-wide bank contraction can be devastating for Main Street. The Great Depression was greatly exacerbated by the collapse of banks. The long stagnation in Japan was in large part the result of a failure to recapitalize the banks.

How bad is the current problem? We do not know how many banks, insurance companies or other financial institutions are in a weakened state, or perhaps even more important, may become weakened as the overall economy deteriorates. The official data published so far don’t really help on this score. The FDIC compiles information on the number and collective assets held by “problem banks,” or those in danger in failing. As of the second quarter of 2008, there were 117 such banks with assets of $78 billion up from 90 in the second quarter with assets of $28 billion., These figures did not include Washington Mutual, which would have failed had it not been bought by J.P. Morgan, or Wachovia, which at this writing, looks like it will be acquired by Wells Fargo (but also was in danger of failing without being acquired by someone). Together these banks hold more than $500 billion in customer deposits. Furthermore, according to recent media reports, even some large insurance companies (beyond AIG) may be having capital problems, having suffered large losses on the securities they hold in reserve to meet future claims.

Can the Asset Purchase Plan Succeed in Recapitalizing the Banks?

In principle, there are two ways in which the original Treasury asset purchase plan would recapitalize the banks. The first method is premised on the view that private markets are unwilling to supply capital to the banks because investors do not know how much their assets are worth. The Treasury, it is argued, would use its asset purchase plan as a way of revealing the prices of the assets and once that information is known, the banks will be able to raise new capital again from private markets. But better pricing will only attract capital if there are investors out there who are willing to supply it. Given the dramatic downturn in equities markets, finding such willing investors will be difficult, to say the least. Those investors that provided capital to banks early on in the crisis have been hit hard by the subsequent decline in equity prices and are reluctant to get burned again. When Bank of America said it would raise $10 billion from the markets, for example, its stock price fell sharply, suggesting there is a lot of market resistance to be overcome before private investors are willing to recapitalize the banking system.

Second, in principle, Treasury could recapitalize the banks by buying distressed assets at prices above those at which the securities are currently carried on the books of the institutions that sell them (original book or purchase value minus any write-offs).[3] In this case, the bank would be able to report a capital gain from its sale to the Treasury, a gain that would reverse, at least in part, the capital losses it had taken in the past and thereby add to its capital.

Treasury has said it will use reverse auctions[4] when it buys assets, and it is possible that the Department will be able to construct some auctions that will enable some holders of troubled assets to sell them to the Treasury at prices that earn a capital gain. But we are somewhat skeptical how many securities will fall into this category. For one thing, asset-backed securities are not homogenous, like traditional equity or bonds. In addition, it would be surprising in the current environment if reverse auctions would reveal prices that are above the written-down values of many of these securities. After all, an auction does not necessarily produce valuations that reflect the “hold to maturity” price rather than the “liquidation” price for the securities, as Fed Chairman Ben Bernanke suggested the purchase plan would accomplish.

Accordingly, we strongly suspect that Treasury will have to purchase many securities in one-on-one deals rather than through auctions. But in doing this, it may be both legally and politically difficult for the Treasury to pay prices in negotiations that are above the valuations banks or other sellers already have given them. Section 101 (e) of EESA specifically requires the Treasury Secretary “to take such steps as may be necessary to prevent unjust enrichment” of participating financial institutions, and Congress could construe such language to preclude such sales.[5] Furthermore, even if there were not a specific prohibition in the EESA, Treasury may wish to avoid the public criticism it would face if it purchased assets at prices that would allow participating institutions to book gains. And, in the case of sales at prices below the explicit or implicit price of the securities carried on an institution’s books, the sales will trigger further accounting losses and thus additional deductions from reported capital.

In short, we are not at all confident that the Treasury’s planned purchases of troubled securities, by themselves, will do much to recapitalize the banking system. This does not mean that the planned asset purchases will not deliver some needed help. Although at this writing the inter-bank lending market remains frozen even though EESA has been enacted and signed into law, one reason why banks and others may not yet have confidence that it will lead to a thaw in credit markets is that the guidelines for the asset purchases have not yet been issued. Once these guidelines are announced and the purchases begin, and the markets start to see real results, it is possible that some of the missing trust in the banking system will come back.[6]

However, Treasury may not need to spend, and for reasons elaborated below we do not believe it should spend, anywhere near the full $700 billion, or perhaps even most of the initial $350 billion tranche in borrowing authority, to liquefy the markets for mortgage and other asset-backed securities. EESA requires Treasury to publish (within two days) information about each of these purchases. We urge the Department to include in such publications (presumably on its website) regular data on the defaults and delinquencies to date of the loans underlying each batch of securities it purchases. Such information should enable financial institutions that are still holding similar securities not only to price them more accurately, but also to give market participants enough confidence to begin trading these securities without further Treasury purchases.

Husbanding its resources should be a prime objective for Treasury. In conducting its purchases of troubled assets, it should target first those asset categories that are the most illiquid. The main objective always should be jump-starting private sector activity or at least bringing greater clarity to the pricing of particular classes of securities. There is no need for Treasury, therefore, to make repeat purchases of similar securities (such as collateralized debt obligations issued within several months of each other, structured in roughly a similar way). Rather, the aim should be to make a market in as many different asset categories as are reasonably necessary to provide guidance to market participants, no more, no less.

Yet no one can be confident at this point that asset purchases alone will give banks sufficient confidence to begin dealing with each other at much lower interest rates. If the asset purchases do the trick, fine. But if they don’t, Treasury should make sure it has enough financial ammunition to pursue a second, more direct, strategy for restoring banks’ confidence – the direct bank recapitalization strategy to which we now turn.

Recapitalizing the Financial System Directly

Having the government put capital into financial institutions directly is not a new idea. It is the approach followed in this crisis for Fannie and Freddie and has been used in other countries. Sweden recapitalized its banks by adding capital to them during its crisis in the 1980s. Most recently, the British government has announced a sweeping bank recapitalization amidst the current crisis. And of more relevance to the U.S. situation, Congress specifically added authority in EESA for Treasury to make direct capital injections into banks.

In recent days, Treasury Secretary Paulson has acknowledged that the Department may take advantage of this authority and thus use some of its funds to buy equity in troubled banks. This is a welcome development. Even if Treasury’s asset purchase program restores confidence in the pricing of troubled securities, many banks still believe that many other banks lack sufficient capital, and thus can still be reluctant to lend to them. The fact that the FDIC stands ready (especially with its new unlimited line of credit at the Treasury) to assist acquiring banks in taking over failing banks is probably not sufficient, even with a successful Treasury asset purchase program, to provide this confidence. Bank lenders to failed banks can still lose money in such transactions, or at the very least may have difficulty accessing their funds for some period, at times when all banks seem to want or need as much liquidity as they can get.

How might such a capital injection program work? Treasury could announce its willingness to entertain applications for capital injections, using a set pricing formula. For publicly traded banks, Treasury could buy at the price as of a given date, such as the price one or more days before its plan was announced, as has been suggested by former St. Louis Federal Reserve Bank President William Poole.[7] For privately-owned banks, Treasury could use a price based on the average price-to-book value for publicly traded banks as of that date. To prevent government intrusion into the affairs of the banks, the stock should be non-voting. Treasury would make clear that it only would take minority positions. There should be no takeovers of more companies—AIG, Fannie and Freddie are quite enough. Treasury also should announce that it will dispose (or sell back to the bank) any stock acquired through these actions as soon as the financial system has stabilized and the bank is in sound financial condition (perhaps a time limit, such as three years, should be a working presumption).

The Treasury will have to be careful when it buys distressed assets to guard against the possibility that banks will just dump their worst stuff on the taxpayers. The Department also will have to be careful when buying equity in banks, especially if it decides to go for a broad, nationwide program. There cannot be an open invitation for owners to move assets out of the bank and then, in effect, say: “We don’t want this bank, you buy it.” This problem suggests that Treasury would need to work closely with the FDIC and other regulators to determine whether or not a particular bank is eligible for an equity injection. Treasury also may need to limit the scope of the program to larger banks, if it becomes infeasible to allow smaller banks to participate.

We presume that Treasury did not initially embrace the idea of a more systematic recapitalization of the banking system out of concern not to have any further government involvement in the banking system, especially on the heels of the Fannie/Freddie conservatorship and the Fed’s rescue of AIG. That Treasury is now considering direct capital injections indicates that this may no longer be a concern. In our view, limiting Treasury’s purchases to non-voting stock in any event would address this concern directly.

Conclusion

Ben Bernanke has compared the current financial crisis to a heart attack in the economy. For some heart attacks, it is enough to administer drugs and change diet and exercise habits. But in acute cases, major surgery is needed and the current crisis is in the acute phase. Direct surgery in the form of capital injected into financial institutions, along with direct asset purchases, should help calm the inter-banking lending market.

Based on recent monthly data it appears that GDP started to fall in mid-year and the economy is moving into recession so the proposals made here will not change that. Nor can the proposals compel banks to make loans to their traditional customers – consumers and businesses – in the current climate of fear. But Treasury can do something to mitigate that fear and thus, along with the recent further easing of monetary policy, likely additional fiscal stimulus and further homeowner relief, the Department will help reduce the severity of the current recession if it uses all the tools in its financial arsenal.



[1] Note: This is the second essay in a series on the financial crisis and how to respond. For the first essay, see http://www.brookings.edu/papers/2008/0922_fixing_finance_baily_litan.aspx

[2] The government’s reported bank capital ratios, for example, did not take account of the off-balance sheet assets and liabilities of the SIVs, which large banks later had to take back on their balance sheets directly.

[3] Some institutions holding these securities may not have fully marked them to “market” under current accounting rules, but instead simply have added to their reserves for possible future losses to reflect the likelihood of such write-downs. In the lattercase, the securities may implicitly be marked down by a percentage reflecting the loan loss reserve attributable to them. If this latter percentage is not publicly stated, Treasury may require participating institutions to break it out for the Department as a condition for participating in the program (and if the Department does not do this, it may be compelled to do so either by the Executive branch Oversight authority or the Congressional oversight committee established under the Act).

[4] A regular auction is where the seller puts an item out on the market and then potential buyers bid for it. The seller then takes the highest price. In a reverse auction, the buyer puts out a notice of what item he or she wants to buy and then sellers compete to supply this item. The buyer then chooses the lowest price. Reverse auctions are the way a lot of private companies and government entities manage their procurement processes.

[5] The rest of this subsection includes as an example of such unjust enrichment the sale of a troubled asset to the Treasury at a higher price than what the seller paid to acquire it. But this language is not exclusive. Congress, the public or the media could construe unjust enrichment also to include sales of securities at prices above those implicitly or explicitly carried by the institution on its books.

[6] The Treasury asset purchase plan would also a provide a valuable service by speeding the de-leveraging process. As we described earlier, banks are leveraged and hold capital that is only a fraction of their assets or liabilities. When they take a hit to their capital base, they must either replenish the capital or scale back their balance sheets. When it became impossible to sell the assets except at fire-sale prices, they were not able to do this. Selling the asset to the Treasury will help them scale down. To get bank lending going again, however, we want them to be able to make new lending, not to just scale back.

[7] Speech made at the National Association of Business Economists conference, Washington DC, October 6, 2008.

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