Event Information

Under the Food and Drug Administration Amendments Act (FDAAA) of 2007, the FDA has the authority to require pharmaceutical manufacturers to develop Risk Evaluation and Mitigation Strategies (REMS) for drugs or biologics that carry serious potential or known risks. Since that time, the REMS program has become an important tool in ensuring that riskier drugs are used safely, and it has allowed FDA to facilitate access to a host of drugs that may not otherwise have been approved. However, concerns have arisen regarding the effects of REMS programs on patient access to products, as well as the undue burden that the requirements place on the health care system. In response to these concerns, FDA has initiated reform efforts aimed at improving the standardization, assessment, and integration of REMS within the health care system. As part of this broader initiative, the agency is pursuing four priority projects, one of which focuses on improving provider-patient benefit-risk counseling for drugs that have a REMS attached.

Under a cooperative agreement with FDA, the Center for Health Policy at Brookings held an expert workshop on July 24 titled, “Risk Evaluation and Mitigation Strategies (REMS): Building a Framework for Effective Patient Counseling on Medication Risks and Benefits”. This workshop was the first in a series of convening activities that will seek input from stakeholders across academia, industry, health systems, and patient advocacy groups, among others. Through these activities, Brookings and FDA will further develop and refine an evidence-based framework of best practices and principles that can be used to inform the development and effective use of REMS tools and processes.

Event Materials

• REMS_PBRC_Meeting_Agenda
• REMS BR Speaker Bios
• REMS BenefitRisk Meeting Summary
• REMS BenefitRisk communication white paper

       

Issuing work permits to refugees in return for donor support for jobs is seen as a “win-win-win” for refugees, host countries, and the international community. It would stem the flow of refugees to Europe, decrease the dangers of radicalization, and prevent the exploitation of refugees as a source of cheap labor. At last February’s “Supporting Syria and the Region” conference co-hosted by the U.K., Germany, Kuwait, Norway, and the United Nations, former British Foreign Secretary David Miliband called for a million work permits to be made available to Syrians, 200,000 each in Jordan and Lebanon and 600,000 in Turkey.

Turkey issued a decree in January 2016 allowing work permits for Syrians. Jordan also agreed to provide work permits for up to 200,000 Syrians over a number of years in exchange for aid and the opening of European markets to goods produced or special economic zones—all this to lead to jobs for one million Jordanians as well when other aid and spending is added in. Lebanon, whose fragile confessional politics makes the one million plus Sunni refugees a more palpable threat, has chosen not to issue work permits. Yet, according to the International Labor Organization (ILO), “around half of (working age) Syrian refugees are economically active and just one-third have access to overwhelmingly informal and low-skilled employment.” That’s around 165, 000 employed informally. The number is around 160,000 in Jordan  with 1.3 million Syrians and over 400,000 in Turkey with 2.7 million Syrian refugees.  

In Turkey and Jordan, as elsewhere, work permits are tied to employers who apply on behalf of employees once residency, registration, and health requirements are met. In both countries, employers must pay the legal minimum wage and social security payments. The permits are renewed annually. But, for the majority of Syrians working in labor markets with an abundance of local and foreign low-skill, low-wage workers, the pay is nowhere near the minimum wage. As to the promised jobs in the special zones, those will take time to materialize, and we already know that, at least in the garment sector, up to 80 percent of the workers are young women from South Asia, largely residing in dorms but at least receiving the minimum wage. Whether Syrians can adapt to this model remains to be seen. In both Jordan and Turkey, there are certain limits on the percentage of Syrians versus locals in many manufacturing and services jobs; in Jordan there is some evidence that “ghost” Jordanian workers are used to get around this requirement.

Jordan already has over 240,000 foreign workers, mainly Egyptians and Asians, who have work permits, with the total number including those working illegally may be as high as a million. There is a move to get Syrians to replace the foreign workers with permits but that seems a bit uncertain. It seems unlikely that employers will be eager to replace employees, often of long standing and for whom they have gone to the expense of getting work permits.  In Turkey, with fewer foreign workers, many locals work informally, though they tend to get paid significantly more than Syrians. The chances of employers hiking up wages to legalize Syrian employees, whether in Jordan or Turkey, are slim and the record to date appears to confirm this.   

In Jordan, the government provided a three-month grace period for workers to receive permits free of charge. Less than 2,000 permits had been granted by April. An ILO survey in Jordan, which looked at workers in the construction and agriculture sectors, noted that while 90 percent of workers had heard about the grace period, none in the agriculture sector and only 85 percent in construction had work permits, though almost all knew that getting caught might mean detention at the Azraq refugee camp. And an inability to pay social security constituted a major barrier. Often a concern is to go through employers to get the permit.  

In Turkey, the numbers are not encouraging either: By May, only 10,000 had actually registered for work permits. Refugees International reports that Turkey’s work permit program may end up benefitting 40,000 Syrians or roughly 10 percent of those actually working. The government, though, thinks that the program will eventually help all those currently working informally.

The ILO, United Nations High Commissioner for Refugees, and Refugees’ International have praised the Jordanian and Turkish governments for granting work permits. The decision was not easy and was politically charged in both countries. But the political and psychological significance of providing an opening for Syrians to slowly integrate themselves and move towards a stable future is certainly worth pursuing, even if it doesn’t bring immediate rewards. Already, Turkey allows Syrian doctors and medical personnel to work in health centers serving refugees. Over 4000 Syrian teachers have received stipends from a Ministry of Education program funded by UNICEF and western donors. And agricultural workers no longer need work permits so long as provincial governors give their approval.

Eventually delinking work permits from employers will help, and the ILO urges Jordan to do so for agricultural and construction workers. In both Jordan and Turkey, lowering social security payments would also smooth the transition. More support to vocational training, health care, education for children are other ideas being pursued. While making work permits available is not the same as a blanket “right-to-work” law for refugees, a right protected under the U.N. 1951 Refugee Convention but accepted in full neither by Jordan nor Turkey (however, the key international treaty that protects the right to work in binding form is the International Covenant on Economic, Social and Cultural Rights to which Jordan and Turkey are signatories), this is an opening and one that the international community should monitor and support. Aside from the February conference, other agreements—such as the one between the EU and Turkey and the upcoming EU deal with Lebanon and Jordan—provide suitable platforms towards improving on this initial phase.   

      

On Monday, the White House Council of Economic Advisers (CEA) released a report examining the long-term decline in the share of prime-age men (aged 25 to 54) who are either working or actively looking for work. What economists call the labor force participation rate for this population decreased from 98 percent in 1954 to 88 percent today, the second largest decrease among OECD countries. This trend has raised concerns not only for its impact on economic growth, but also because it seems to track an increase in mortality over that time, particularly among white males, as economists Anne Case and Angus Deaton have found.

The CEA report documents a number of possible explanations for this trend, including increasing rates of women in the workforce, rising disability insurance claims, falling demand for less-skilled workers, and barriers to employment for those with criminal records.

The report’s national analysis alone, however, obscures tremendous variation across the United States in employment among this critical group.

According to data from the Census Bureau’s American Community Survey, in 2014, 81 percent of prime-age men nationwide were employed (this statistic differs from the labor force participation rate in that it omits those who are looking for, but not in, work). Yet among the nation’s 374 metropolitan areas for which data are available, that rate ranged from over 93 percent in the oil boomtown of Midland, TX, to just over 50 percent in Kings County in California’s Central Valley.

There are clear regional patterns to this important statistic. Many of the metro areas with the highest employment rates for prime-age men are smaller places located in the middle of the country, from the Upper Midwest, to energy-rich areas in Texas and the Plains states, to the Intermountain West. In several large, economically dynamic metro areas such as Denver, Houston, Minneapolis, San Jose, and Washington, D.C., rates of work among prime-age men are also very high.

Of much greater concern is the large number of metropolitan regions with very low rates of work among prime-age men. These include many small former industrial centers in states like Michigan, Indiana, and Ohio; areas of West Virginia and Louisiana that rely on declining-employment industries like mining; and long-struggling agricultural economies in Arkansas, Texas, and inland California.

These patterns echo findings from the CEA report that falling demand for labor is an important part of the long-term decline in prime-age male employment. In many places where a high school diploma alone once provided the gateway to a middle-class job, nearly one-third of men in this age group are out of work. This is also evident in the local relationship between educational attainment and work—where educational attainment rates are higher among prime-age men, members of that group are more likely to be employed. A 10-percentage point difference in employment rates separates the most highly-educated quarter of metro areas from the least highly-educated quarter.

Beyond education, size seems to matter, too. Large metro areas exhibit higher rates of work among prime-age men than small metro areas. Across the 100 largest U.S. metro areas, 83.2 percent of prime-age males are employed, compared to 79.8 percent in the smaller 274 metro areas. This relationship partly reflects that men in large metro areas have higher rates of educational attainment than those in small metro areas. Yet even men who have no more than a high-school diploma work at higher rates in large metro areas (64 percent) than similarly educated men in smaller metro areas (62 percent). Larger regional economies with greater economic diversity may stimulate stronger demand for workers at lower skill levels.

Several of the policies that the CEA report recommends to improve prime-age male labor force participation, such as bolstering investment in public infrastructure, reforming unemployment insurance, and boosting educational attainment could help boost rates of work in lagging U.S. metro areas. However, none directly addresses the fact that problems in male employment disproportionately affect small and often economically isolated U.S. regions. This evidence suggests that policies to help dislocated workers relocate to larger, more economically dynamic metro areas—particularly by improving the supply of affordable housing in those regions—should be part of a comprehensive strategy to help reverse the troubling long-term decline in men’s work.

      

Unlike prime-age Americans, who have experienced declines in employment and labor force participation since the onset of the Great Recession, Americans past 60 have seen their employment and labor force participation rates increase.

In order to understand the contrasting labor force developments among the old, on the one hand, and the prime-aged, on the other, this paper develops and analyzes a new data file containing information on monthly labor force changes of adults interviewed in the Current Population Survey (CPS).

The paper documents notable differences among age groups with respect to the changes in labor force transition rates that have occurred over the past two decades. What is crucial for understanding the surprising strength of old-age labor force participation and employment are changes in labor force transition probabilities within and across age groups. The paper identifies several shifts that help account for the increase in old-age employment and labor force participation:

• Like workers in all age groups, workers in older groups saw a surge in monthly transitions from employment to unemployment in the Great Recession.
• Unlike workers in prime-age and younger groups, however, older workers also saw a sizeable decline in exits to nonparticipation during and after the recession. While the surge in exits from employment to unemployment tended to reduce the employment rates of all age groups, the drop in employment exits to nonparticipation among the aged tended to hold up labor force participation rates and employment rates among the elderly compared with the nonelderly. Among the elderly, but not the nonelderly, the exit rate from employment into nonparticipation fell more than the exit rate from employment into unemployment increased.
• The Great Recession and slow recovery from that recession made it harder for the unemployed to transition into employment. Exit rates from unemployment into employment fell sharply in all age groups, old and young.
• In contrast to unemployed workers in younger age groups, the unemployed in the oldest age groups also saw a drop in their exits to nonparticipation. Compared with the nonaged, this tended to help maintain the labor force participation rates of the old.
• Flows from out-of-the-labor-force status into employment have declined for most age groups, but they have declined the least or have actually increased modestly among older nonparticipants.

Some of the favorable trends seen in older age groups are likely to be explained, in part, by the substantial improvement in older Americans’ educational attainment. Better educated older people tend to have lower monthly flows from employment into unemployment and nonparticipation, and they have higher monthly flows from nonparticipant status into employment compared with less educated workers.

The policy implications of the paper are:

• A serious recession inflicts severe and immediate harm on workers and potential workers in all age groups, in the form of layoffs and depressed prospects for finding work.
• Unlike younger age groups, however, workers in older groups have high rates of voluntary exit from employment and the workforce, even when labor markets are strong. Consequently, reduced rates of voluntary exit from employment and the labor force can have an outsize impact on their employment and participation rates.
• The aged, as a whole, can therefore experience rising employment and participation rates even as a minority of aged workers suffer severe harm as a result of permanent job loss at an unexpectedly early age and exceptional difficulty finding a new job.
• Between 2001 and 2015, the old-age employment and participation rates rose, apparently signaling that older workers did not suffer severe harm in the Great Recession.
• Analysis of the gross flow data suggests, however, that the apparent improvements were the combined result of continued declines in age-specific voluntary exit rates, mostly from the ranks of the employed, and worsening reemployment rates among the unemployed. The older workers who suffered involuntary layoffs were more numerous than before the Great Recession, and they found it much harder to get reemployed than laid off workers in years before 2008. The turnover data show that it has proved much harder for these workers to recover from the loss of their late-career job loss.

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Editor's Note: This piece originally appeared on Lawfare.

The United States began to use drones in Yemen in 2002 to kill individuals affiliated with al-Qaida in the Arabian Peninsula (AQAP) and its predecessor organizations and disrupt its operations there and abroad. Since then, over 200 strikes have killed over a thousand Yemenis, tens of children, and at least a handful of U.S. citizens – one of whom was a deliberate target. The program has drawn widespread condemnation from human rights organizations and some UN bodies, yet it remains in place because the administrations of George W. Bush and Barack Obama view it as a success, as both have publicly stated.

Criticism of the program often takes the form of debates about which legal regime is relevant to judging a state’s use of targeted killings, which critics call “extra-judicial executions” or simply “assassinations.” While dissent has been strongest in academic and human rights communities, some scholars have echoed the arguments made by states that the imperatives of self-defense permit states to carry out such killings as legitimate acts of war. The Lawfare consensus seems in favor of these strikes.

I share the views of the moral and legal dissenters and hesitate to move beyond those debates because I don’t want to suggest that I accept the program’s legality. 

But I do want to engage those who do view the program as working — after all, if the U.S. administration did not believe it was working, it wouldn’t need to justify it legally. But by what metrics should we consider judging its success?

Perhaps the most obvious metric is whether AQAP leaders are actually being killed and, even more, whether their deaths substantially disrupted the group’s activities in Yemen or its ability to pursue objectives outside of Yemen. For advocates of this metric, the program has been successful in the short term — individuals killed – even if the longer-term impact is less clear because new leaders seem to step in with regularity.

Yet the success in taking out AQAP’s leadership is overstated. The numbers of AQAP members and supporters officially reported as killed are questionable, and probably grossly exaggerated. This is because the U.S. administration considers all adult males in the vicinity of the strikes to be combatants, not civilians, unless their civilian status can be established subsequently. Full investigations are neither desirable nor pragmatic for the U.S. government – particularly now that Yemen is the site of a civil and regional war. Even more troubling is that at times the U.S. may not even be certain of its primary targets. It frequently uses language that is so conditional that there seems to be more than a bit of guessing about the identities of those being targeted.

But I would like to focus on different metric: the longer-term impact of the drone strikes on the legitimacy and attractiveness of al-Qaida’s message in Yemen and its ability to recruit among Yemenis themselves. Drone strikes are widely reported in local media and online and are a regular topic of discussion at weekly qat chewing sessions across the country. Cell phone calls spike after drone strikes, which are also widely reported on Twitter and Facebook. The strikes are wildly unpopular, with attitudes toward the United States increasingly negative. An Arab Barometer survey carried out in 2007 found that 73.5 percent of Yemenis believed that U.S. involvement in the region justified attacks on Americans everywhere.

The narrative that the West, and especially the United States, fears the Muslim world is powerful and pervasive in the region. The U.S. intervenes regularly in regional politics and is a steadfast ally of Israel. It supports Saudi Arabia and numerous other authoritarian regimes that allow it to establish permanent U.S. military bases on Arab land. It cares more about oil and Israel than it does about the hundreds of millions in the region suffering under repressive regimes and lacking the most basic human securities. These ideas about the American role in Middle East affairs – many of them true – are among those in wide circulation in the region.

Al-Qaida has since 1998 advanced the argument that Muslims need to take up arms against the United States and its allied regimes in the region. Yet al-Qaida’s message largely fell on deaf ears in Yemen for many years. Yes, it did attract some followers, mostly those disappointed to have missed the chance to fight as mujahidin in Afghanistan. But al-Qaida’s narrative of attacking the foreign enemy at home did not resonate widely. The movement remained isolated for many years, garnering only limited sympathy from the local communities in which they sought refuge. 

 The dual effect of U.S. acceleration in drone strikes since 2010 and of their continued use during the “transitional” period that was intended to usher in more accountable governance has shown Yemenis how consistently their leaders will cede sovereignty and citizens’ security to the United States. While Yemenis may recognize that AQAP does target the United States, the hundreds of drone strikes are viewed as an excessive response. The weak sovereignty of the Yemeni state is then treated as the “problem” that has allowed AQAP to expand, even as state sovereignty has been directly undermined by U.S. policy – both under President Ali Abdullah Salih and during the transition. American “security” is placed above Yemeni security, with Yemeni sovereignty violated repeatedly in service of that cause. Regardless of what those in Washington view as valid and legitimate responses to “terrorist” threats, the reality for Yemenis is that the United States uses drone strikes regularly to run roughshod over Yemeni sovereignty in an effort to stop a handful of attacks – most of them failed – against U.S. targets. The fact that corrupt Yemeni leaders consent to the attacks makes little difference to public opinion.

Regardless of what those in Washington view as valid and legitimate responses to “terrorist” threats, the reality for Yemenis is that the United States uses drone strikes regularly to run roughshod over Yemeni sovereignty in an effort to stop a handful of attacks – most of them failed – against U.S. targets.

The United States cut aid to Yemen in 1990 when the newly united Yemeni state, which had just rotated into the Arab seat on the UN Security Council, voted against authorization for a U.S.-led coalition to reverse the Iraqi invasion of Kuwait. Yemen suffered a tremendous economic blow, as the United States joined Kuwait and Saudi Arabia in unilaterally severing aid to what was then and still is the poorest Arab nation. But with the rise of jihadi activism on the Arabian Peninsula over the next decade, and particularly after the bombing of USS Cole in 2000, Salih welcomed the return of U.S. aid to Yemen. This included a strong security dimension as the United States began tracking those suspected of involvement in the Cole attacks and other al-Qaida activities. Conspicuous caravans of FBI agents became a topic of local conversations, so the return of a U.S. presence in Yemen was also more visible than it had been previously. Salih claimed to have had advance knowledge of every drone strike.

Saudi Arabia has meddled in Yemen at least since the fall of the northern Mutawakkilite monarchy in the late 1960s. The Saudi intervention that began with air strikes in March of this year and escalated to ground troops is thus only the latest — and most egregious — of the kingdom’s efforts to affect Yemen politics. This background is necessary to understand that if Yemen is a “failed state,” despite scholarly protestations otherwise, it is at least in part due to decades of external actors violating Yemeni sovereignty with near impunity. The drone program, like the Saudi-led war, is merely a recent and overt example.

I lived in Yemen for several years spread over the period from 1994-1999. During that time, the optimism about the democratic opening of 1990 gave way to increasing frustrations as Salih solidified his control over united Yemen. He defeated the southern leadership in the 1994 war and curtailed the freedoms and pluralism that marked the early unification period, but open public debate has always been vibrant. Travel throughout Yemen was easy at that time, the only obstacle being the need to hire an all-terrain vehicle and driver who knew the many poorly marked roads.

The Yemenis I met cut across social classes and regions, but were overwhelmingly welcoming and friendly toward Americans. In my research on Islamist political parties in Yemen and Jordan, I talked to hundreds of self-described Islamists. I spoke to people in the larger cities, the smaller towns, and in rural areas. We spent long hours talking about Islam and debating the contemporary political problems facing Yemen, the United States, and the world. In 1995 we spoke extensively about race and class in America as Yemenis watched the O.J. Simpson trial on CNN International. I often marveled at the knowledge Yemenis had of the U.S. political system; I wondered if most Americans had comparable knowledge of any other country at all. I was welcomed into homes and shared holidays with families.

What strikes me now is how most Islamists saw jihadi groups as having no place in Yemeni politics. There were jihadis in Yemen, of course, primarily the “Afghan Arabs” who had returned from fighting abroad in Afghanistan and other theaters of jihad and faced difficulties reassimilating. Islamists donning mustaches complained about Taliban proclamations that adult male Muslims must sport a beard at least a fist long. They also complained of the Saudi-sponsored “scientific institutes” that taught the super-conservative Wahhabi take on Islam. Salih had even enjoined these extremists to launch deadly attacks against Southern socialists in the first years after unification. Most of the individuals influenced by these trends eventually found their way into al-Qaida circles.

But they were relatively few. Al-Qaida found little success in attracting Yemenis who were not already drawn to jihadi ideas. The al-Qaida recruiting pitch of attacking foreign powers inside of Yemen simply rang hollow. Even the 2000 attack upon USS Cole — a warship docked in Aden — was not widely viewed as the legitimate targeting of a foreign military power intervening in Yemeni politics. Al-Qaida had to resort to extremist tactics precisely because its ideas did not attract a following significant enough to spark a popular mobilization.

For al-Qaida, the drone program is a gift from the heavens. Its recruiting narrative exploits common misperceptions of American omnipotence, offering an alternative route to justice and empowerment. Regardless of American perceptions about the legitimacy or efficacy of the attacks, what Yemeni could now deny that the United States is waging an undeclared war on Yemen?

Most recently, this narrative of direct U.S. intervention has been further substantiated by U.S. material and intelligence support for the Saudi-led military campaign aimed at the return to power of the unpopular and exiled-President Abed Rabbo Mansour Hadi. Photographs of spent U.S.-made cluster bombs are widely circulated. Nor have drone attacks ceased; alongside the often indiscriminate Saudi-led bombing, American drones continue their campaign of targeted assassination. 

One might think that the Saudi attacks would not help al-Qaida, but it is contributing to al-Qaida’s growth in Yemen. The indiscriminate targeting of the Saudi-led campaign undermines any sense of security, let alone Yemeni sovereignty. And AQAP-controlled areas like the port of Mukalla are not being targeted by Saudi or Gulf troops at all. The United States aims to take up the job of targeting AQAP while the Saudi-led (and U.S.-backed) forces focus on defeating the Houthis and restoring Hadi to power. But the overall situation is one in which those multiple interventions in Yemen are creating an environment in which al-Qaida is beginning to appeal in ways it never had before.

For al-Qaida, the drone program is a gift from the heavens. Its recruiting narrative exploits common misperceptions of American omnipotence, offering an alternative route to justice and empowerment.

For these reasons, the U.S. use of drones to kill even carefully identified AQAP leaders in Yemen is counterproductive: it gives resonance to the claims of the very group it seeks to destroy. It provides evidence that al-Qaida’s claims and strategies are justified and that Yemenis cannot count on the state to protect them from threats foreign and domestic.

U.S. officials have argued that the drone program has not been used as a recruiting device for al-Qaida. But it is hard to ignore the evidence to the contrary, from counterinsurgency experts who have worked for the U.S. government to Yemeni voices like Farea Muslimi.

It’s not just that drone strikes make al-Qaida recruiting easier, true as that probably is, but that they broaden the social space in which al-Qaida can function. America does not need to win the “hearts and minds” of Yemenis in the service of some grand U.S. project in the region. But if America wants to weaken al-Qaida in Yemen, it needs at a minimum to stop pursuing policies that are bound to enrage and embitter Yemenis who might otherwise be neutral. 

There is an old saying that when the only tool you have is a hammer, everything starts to look like a nail. The U.S. military — let alone its drones — is not the only tool on which the United States can rely. But when the measure of success is as narrow as the killing of a specific person, the tool gets used with increasing frequency. Indeed, drone strikes have significantly expanded under the Obama administration.

It is crucial to see the bigger picture, the one in which long-time Yemeni friends tell me of growing anti-U.S. sentiment where there was previously very little. Public opinion toward America has clearly deteriorated over the past decade, and to reverse it may take much longer. But the use of drones to kill people deemed enemies of the United States, along with the Saudi-led war against the Houthis, is expanding the spaces in which al-Qaida is able to function.  

       

       

Abstract

Scaling up of development interventions is much debated today as a way to improve their impact and effectiveness. Based on a review of scaling up literature and practice, this paper develops a framework for the key dynamics that allow the scaling up process to happen. The authors explore the possible approaches and paths to scaling up, the drivers of expansion and of replication, the space that has to be created for interventions to grow, and the role of evaluation and of careful planning and implementation. They draw a number of lessons for the development analyst and practitioner. More than anything else, scaling up is about political and organizational leadership, about vision, values and mindset, and about incentives and accountability—all oriented to make scaling up a central element of individual, institutional, national and international development efforts. The paper concludes by highlighting some implications for aid and aid donors.

An annotated bibliography of the literature on scaling up and development aid effectiveness was created by Oksana Pidufala to supplement this working paper. Read more »

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It is well recognized across the health care industry that the major goals of the Affordable Care Act (ACA) include not only expanding health insurance coverage, but also improving the quality of care and the patient health care experience. A key strategy in achieving these goals is improving the efficiency and delivery of care through innovative financing mechanisms and new delivery models, such as Accountable Care Organizations (ACOs), patient-centered medical homes (PCMHs), bundled payments for acute and post-acute care, and population-based models that aim to improve the health of entire communities. These alternative models emphasize quality and outcomes, while moving care away from the traditional and predominant method of fee-for-service (FFS).¹

The Frontline Work Force
Many conversations focused on the implementation of these models typically emphasize the role of physicians. However, the success of these models relies heavily on the support and manpower of a multidisciplinary team; particularly "frontline health care workers." Frontline workers may include medical assistants (MAs), medical office assistants, pharmacy aides, and health care support workers. Oftentimes, they provide routine, critical care that does not require post-baccalaureate training.²

For example, MAs can play an important role in a medical home model. Upon discharge from the hospital, frontline workers can provide direct outreach to patients that are at high risk for readmission, and discuss any lingering symptoms, worsening of conditions, or medication issues. If necessary, MAs can assign a high-risk patient to a social worker, care coordinator or nurse.³

In a team care environment, frontline health care workers are essential for taking over routine tasks and allowing physicians to employ their specialized skills on their most complex patient cases, which allows all team members to work at “the top of their license”.⁴ Frontline workers can also bridge the gap between patients and a multitude of providers and specialists; help deliver care that is culturally and linguistically appropriate; and provide critical patient education and outreach outside of regular office visits. 

A Workforce in Need of Reform
While team-based care is widely accepted as an industry norm, its current infrastructure is not well-supported. While the frontline workforce represents nearly half of all health care professionals, they are markedly underpaid, underappreciated, and lack formal training to transition into higher-skilled and/or higher paid positions.

A recent study by the Brookings Metropolitan Policy Program “Part of the Solution: Pre-Baccalaureate Healthcare Workers in a Time of Health System Change” demonstrates this glaring disparity between current frontline workforce investment and its value to health reform efforts. The study analyzes the characteristics of the top ten ‘pre-baccalaureate health care workers’ (staff that holds less than an associate’s degree) within the US’s one-hundred largest metropolitan areas (see Table 1).

Table 1: Top ten pre-baccalaureate health care workers in the US’s top one-hundred metropolitan areas

Personal care aides represent a striking example of the underinvestment in frontline workers. The study shows that personal care aides have the lowest levels of educational attainment compared to their peers (32% have no more than a high school diploma), and have the lowest median earnings ($20,000 annually). Meanwhile, The Center for Health Workforce Studies’ (CHWS) estimates that this profession is among the top three national occupations with the highest projected job growth between 2010 and 2020. They are also in highest demand: between 2010 and 2020 there will be an estimated 600,000 personal aide vacancies.⁵ According to this study, MAs are also among the least educated and lowest paid frontline professions. Ninety percent lack a bachelor’s degree and a significant share (29%) are classified as ‘working poor.’

Policy Solutions

A number of policy solutions can be applied to enhance the frontline worker infrastructure. Our recommendations include:

Invest in front line health care workforce training and education. Case studies from a recent Engelberg Center toolkit, outlines how providers are training their frontline workforce to master fundamental skills including care management, patient engagement, teamwork, and technological savviness.

For example, a New Jersey ACO carried out clinical transformation by investing in new frontline staff, and by redefining the role of medical assistants to include health coaching. The return on investment for employers is potentially large. After injecting a substantial initial investment into this project, this ACO saw a 12.3% decrease in net health care costs within the first year of the program’s implementation; as well as significantly improved efficiency, quality of care and patient experience. As the educational curricula for frontline professions are largely variable, more attention should also be spent on the quality of educational content to train these occupations, as well as on developing an understanding of how delivery systems are augmenting traditional educational curricula.

2. Active inclusion of frontline health care workers in payment reform. Although the services of frontline health care workers are beginning to play a role in new payment models, typically frontline staff does not benefit directly from any bonus payments or shared savings incentives. However, their increasingly valuable role in the care team may warrant allowing frontline health care staff to be included in the receipt of shared savings and/or bonus payments based on the achievement of specifically tailored performance and outcomes targets.

The increasing demand for frontline health care workers, driven in part by the ACA’s payment and delivery reforms, will likely spell out a brighter future for these occupations, whose services had routinely been undervalued and underpaid. Future policy efforts should be focused on extending educational grants that have been aimed at primary care and nursing to frontline workers, as well as considering dedicating portions of shared savings to enhancing the earning potential for frontline workers. Some efforts, such as the U.S. Department of Labor’s recent rule to grant wage and overtime protections to home health and personal care aides, are early suggestions of a shift toward greater respect and empowerment for these occupations. It is yet to be seen what effects the continuation of such efforts will have on their high projected attrition trends.

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Since September of 2014, Jordan has joined other Western and Arab coalition partners in striking Islamic State (IS) positions in Syria, with the country’s King Abdullah framing the war against IS as a “third world war.” How have conflicts on Jordan’s borders and now the country’s direct intervention strained the country’s resources? How have the country’s leaders presented their participation at home and abroad?

In a timely Policy Briefing based on field research, Sultan Barakat and Andrew Leber assess Jordan’s vulnerabilities to regional conflicts and domestic pressures. Despite broad public support for action against IS, they note a growing gap between state and society only exacerbated by adverse events such as the capture and uncertain fate of a downed Jordanian pilot.

Read "Fortress Jordan: Putting the Money to Work"

Ultimately, Barakat and Leber note Jordan’s strategic importance to its allies but caution against it playing a front-line combat role. The authors contend that reducing threats to Jordanian stability lies not in “taking the fight to IS” abroad, but in strengthening Jordanian society at home.

While calling for improved governance in the Kingdom, the authors note reluctance on the part of Jordan’s ruling elites and their allies to promote full-scale political reforms. Barakat and Leber contend that they should therefore channel their fears about regional instability and extremism into productive action on Jordan’s economy. This will entail restructuring aid flows to the country toward productive investment, selectively incorporating Syrian refugees into the workforce, and putting forward a credible vision for the country’s economic future.

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Since it was created in 1935, Social Security has grown from covering about half of the work force to covering nearly all workers.  The largest remaining exempted group is a subset of state and local government workers (SLGWs).  As of 2008, Social Security did not cover about 27 percent of the 23.8 million SLGWs (Congressional Research Service 2011).  Non-coverage of SLGWs is concentrated in certain states scattered around the country and includes workers in a diverse set of jobs, ranging from administrators to custodial staff.  Some police and fire department employees are not covered.  About 40 percent of public school teachers are not covered by Social Security (Kan and Alderman 2014).    

Under current law, state and local governments that do not offer their own retirement plan must enroll their employees in Social Security.  But if it does offer a retirement plan, the state or local government can choose whether to enroll its workers in Social Security.  

This paper reviews and extends discussion on whether state and local government workers should face mandatory coverage in Social Security.^[1]  Relative to earlier work, we focus on links between this issue and recent developments in state and local pensions.  Although some of the issues apply equally to both existing and newly hired SLGWs, it is most natural to focus on whether newly hired employees should be brought into Social Security.^[2]  

The first thing to note about this topic is that it is purely a transitional issue.  If all SLGWs were already currently enrolled in Social Security, there would not be a serious discussion about whether they should be removed.  For example, there is no discussion of whether the existing three quarters of all SLGWs that are enrolled in Social Security should be removed from coverage.

Bringing state and local government workers into the system would allow Social Security to reach the goal of providing retirement security for all workers.  The effects on Social Security finances are mixed.  Bringing SLGWs into the system would also help shore up Social Security finances over the next few decades and, under common scoring methods, push the date of trust fund insolvency back by one year, but after that, the cost of increased benefit payments would offset those improvements. 

Mandatory coverage would also be fairer.  Other workers pay, via payroll taxes, the “legacy” costs associated with the creation of Social Security as a pay-as-you-go system.   Early generations of Social Security beneficiaries received far more in payouts than they contributed to the system and those net costs are now being paid by current and future generations.  There appears to be no convincing reason why certain state and local workers should be exempt from this societal obligation.  As a result of this fact and the short-term benefit to the program’s finances, most major proposals and commissions to reform Social Security and all commissions to shore up the long-term federal budget have included the idea of mandatory coverage of newly hired SLGWs.

While these issues are long-standing, recent developments concerning state and local pensions have raised the issue of mandatory coverage in a new light. Linking the funding status of state and local pension plans and the potential risk faced by those employees with the mandatory coverage question is a principal goal of this paper.  One factor is that many state and local government pension plans are facing significant underfunding of promised pension benefits.  In a few municipal bankruptcy cases, the reduction of promised benefits for both current employees and those who have already retired has been discussed.  The potential vulnerability of these benefits emphasizes the importance of Social Security coverage, and naturally invites a rethinking of whether newly hired SLGWs should be required to join the program.  On the other hand, the same pension funding problems imply that any policy that adds newly-hired workers to Social Security, and thus requires the state to pay its share of those contributions, would create added overall costs for state and local governments at a time when pension promises are already hard to meet.  The change might also divert a portion of existing employee or employer contributions to Social Security and away from the state pension program. 

We provide two key results linking state government pension funding status and SLGW coverage. First, we show that states with governmental pension plans that have greater levels of underfunding tend also to have a smaller proportion of SLGW workers that are covered by Social Security.  This tends to raise the retirement security risks faced by those workers and provides further fuel for mandatory coverage.  While one can debate whether future public pension commitments or future Social Security promises are more risky, a solution resulting in less of both is the worst possible outcome for the workers in question.  Second, we show that state pension benefit levels for career workers are somewhat compensatory, in that states with lower rates of Social Security coverage for SLGWs tend to have somewhat higher pension benefit levels.  The extent to which promised but underfunded benefits actually compensate for the higher risk to individual workers of non-Social Security coverage is an open question, though.  

Mandatory coverage of newly hired SLGWs could improve the security of their retirement benefits (by diversifying the sources of their retirement income), raise average benefit levels in many cases (even assuming significant changes in state and local government pensions in response to mandatory coverage), and would improve the quality of benefits received, including provisions for full inflation indexation, and dependent, survivor and disability benefits in Social Security that are superior to those in most state pension plans.  The ability to accrue and receive Social Security benefits would be particularly valuable for the many SLGWs who leave public service either without ever having been vested in a government pension or having been vested but not reaching the steep part of the benefit accrual path.  

Just as there is strong support for mandatory coverage in the Social Security community and literature, there is strong opposition to such a change in elements of the state and local government pension world.  The two groups that are most consistently and strongly opposed to mandatory coverage of newly hired SLGWs are the two parties most directly affected – state and local governments that do not already provide such coverage and their uncovered employees.  Opponents cite the higher cost to both employees and the state and local government for providing that coverage and the potential for losing currently promised pension benefits. They note that public pensions – unlike Social Security – can invest in risky assets and thus can provide better benefits at lower cost.  This, of course, is a best-case alternative as losses among those risky assets could also increase pressure on pension finances.

There is nothing inconsistent about the two sides of these arguments; one set tends to focus on benefits, the other on costs.  They can be, and probably are, all true simultaneously.  There is also a constitutional issue that used to hang over the whole debate – whether the federal government has the right to tax the states and local government units in their roles as employers – but that seems resolved at this point.

Section II of this paper discusses the history and current status of Social Security coverage for SLGWs.   Section III discusses mandatory coverage in the context of Social Security funding and the federal budget.  Section IV discusses the issues in the context of state and local budgets, existing pension plans, and the risks and benefits to employees of those governments.  Section V concludes.

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Note: A revised version of this paper is forthcoming in The Journal of Retirement.

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Editor’s Note: This blog post is one in a series of posts in which guest bloggers respond to the Brookings paper, “The potential and limitations of impact bonds: Lessons from the first five years of experience worldwide."

Constitutional mandate for ECD in Kenya

In 2014, clause 5 (1) of the County Early Childhood Education Bill 2014 declared free and compulsory early childhood education a right for all children in Kenya. Early childhood education (ECE) in Kenya has historically been located outside of the realm of government and placed under the purview of the community, religious institutions, and the private sector. The disparate and unstructured nature of ECE in the country has led to a proliferation of unregistered informal schools particularly in underprivileged communities. Most of these schools still charge relatively high fees and ancillary costs yet largely offer poor quality of education. Children from these preschools have poor cognitive development and inadequate school readiness upon entry into primary school.

Task to the county government

The Kenyan constitution places the responsibility and mandate of providing free, compulsory, and quality ECE on the county governments. It is an onerous challenge for these sub-national governments in taking on a large-scale critical function that has until now principally existed outside of government.

In Nairobi City County, out of over 250,000 ECE eligible children, only about 12,000 attend public preschools. Except for one or two notable public preschools, most have a poor reputation with parents. Due to limited access and demand for quality, the majority of Nairobi’s preschool eligible children are enrolled in private and informal schools. A recent study of the Mukuru slum of Nairobi shows that over 80 percent of 4- and 5-year-olds in this large slum area are enrolled in preschool, with 94 percent of them attending informal private schools.

In early 2015, the Governor of Nairobi City County, Dr. Evans Kidero, commissioned a taskforce to look into factors affecting access, equity, and quality of education in the county. The taskforce identified significant constraints including human capital and capacity gaps, material and infrastructure deficiencies, management and systemic inefficiencies that have led to a steady deterioration of education in the city to a point where the county consistently underperforms relative to other less resourced counties. 

Potential role of impact bonds

Nairobi City County now faces the challenge of designing and implementing a scalable model that will ensure access to quality early childhood education for all eligible children in the city by 2030. The sub-national government’s resources and implementation capacity are woefully inadequate to attain universal access in the near term, nor by the Sustainable Development Goal (SDG) deadline of 2030. However, there are potential opportunities to leverage emerging mechanisms for development financing to provide requisite resource additionality, private sector rigor, and performance management that will enable Nairobi to significantly advance the objective of ensuring ECE is available to all children in the county.

Social impact bonds (SIBs) are one form of innovative financing mechanism that have been used in developed countries to tap external resources to facilitate early childhood initiatives. This mechanism seeks to harness private finance to enable and support the implementation of social services. Government repays the investor contingent on the attainment of targeted outcomes. Where a donor agency is the outcomes funder instead of government, the mechanism is referred to as a development impact bond (DIB).

The recent Brookings study highlights some of the potential and limitations of impact bonds by researching in-depth the 38 impact bonds that had been contracted globally as of March, 2015. On the upside, the study shows that impact bonds have been successful in achieving a shift of government and service providers to outcomes. In addition, impact bonds have been able to foster collaboration among stakeholders including across levels of government, government agencies, and between the public and private sector. Another strength of impact bonds is their ability to build systems of monitoring and evaluation and establish processes of adaptive learning, both critical to achieving desirable ECD outcomes. On the downside, the report highlights some particular challenges and limitations of the impact bonds to date. These include the cost and complexity of putting the deals together, the need for appropriate legal and political environments and impact bonds’ inability thus far to demonstrate a large dent in the ever present challenge of achieving scale.

Challenges in implementing social impact bonds in Kenya

In the Kenyan context, especially at the sub-national level, there are two key challenges in implementing impact bonds.

To begin with, in the Kenyan context, the use of a SIB would invoke public-private partnership legislation, which prescribes highly stringent measures and extensive pre-qualification processes that are administered by the National Treasury and not at the county level. The complexity arises from the fact that SIBs constitute an inherent contingent liability to government as they expose it to fiscal risk resulting from a potential future public payment obligation to the private party in the project.

Another key challenge in a SIB is the fact that Government must pay for outcomes achieved and for often significant transaction costs, yet the SIB does not explicitly encompass financial additionality. Since government pays for outcomes in the end, the transaction costs and obligation to pay for outcomes could reduce interest from key decision-makers in government.

A modified model to deliver ECE in Nairobi City County

The above challenges notwithstanding, a combined approach of results-based financing and impact investing has high potential to mobilize both requisite resources and efficient capacity to deliver quality ECE in Nairobi City County. To establish an enabling foundation for the future inclusion of impact investing whilst beginning to address the immediate ECE challenge, Nairobi City County has designed and is in the process of rolling out a modified DIB. In this model, a pool of donor funds for education will be leveraged through the new Nairobi City County Education Trust (NCCET).

The model seeks to apply the basic principles of results-based financing, but in a structure adjusted to address aforementioned constraints. Whereas in the classical SIB and DIB mechanisms investors provide upfront capital and government and donors respectively repay the investment with a return for attained outcomes, the modified structure will incorporate only grant funding with no possibility for return of principal. Private service providers will be engaged to operate ECE centers, financed by the donor-funded NCCET. The operators will receive pre-set funding from the NCCET, but the county government will progressively absorb their costs as they achieve targeted outcomes, including salaries for top-performing teachers. As a result, high-performing providers will be able to make a small profit. The system is designed to incentivize teachers and progressively provide greater income for effective school operators, while enabling an ordered handover of funding responsibilities to government, thus providing for program sustainability.

Nairobi City County plans to build 97 new ECE centers, all of which are to be located in the slum areas. NCCET will complement this undertaking by structuring and implementing the new funding model to operationalize the schools. The structure aims to coordinate the actors involved in the program—donors, service providers, evaluators—whilst sensitizing and preparing government to engage the private sector in the provision of social services and the payment of outcomes thereof.

      

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.

       

       

Editor's Note: This article was originally published in Pediatrics, a subscription-only journal. To obtain a subscription or log in to access the full article, click here.

ABSTRACT

Building a strong foundation for healthy development in the early years of life is a prerequisite for individual well-being, economic productivity, and harmonious societies around the world. Growing scientific evidence also demonstrates that social and physical environments that threaten human development (because of scarcity, stress, or instability) can lead to short-term physiologic and psychological adjustments that are necessary for immediate survival and adaptation, but which may come at a significant cost to long-term outcomes in learning, behavior, health, and longevity. Generally speaking, ministries of health prioritize child survival and physical well-being, ministries of education focus on schooling, ministries of finance promote economic development, and ministries of welfare address breakdowns across multiple domains of function. Advances in the biological and social sciences offer a unifying framework for generating significant societal benefits by catalyzing greater synergy across these policy sectors. This synergy could inform more effective and efficient investments both to increase the survival of children born under adverse circumstances and to improve life outcomes for those who live beyond the early childhood period yet face high risks for diminished life prospects.

Read the full article at Pediatrics »

       

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Despite the notable success in enrolling children in primary school over the past decade, the education agenda is unfinished as millions of children are still excluded from learning opportunities and millions more leave school without having acquired the essential knowledge and skills needed to participate in society.

On January 27, the Center for Universal Education at Brookings hosted a half-day conference that focused on the research examining “what works in education” to achieve improved learning opportunities and outcomes. In addition to hearing from researchers studying the effectiveness of various education strategies, participants discussed how to facilitate a future research agenda that could have the most meaningful impact on learning. Senior Fellow Jacques van der Gaag moderated the discussion.

View the full event summary »

Transcript

• Improving Education in the Developing World: Evidence from Randomized Evaluations Presentation (.pdf)
• Sociocultural Gradients for Language Scores by Country Slide (.pdf)
• School Resources and Educational Outcomes in Developing Countries Presentation (.pdf)
• Making Learning for All a Reality Presentation (.pdf)
• Addressing the Global Learning Crisis Presentation (.pdf)

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• 0127_slide_vandergaag
• 0127_edinptoh
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• 0127_wagner

       

Event Information

On January 25, 2013, the Center for Universal Education at Brookings (CUE) and the UNESCO Institute for Statistics (UIS) hosted a technical workshop on national education accounts (NEAs). Participants discussed experiences and challenges related to developing various tools to track financial expenditures in education, with a focus on national education accounts. After discussing particular experiences with NEAs and the framework underlying them, participants worked to identify priorities for expanding their reach.

Jacques van der Gaag, from the Center for Universal Education opened the workshop by underlining its primary goals—to find out what different groups and individuals have been able to accomplish in relation to comprehensively tracking expenditures, connecting those expenditures with learning outcomes in education systems and collaborating where possible to advance the use of NEAs. Following this introduction, participants gave an overview of their experiences in using financial tracking tools and NEAs in particular. Igor Kheyfets of the World Bank presented BOOST, a tool that the World Bank has used over the past three years to bring together detailed data on public expenditures. Next, Jean Claude Ndabananiye, from UNESCO Pole de Dakar, discussed country status reports, which aggregate and analyze government data on expenditures. Afterward, Elise Legault of UIS described their collection of education statistics, which is completed through annual country questionnaires, of which one in particular has a finance focus. Quentin Wodon of the World Bank described other World Bank efforts aside from BOOST in capturing education finance data, including a cross-sector effort on public expenditure reviews (PERs).

Download the agenda »
Download the full summary »
Download USAID's National Education Accounts presentation »
Download the Estimation of Household Spending on Education Using Household Surveys presentation »
Download From Enrollment to Learning Outcomes: What Does the Shift in the Education Agenda Mean for NEAs? »
Download Thailand's National Education Accounts (NEA) »
Download the BOOST presentation »

Event Materials

• 0125_NEA_Agenda
• NEA_Event_Summary_Final
• BOOST presentation to NEA workshop at Brookings_final
• NEAs Presentation_van der Gaag
• Thai NEA
• USAID Creative_NEA_Presentation_25Jan13
• Pole de Dakar presentation Estimation of HH spending on education_2

       

       

       

Event Information

A conversation with Deputy Secretary of State Antony Blinken

One year after the White House Summit on Countering Violent Extremism, the United States continues to adapt its efforts to blunt the appeal of violent extremism. As part of this effort, the State Department is launching a series of new initiatives to better coordinate the U.S. response to terrorist propaganda and recruitment.

On February 16, the Foreign Policy program at Brookings hosted The Honorable Antony J. Blinken, deputy secretary of state, for a discussion of the United States’ civilian-led initiatives to counter the spread of the Islamic State and other violent extremist groups. Blinken will chart the path forward, to include partnerships with industry and civil society, and outlined the challenges that lie ahead.

Brookings President Strobe Talbott offered welcoming remarks. General John Allen, senior fellow and co-director of the Center for 21st Century Security and Intelligence at Brookings, introduced Deputy Secretary Blinken, and Tamara Cofman Wittes, senior fellow and director of the Center for Middle East Policy at Brookings, joined Deputy Secretary Blinken in conversation following his remarks.

Join the conversation on Twitter using #CVE

Video

• New frameworks for countering terrorism and violent extremism
• American diplomacy best instrument against extremism
• Islamic State numbers lowest since 2014
• Common denominators of violent extremists
• Progress in Syria against Islamic State

Audio

• New frameworks for countering terrorism and violent extremism

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160216_cve_blinken_transcript

      

How are two innovation districts in Stockholm successfully melding their tech and life science clusters to create new products?

What can the Wake Forest Innovation Quarter in North Carolina teach us about creating strong, vibrant, and innovative places?

How are innovation districts in Australia leveraging government policies and programs to accelerate their development?

Over the last year, members of the Anne T. and Robert M. Bass Initiative on Innovation and Placemaking team talked with hundreds of local leaders and practitioners advancing innovation districts in almost every global region. These conversations revealed the remarkable level of creativity and innovative, out-of-the-box thinking being employed to grow individual innovation districts.

In the course of our work, we have been intrigued by the question, is there value to be gained from a global network of innovation districts? To this end, we have reached out to successful global networks in Europe, the United States, and Asia to distill what it takes to make a strong and sustainable global network. Among our findings so far:

• Network members are solving on-the-ground challenges by talking with and learning from their peers. Several said that these horizontal exchanges are essential to leapfrogging ahead. 

• Online interaction is growing but network members say that face-to-face contact is critical. Comparing notes, asking questions, and engaging in conversations foster collaboration while maintaining a healthy dose of competition. 

• The right tools and supports can make all the difference. In networks where participants had full schedules, developing new ways to share intelligence, like early morning webinars or virtual conferences, regular e-newsletters, and simple methods to share data helped facilitate their learning. 

To what extent do you feel that a network of innovation districts might supercharge your own efforts and successes?

It would help our work tremendously if you could complete our on-line survey. It will take two minutes or less!

Editor's Note: If you're interested in receiving the latest news from the Bass Initiative, please sign up for our newsletter at this link, http://connect.brookings.edu/bass-initiative-newsletter-signup. Feel free to share it widely.

       

Critics of the nation's retirement system regularly complain that the system is in crisis. Too many private companies fail to offer their employees a retirement plan. Many employees who are covered by a plan fail to make contributions to it. Those who do make contributions may contribute too little or invest their savings unwisely. The end result: Many of us will reach retirement age with miniscule pensions or too little savings to enjoy a comfortable old age.

The argument that our retirement system has gaping holes is well founded. The notion that it faces an imminent "crisis" is nonsense. If the system currently faces a crisis, it has faced the same one for the past 40 years. While elderly Americans have seen their incomes and living standards improve in recent decades, the median working-age family has experienced little improvement in its real income. Nonelderly families that depend solely on the earnings of breadwinners who have below-average schooling saw a drop in their incomes.

In recent research with Brookings colleagues, I tracked the real incomes of families headed by aged and nonaged Americans. In the 34 years ending in 2012, the median real income of working-age families climbed a little more than 2 percent (in other words, by less than one-tenth of a percentage point per year). The median real income of families headed by someone past 62 increased a little more than 40 percent. The numbers suggest our retirement system is doing a decent job improving the living standards of the aged. Unfortunately, the labor market is doing a much worse job boosting the living standards of middle-class wage earners.

Critics of the retirement system might worry that it succeeds in protecting the incomes of the middle class elderly but fails to protect the incomes of the poor -- a concern not supported by the evidence. Income inequality has gone up among the elderly as it has among the nonelderly. But older low-income Americans have fared much better than low-income working-age adults. In the late 1950s, by far the highest poverty rate of any age group was that for people over 65. Even in the late 1980s, the elderly had a higher poverty rate than adults between 18-64. Since the middle of the last decade, however, the elderly have had the lowest poverty rate of any age group.

People who warn us of a retirement "crisis" are nonetheless correct in pointing to sizeable holes in the current system. Too few companies, especially small ones, offer their workers a retirement plan. According to recent government estimates, only about half of workers in companies with fewer than 100 employees are offered a retirement plan. Offer rates are higher in bigger companies and in government agencies, but about 30 percent of all employees are not offered any pension or retirement savings plan where they work. When retirement plans are offered, however, workers are very likely to participate in them -- even if they must make a voluntary contribution out of their pretax wages.

What is crucial for a retirement savings plan's success is automatic payroll withholding. Dollars that are withheld from workers' paychecks are harder for workers to spend on something other than retirement savings. A crucial improvement in our current system would be to require all employers to establish automatic payroll withholding for voluntary retirement savings in an IRA (individual retirement account). Companies that already offer a qualified pension or retirement savings plan should be exempt from any extra obligation.

The harshest critics of the current retirement system would go much further than this. Many want to bring back traditional retirement plans that guaranteed workers a specific monthly pension linked to their job tenure, final pay, and age at retirement. The advantages of such a plan for workers are that their employer is typically responsible for funding the plan and for ensuring that pensions are paid, regardless of the ups and downs of financial markets. A big disadvantage is that the promised benefits are not worth much if the worker's career with a company is cut short, either because of a layoff or quitting.

People who are nostalgic for old-fashioned pensions may be right that workers would prefer to be covered by such a plan, despite their disadvantages for short-tenure workers. I'm less persuaded that traditional pensions offer better protection to typical workers than modern 401(k)-type plans. Regardless of the pros and cons of the two kinds of plan, it is wildly unrealistic to think small employers or new employers will want to take on the risks and administrative burdens connected with an old-fashioned pension plan.

All U.S. workers are covered by a traditional, defined-benefit pension: it's called Social Security. It has worked well over the past four decades in protecting and even lifting the incomes of the retired elderly. It may not work as well in the future if benefits are cut substantially to keep the program solvent. Boosting workplace retirement savings is a sensible way to insure future retirees will have adequate incomes, even if Social Security benefits have to be trimmed. An essential first step to boosting savings is to require companies to put a retirement savings plan in every workplace.

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Editor's note: This piece originally appeared in Real Clear Markets.

       

Jamie Dimon, chief executive of JP Morgan Chase, this week announced a raise for his bank’s lowest pay employees. The company’s worst paid workers currently earn $10.15 an hour. By next February their pay will increase to at least $12 an hour, a jump of 18 percent. Dimon’s announcement follows widely reported wage hikes at Starbucks, Target, Walmart and other employers with sizeable numbers of low-pay workers.

These pay hikes signal further tightening in the nation’s job markets, including the market for low-wage workers. The drop in the unemployment rate below 5 percent has made it harder for employers to fill job vacancies, putting pressure on them to boost pay, both to attract new workers and to retain the ones already on their payrolls. Although highly compensated men have obtained the biggest pay increases in recent years, men and women earning bottom-end pay have fared better in the past year compared with workers in the middle of the earnings distribution.

The good news on the wage front tells us two things. First, the tightening of the job market is finally translating into gains for ordinary workers. More workers who want jobs are finding them. And adults who’ve managed to hang on to jobs are now enjoying faster growth in paychecks. Between 2011 and 2014, hourly pay gains averaged a little less than 2.0 percent a year. Since the end of 2014 they’ve averaged about 2.5 percent. The improvement in nominal pay gains has been magnified by exceptionally slow consumer price inflation. In the two years ending in May, real hourly pay has climbed 1.9 percent a year.

Second, the recent tilt in pay gains in favor of low wage workers shows that increases in the legal minimum wage can have an impact. Even though the federal minimum wage has remained at $7.25 an hour for the past seven years, 29 states have minimum wages above that level; 11 have a minimum equal to or greater than $9.00 an hour. Not surprisingly, low-wage workers in states that have recently raised minimum wages have seen faster gains than those in states that have left minimums unchanged. Since a growing number of states and localities are boosting minimum wage levels, this trend toward faster pay gains at the bottom may continue for a while.

The recovery from the Great Recession has been slow and disappointing, but it has been lengthy. One indicator that has been slowest to recover is wages. At long last wages are climbing, both in the middle and at the bottom of the pay scale.

       

Unlike prime-age Americans, who have experienced declines in employment and labor force participation since the onset of the Great Recession, Americans past 60 have seen their employment and labor force participation rates increase.

In order to understand the contrasting labor force developments among the old, on the one hand, and the prime-aged, on the other, this paper develops and analyzes a new data file containing information on monthly labor force changes of adults interviewed in the Current Population Survey (CPS).

The paper documents notable differences among age groups with respect to the changes in labor force transition rates that have occurred over the past two decades. What is crucial for understanding the surprising strength of old-age labor force participation and employment are changes in labor force transition probabilities within and across age groups. The paper identifies several shifts that help account for the increase in old-age employment and labor force participation:

• Like workers in all age groups, workers in older groups saw a surge in monthly transitions from employment to unemployment in the Great Recession.
• Unlike workers in prime-age and younger groups, however, older workers also saw a sizeable decline in exits to nonparticipation during and after the recession. While the surge in exits from employment to unemployment tended to reduce the employment rates of all age groups, the drop in employment exits to nonparticipation among the aged tended to hold up labor force participation rates and employment rates among the elderly compared with the nonelderly. Among the elderly, but not the nonelderly, the exit rate from employment into nonparticipation fell more than the exit rate from employment into unemployment increased.
• The Great Recession and slow recovery from that recession made it harder for the unemployed to transition into employment. Exit rates from unemployment into employment fell sharply in all age groups, old and young.
• In contrast to unemployed workers in younger age groups, the unemployed in the oldest age groups also saw a drop in their exits to nonparticipation. Compared with the nonaged, this tended to help maintain the labor force participation rates of the old.
• Flows from out-of-the-labor-force status into employment have declined for most age groups, but they have declined the least or have actually increased modestly among older nonparticipants.

Some of the favorable trends seen in older age groups are likely to be explained, in part, by the substantial improvement in older Americans’ educational attainment. Better educated older people tend to have lower monthly flows from employment into unemployment and nonparticipation, and they have higher monthly flows from nonparticipant status into employment compared with less educated workers.

The policy implications of the paper are:

• A serious recession inflicts severe and immediate harm on workers and potential workers in all age groups, in the form of layoffs and depressed prospects for finding work.
• Unlike younger age groups, however, workers in older groups have high rates of voluntary exit from employment and the workforce, even when labor markets are strong. Consequently, reduced rates of voluntary exit from employment and the labor force can have an outsize impact on their employment and participation rates.
• The aged, as a whole, can therefore experience rising employment and participation rates even as a minority of aged workers suffer severe harm as a result of permanent job loss at an unexpectedly early age and exceptional difficulty finding a new job.
• Between 2001 and 2015, the old-age employment and participation rates rose, apparently signaling that older workers did not suffer severe harm in the Great Recession.
• Analysis of the gross flow data suggests, however, that the apparent improvements were the combined result of continued declines in age-specific voluntary exit rates, mostly from the ranks of the employed, and worsening reemployment rates among the unemployed. The older workers who suffered involuntary layoffs were more numerous than before the Great Recession, and they found it much harder to get reemployed than laid off workers in years before 2008. The turnover data show that it has proved much harder for these workers to recover from the loss of their late-career job loss.

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The decision by the Federal Election Commission to defer action on new rules to constrain the activities of so-called 527 political organizations is being portrayed as an utter collapse of the new McCain-Feingold campaign finance law. In fact, nothing could be further from reality.

The dispute over whether several new Democratic-leaning independent political groups should be required to register with the FEC and abide by contribution limits is a legitimate one, and there is merit in the regulatory proposal — rejected by the full commission — that was offered by Commissioners Scott Thomas and Michael Toner. But this argument largely concerns unresolved questions stemming from judicial and FEC interpretations of the 1974 law that governs federal election law — not McCain-Feingold.

Had the Thomas-Toner proposal been adopted, the Media Fund and America Coming Together would have faced tougher requirements on the sources and amounts of contributions they receive. But supporters of the Media Fund and ACT still would have had legal options to continue their campaign activities. ACT would have had to raise more hard money to match its soft-money contributions, but it had already been moving in that direction, as had Moveon.org, which is now focusing its campaign activities on hard-money fundraising and expenditures.

Millionaire contributors to the Media Fund could have separately made independent expenditures in the form of television ads that expressly advocated the defeat of President Bush. Unions could have financed their own "issue ads" supporting Sen. John Kerry (D-Mass.) and attacking Bush until 30 days before the party convention or 60 days before the general election. Corporations would have retained the option to sponsor similar ads. Thereafter, even without FEC action, a key provision of McCain-Feingold kicks in. As the election nears, no 527 organization can use corporate or union money to finance broadcast ads that feature federal candidates.

McCain-Feingold was not written to bring every source of unregulated federal campaign funding within the scope of the law. Rather, it was designed to end the corrupting nexus of soft money that ties together officeholders, party officials and large donors. The law's principal goal was to prohibit elected officials and party leaders from extracting unregulated gifts from corporations, unions and individual donors in exchange for access to and influence with policymakers.

Indeed, the law has accomplished this objective. Members of Congress and national party officials are no longer soliciting unlimited contributions for the party committees, nor are they involved in the independent fundraising efforts of the leading 527 groups. The FEC's decision to defer action, therefore, does not pose the same risk of corruption as did the soft-money decisions of the past.

One of the fundamental concerns raised by the activities of 527s is that these groups, with their ability to receive unlimited contributions, would overshadow the candidates and weaken the role of parties in the electoral process. The new law, however, increased contribution limits to candidates and parties, to offset the effects of inflation and to ensure that parties remain major players in federal elections. Here, the evidence is overwhelming that the law's objective is being realized.

Bush and Kerry have both registered extraordinary fundraising success. Kerry has already raised more than $110 million, while the president has raised more than $200 million. In raising these sums, the presidential nominees have attracted the support of more than 500,000 donors who did not give money during the 2000 campaign. Congressional candidates, too, are also reaching out to new donors, with fundraising up 35 percent over the last cycle.

And in the first 15 months of this cycle, the national party committees have raised more than $430 million in hard money alone — $60 million more than they had raised in hard and soft money combined at the comparable point in the previous presidential cycle. This financial strength reflects the parties' success at adding more than 2 million new donors to their party rolls. For all the attention they are garnering, these 527 groups — both Democratic-leaning and Republican-leaning — pale when compared to the activities of the parties and candidates.

The 2004 elections have enormously high stakes. Supporters of Bush and Kerry are highly motivated to boost the election prospects of their favored candidate. All signs point to a vibrant get-out-the-vote effort by both parties and a rough equality in funding by and on behalf of the two major presidential campaigns. This reflects the 50/50 partisan division in the country and suggests that a disparity in resources is unlikely to determine the outcome of the presidential election.

The FEC has cheered some and disappointed others with its decision to defer new rulemaking on independent political organizations. While we empathize with the critics' concerns, we nonetheless take satisfaction that the major objectives of the new campaign-finance law are being realized.

      

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The 2008 elections showcased the power of the Internet to generate voter enthusiasm, mobilize volunteers and increase small-donor contributions. After the political world has been arguing about campaign finance policy for decades, the digital revolution has altered the calculus of participation.

On January 14, a joint project of the Campaign Finance Institute, American Enterprise Institute and the Brookings Institution unveiled a new report that seeks to change the ongoing national dialogue about money in politics. At this event, the four authors of the report will detail their findings and recommendations. Relying on lessons from the record-shattering 2008 elections and the rise of Internet campaigning, experts will present a new vision of how campaign finance and communications policy can help further democracy through broader participation.

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• Thomas Mann
• Michael Malbin
• Anthony Corrado
• Norm Ornstein

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• Campaign Reform in the Networked Age: Fostering Participation through Small Donors and Volunteers

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Executive Summary

The political world has been arguing about campaign finance policy for decades. A once rich conversation has become a stale two-sided battleground. One side sees contribution or spending limits as essential to restraining corruption, the appearance of corruption, or the “undue influence” of wealthy donors. The other resists any such limits in the name of free speech. The time has come to leap over this gulf and, as much as possible, move the disputes from the courts. Preventing corruption and protecting free speech should each be among the key goals of any policy regime, but they should not be the only objectives. This report seeks to change the ongoing conversation. Put simply, instead of focusing on attempts to further restrict the wealthy few, it seeks to focus on activating the many.

This is not a brief for deregulation. The members of this working group support limits on contributions to candidates and political parties. But we also recognize the limits of limits. More importantly, we believe that some of the key objectives can be pursued more effectively by expanding the playing field.

Interactive communications technology potentially can transform the political calculus. But technology alone cannot do the trick. Sound governmental policies will be essential: first, to protect the conditions under which a politically beneficial technology may flourish and, second, to encourage more candidates — particularly those below the top of the national ticket — to reach out to small donors and volunteers.

We focus on participation for two reasons. First, if enough people come into the system at the low end there may be less reason to worry about the top. Second, heightened participation would be healthy for its own sake. A more engaged citizenry would mean a greater share of the public following political events and participating in public life. And the evidence seems to suggest that giving and doing are reciprocal activities: volunteering stimulates giving, while giving small amounts seems to heighten non-financial forms of participation by people who feel more invested in the process.

For these reasons, we aim to promote equality and civic engagement by enlarging the participatory pie instead of shrinking it. The Supreme Court has ruled out pursuing equality or civic engagement by constraining speech. But the Court has never ruled out pursuing these goals through policies that do not constrain speech.

This report will show how to further these ends. The first half surveys current conditions; the second contains detailed recommendations for moving forward.

The report begins with new opportunities. The digital revolution is altering the calculus of participation by reducing the costs of both individual and collective action. Millions of American went online in 2008 to access campaign materials, comment on news reports, watch campaign videos and share information. The many can now communicate with the many without the intervention of elite or centralized organizations. This capacity has made new forms of political organizations easier to create, while permitting the traditional organizations — candidates and parties — to achieve unprecedented scales of citizen participation. No example better illustrates this potential than the Obama campaign of 2008, which is discussed at length in the full report.

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• Expanding Participation
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Tuesday night, President Obama presented four critical questions about the future of America and I should like to comment on the first two:

1. How to produce equal opportunity, emphasizing economic security for all.
2. In his words, “how do we make technology work for us, and not against us,” particularly to meet the “urgent challenges” of our days.

The challenges the president wishes to meet by means of technological development are climate change and cancer. Let’s consider cancer first. There are plenty of reasons to be skeptical: this is not the first presidential war against cancer, President Nixon tried that once and, alas cancer still has the upper hand. It is ironic that Mr. Obama chose this particular ”moonshot”, because not only are the technical aspects of cancer more uncertain than those of space travel, political support for the project is vastly different and we cannot be sure that even another Democrat in the White House would see this project to fruition. In effect, neither Mr. Obama nor his appointed “mission control”, Vice President Biden, have time in office to see fruits from their efforts on this front.

The second challenge the president wishes to address with technology is problematic beyond technical and economic feasibility (producing renewable energy at competitive prices); curbing carbon emissions has become politically intractable. The president correctly suggested that being leaders in the renewable energy markets of the future makes perfect business sense, even for global warming skeptics. Nevertheless, markets have a political economy, and current energy giants have a material interest in not allowing any changes to the rules that so favor them (including significant federal subsidies). Only when the costs of exploration, extraction, and distribution of fossil fuels rise above those of renewable sources, we can expect policy changes enabling an energy transition to become feasible. When renewables are competitive on a large scale, it is not very likely that their production will be controlled by new industrial players. Such is the political economy of free markets. What’s more, progressives should be wary of standard solutions that would raise the cost of energy (such as a tax on carbon emissions), because low income families are quite sensitive to energy prices; the cost of electricity, gas, and transportation is a far larger proportion of their income than that of their wealthier neighbors.

It’s odd that the president proposes technological solutions to challenges that call for a political solution. Again, in saying this, I’m allowing for the assumption that the technical side is manageable, which is not necessarily a sound assumption to make. The technical and economic complexity of these problems should only compound political hurdles. If I’m skeptical that technological fixes would curb carbon emissions or cure cancer, I am simply vexed by the president’s answer to the question on economic opportunity and security: expand the safety net. It is not that it wouldn’t work; it worked wonders creating prosperity and enlarging the middle-class in the post-World War II period. The problem is that enacting welfare state policies promises to be a hard political battle that, even if won, could result in pyrrhic victories. The greatest achievement of Mr. Obama expanding the safety net was, of course, the Affordable Care Act. But his policy success came at a very high cost: a majority of the voters have questions about the legitimacy of that policy. Even its eponymous name, Obamacare, was coined as a term of derision. It is bizarre that opposition to this reform is often found amidst people who benefit from it. We can blame the systematic campaign against it in every electoral contest, the legal subterfuges brought up to dismantle it (that ACA survived severely bruised), and the AM radio vitriol, but even controlling for the dirty war on healthcare reform, passing such as monumental legislation strictly across party lines has made it the lighting rod of distrust in government.

Progressives are free to try to increase economic opportunity following the welfare state textbook. They will meet the same opposition that Mr. Obama encountered. However, where progressives and conservatives could agree is about increasing opportunities for entrepreneurs, and nothing gives an edge to free enterprise more than innovation. Market competition is the selection mechanism by which an elite of enterprises rises from a legion created any given year; this elite, equipped with a new productive platform, can arm-wrestle markets from the old guard of incumbents. This is not the only way innovation takes place: monopolies and cartels can produce innovation, but with different outcomes. In competitive markets, innovation is the instrument of product differentiation; therefore, it improves quality and cuts consumer prices. In monopolistic markets, innovation also takes place, but generally as a monopolist’s effort to raise barriers to entry and secure high profits. Innovation can take place preserving social protections to the employees of the new industries, or it can undermine job security of its labor force (a concern with the sharing economy). These different modes of innovation are a function of the institutions that govern innovation, including industrial organization, labor and consumer protections.

What the President did not mention is that question two can answer question one: technological development can improve economic opportunity and security, and that is likely to be more politically feasible than addressing the challenges of climate change and cancer. Shaping the institutions that govern innovative activity to favor modes of innovation that benefit a broad base of society is an achievable goal, and could indeed be a standard by which his and future administrations are measured. This is so because these are not the province of the welfare state. They are policy domains that have historically enjoyed bipartisan consensus (such as federal R&D funding, private R&D tax credits) or low contestation (support for small business, tech transfer, loan guarantees).

As Mr. Obama himself suggested, technology can be indeed be made to work for us, all of us.