With more than 700 deaths reported over three days last week, and with a confirmed 800,000 more migrants waiting in Libya to attempt the crossing into Europe, it is becoming increasingly clear that Italy could become the new Greece in the global refugee crisis, and that the central Mediterranean could become the new Aegean.

The dirty deal cut between the European Union and Turkey this spring seems to be working: It’s effectively shut down the eastern Mediterranean route to Europe. But it has also pushed those attempting to reach the continent onto the arguably more dangerous central Mediterranean route, which claimed thousands of lives last summer. Now we’re seeing the consequences.

It’s clear that this crisis will not be resolved in Libya. The country may be ground zero for migration from North Africa to southern Europe—the result of a power vacuum left by Western powers after the fall of Muammar al-Qaddafi in 2011—but coming up with a solution that involves this troubled country will be difficult, to put it mildly. Libya is a failed state. Or rather, it is a jigsaw of four ethnic groups (Arab, Berber, Tuareg, and Toubou) and several dozen Ashraf tribes with no serious central authority to speak of. While a unity government and a draft constitution are in place, the former effectively controls only parts of Tripoli, while the latter is littered with both procedural deficiencies and substantive flaws.

Libya is also a security nightmare. The Islamic State controls over 150 miles of the coast around the city of Sirte, while dozens of militias vie for supremacy in localized, low-intensity conflicts throughout the country. The increasing military involvement of both the United States and its European allies in Libya is testimony to the concern elicited by the Islamic State’s presence. Were this not enough, Libya has a terrible record when it comes to its treatment of migrants and asylum seekers. The country never signed up to the 1951 Refugee Convention and its 1967 Protocol; it is host to detention centers where migrants survive in atrocious conditions; and it has signed up to appalling migration deals with Italy under Silvio Berlusconi. Multiple reports talk of the regular abuses, which include abysmal sanitary conditions, beatings, torture, hard labor, and even murder, which migrants have suffered in the country.

Up until recently, European officials appeared to be discussing plans to strike a deal with Libya similar to the one cut with Recep Tayyip Erdogan’s government in Turkey. Italian Interior Minister Angelino Alfano, for example, repeatedly claimed that what Europe needed was a migration compact with Libya along the lines of the one Brussels signed with Ankara in March. But such a deal, for the time being at least, is hardly a likely prospect. The deal with Turkey rested on the assumption that, with the right incentives in place, Ankara could exercise a baseline level of control over its borders. Brussels should not worry about Libya’s willingness to fulfill the key provisions of a similar migration compact. What Europeans should be concerned about, rather, is that the Libyan state—with its malfunctioning government, which lacks a bare minimum of administrative capacity—has no ability to fulfill them.

In the long run, Libya and Europe need to seek a comprehensive solution to this migration crisis. But with the high season for smuggling and trafficking across the Mediterranean almost upon us, an interim solution is critical.

Libya, which sits 280 miles from the southernmost point of mainland Italy, is the primary launching point for those seeking to cross from Africa to Europe. But it remains only one variable within the broader migration equation. An interim solution for the current crisis needs a broader focus and should involve three geographic areas: Libya, the countries sharing land borders with Libya, and the Mediterranean Sea itself.

In Libya, EU governments should pressure the unity government to immediately sign up to the 1951 Refugee Convention and its 1967 protocol. These would provide a firm legal framework within which all stakeholders would have to operate. Signing them would make it clear that Libya is ready to respect the rights of migrants under international law. And, crucially, it would mandate Libya to respect refugees’ right, in particular, to non-refoulement—that is, to not be returned to countries where they risk physical harm or abuse. Secondly and where the security situation allows, the International Committee of the Red Cross, the International Organization for Migration, and the Office of the United Nations High Commissioner for Refugees should be provided with all necessary means to massively scale up their presence in the country. By doing so, they would be able to become crucial representatives for the rights of migrants and asylum seekers.

Finally—and with the explicit permission of the unity government—the European Union should start patrolling Libyan territorial waters, while international humanitarian organizations must take over the management of Libyan detention centers where migrants are held. Because Libyan authorities do not exercise any meaningful control over the coastline and because they lack the resources to adequately administer the detention centers they are supposedly managing, these measures would only technically—but not substantively—infringe upon the central government’s sovereignty.

Europe must also seek to form partnerships with Libya’s neighbors—a strategy it appears to be beginning to pursue. Countries sharing land borders with Libya have a significant comparative advantage over Tripoli when it comes to being candidates for partnerships: They have (relatively) stable governments. Algeria, Chad, Egypt, Niger, Sudan, and Tunisia face tremendous challenges in a variety of policy areas, yet they have the bare minimum of what it takes to resolve those challenges: established state structures.

These countries are often the countries of origin or earlier transit for the sub-Saharan migrants who converge on Libya as a springboard to Europe. Crucially, the European Union has a well-established relationship with all these governments through the second revision of the Cotonou Agreement between the European Union and African, Caribbean, and Pacific countries. More specifically, the Khartoum Process for East Africa, the Rabat Process for West Africa, and the EU strategy for the Sahel provide regional frameworks within which Europe and its partner countries can address migration issues. These regular and structured dialogues between European and African governments provide a system of financial and diplomatic rewards for African countries that proactively engage with migration issues. In particular, they’ve resulted in concrete projects that aim to discourage irregular migration by establishing readmission agreements while providing legal avenues for those trying to get to Europe, such as temporary migration plans.

It is high time for Brussels to further increase cooperation by providing additional resources to address migration issues: Europe must enable its African partners to set up projects that contribute to creating employment opportunities, ensuring food and nutrition security, improving migration management, and promoting conflict prevention. The EU Emergency Trust Fund for Africa should substantially be boosted for this purpose.

Europe appears to be taking steps to make migration control a cornerstone of its relationship with its African neighbors. Ad hoc migration compacts are in the works with selected origin and transit countries, including Ethiopia, Mali, Niger, Nigeria and Senegal, and proposals are being made to launch a comprehensive €62 billion investment plan to tackle the long-term root causes of economic migration. The EU has renewed its focus on re-admissions to these countries, prioritizing speedy returns for those whose asylum claims are rejected over establishing formal readmission agreements, which is a sign of Europe’s determination to push this through—though also a warning of the potential dodginess of the various deals in the making.

Lastly, Brussels must do its homework where it is most able to bring about change: in the Mediterranean Sea and along Europe’s southern coast. The EU’s naval Operation Sophia in the south-central Mediterranean is trying to tackle migrant smuggling at sea. Its geographic scope, however, is significantly more limited compared with the Operation Mare Nostrum carried out by the Italian Navy and later superseded by Frontex’s Operation Triton. This should be expanded again. At the same time, the mandate of the operation should be widened to explicitly encourage search-and-rescue operations on top of its primary aim of disrupting smugglers’ networks. On its Italian shores, Europe should intensify its support for Italian authorities engaged in the establishment and management of so-called migrant hot spots. Indeed, while Rome has fulfilled most of its obligations by setting up new headquarters and boosting its processing rates, its European partners are struggling to make available specialized personnel for the hot spots and to relocate migrants already in Italy.

The ideas above are only a short-term interim solution, however. In the medium to long term, the international community needs to address the tremendous underlying challenges producing chaos in Libya. The newly established Government of National Accord must secure the support of all ethnic groups and major tribes. Having done that, the Islamic State must be rooted out through a very high-intensity but hopefully brief and localized conflict. Finally, a minimum degree of administrative capacity must be re-established beyond Tripoli.

All of the above require meaningful engagement with Libya on the part of Europe that will probably take years to reap benefits. Until that is forthcoming, an interim solution must be found, for the sake of the hundreds of thousands of lives at risk.

The piece was originally published in Foreign Policy. 

With more than 700 deaths reported over three days last week, and with a confirmed 800,000 more migrants waiting in Libya to attempt the crossing into Europe, it is becoming increasingly clear that Italy could become the new Greece in the global refugee crisis, and that the central Mediterranean could become the new Aegean.

The dirty deal cut between the European Union and Turkey this spring seems to be working: It’s effectively shut down the eastern Mediterranean route to Europe. But it has also pushed those attempting to reach the continent onto the arguably more dangerous central Mediterranean route, which claimed thousands of lives last summer. Now we’re seeing the consequences.

It’s clear that this crisis will not be resolved in Libya. The country may be ground zero for migration from North Africa to southern Europe—the result of a power vacuum left by Western powers after the fall of Muammar al-Qaddafi in 2011—but coming up with a solution that involves this troubled country will be difficult, to put it mildly. Libya is a failed state. Or rather, it is a jigsaw of four ethnic groups (Arab, Berber, Tuareg, and Toubou) and several dozen Ashraf tribes with no serious central authority to speak of. While a unity government and a draft constitution are in place, the former effectively controls only parts of Tripoli, while the latter is littered with both procedural deficiencies and substantive flaws.

Libya is also a security nightmare. The Islamic State controls over 150 miles of the coast around the city of Sirte, while dozens of militias vie for supremacy in localized, low-intensity conflicts throughout the country. The increasing military involvement of both the United States and its European allies in Libya is testimony to the concern elicited by the Islamic State’s presence. Were this not enough, Libya has a terrible record when it comes to its treatment of migrants and asylum seekers. The country never signed up to the 1951 Refugee Convention and its 1967 Protocol; it is host to detention centers where migrants survive in atrocious conditions; and it has signed up to appalling migration deals with Italy under Silvio Berlusconi. Multiple reports talk of the regular abuses, which include abysmal sanitary conditions, beatings, torture, hard labor, and even murder, which migrants have suffered in the country.

Up until recently, European officials appeared to be discussing plans to strike a deal with Libya similar to the one cut with Recep Tayyip Erdogan’s government in Turkey. Italian Interior Minister Angelino Alfano, for example, repeatedly claimed that what Europe needed was a migration compact with Libya along the lines of the one Brussels signed with Ankara in March. But such a deal, for the time being at least, is hardly a likely prospect. The deal with Turkey rested on the assumption that, with the right incentives in place, Ankara could exercise a baseline level of control over its borders. Brussels should not worry about Libya’s willingness to fulfill the key provisions of a similar migration compact. What Europeans should be concerned about, rather, is that the Libyan state—with its malfunctioning government, which lacks a bare minimum of administrative capacity—has no ability to fulfill them.

In the long run, Libya and Europe need to seek a comprehensive solution to this migration crisis. But with the high season for smuggling and trafficking across the Mediterranean almost upon us, an interim solution is critical.

Libya, which sits 280 miles from the southernmost point of mainland Italy, is the primary launching point for those seeking to cross from Africa to Europe. But it remains only one variable within the broader migration equation. An interim solution for the current crisis needs a broader focus and should involve three geographic areas: Libya, the countries sharing land borders with Libya, and the Mediterranean Sea itself.

In Libya, EU governments should pressure the unity government to immediately sign up to the 1951 Refugee Convention and its 1967 protocol. These would provide a firm legal framework within which all stakeholders would have to operate. Signing them would make it clear that Libya is ready to respect the rights of migrants under international law. And, crucially, it would mandate Libya to respect refugees’ right, in particular, to non-refoulement—that is, to not be returned to countries where they risk physical harm or abuse. Secondly and where the security situation allows, the International Committee of the Red Cross, the International Organization for Migration, and the Office of the United Nations High Commissioner for Refugees should be provided with all necessary means to massively scale up their presence in the country. By doing so, they would be able to become crucial representatives for the rights of migrants and asylum seekers.

Finally—and with the explicit permission of the unity government—the European Union should start patrolling Libyan territorial waters, while international humanitarian organizations must take over the management of Libyan detention centers where migrants are held. Because Libyan authorities do not exercise any meaningful control over the coastline and because they lack the resources to adequately administer the detention centers they are supposedly managing, these measures would only technically—but not substantively—infringe upon the central government’s sovereignty.

Europe must also seek to form partnerships with Libya’s neighbors—a strategy it appears to be beginning to pursue. Countries sharing land borders with Libya have a significant comparative advantage over Tripoli when it comes to being candidates for partnerships: They have (relatively) stable governments. Algeria, Chad, Egypt, Niger, Sudan, and Tunisia face tremendous challenges in a variety of policy areas, yet they have the bare minimum of what it takes to resolve those challenges: established state structures.

These countries are often the countries of origin or earlier transit for the sub-Saharan migrants who converge on Libya as a springboard to Europe. Crucially, the European Union has a well-established relationship with all these governments through the second revision of the Cotonou Agreement between the European Union and African, Caribbean, and Pacific countries. More specifically, the Khartoum Process for East Africa, the Rabat Process for West Africa, and the EU strategy for the Sahel provide regional frameworks within which Europe and its partner countries can address migration issues. These regular and structured dialogues between European and African governments provide a system of financial and diplomatic rewards for African countries that proactively engage with migration issues. In particular, they’ve resulted in concrete projects that aim to discourage irregular migration by establishing readmission agreements while providing legal avenues for those trying to get to Europe, such as temporary migration plans.

It is high time for Brussels to further increase cooperation by providing additional resources to address migration issues: Europe must enable its African partners to set up projects that contribute to creating employment opportunities, ensuring food and nutrition security, improving migration management, and promoting conflict prevention. The EU Emergency Trust Fund for Africa should substantially be boosted for this purpose.

Europe appears to be taking steps to make migration control a cornerstone of its relationship with its African neighbors. Ad hoc migration compacts are in the works with selected origin and transit countries, including Ethiopia, Mali, Niger, Nigeria and Senegal, and proposals are being made to launch a comprehensive €62 billion investment plan to tackle the long-term root causes of economic migration. The EU has renewed its focus on re-admissions to these countries, prioritizing speedy returns for those whose asylum claims are rejected over establishing formal readmission agreements, which is a sign of Europe’s determination to push this through—though also a warning of the potential dodginess of the various deals in the making.

Lastly, Brussels must do its homework where it is most able to bring about change: in the Mediterranean Sea and along Europe’s southern coast. The EU’s naval Operation Sophia in the south-central Mediterranean is trying to tackle migrant smuggling at sea. Its geographic scope, however, is significantly more limited compared with the Operation Mare Nostrum carried out by the Italian Navy and later superseded by Frontex’s Operation Triton. This should be expanded again. At the same time, the mandate of the operation should be widened to explicitly encourage search-and-rescue operations on top of its primary aim of disrupting smugglers’ networks. On its Italian shores, Europe should intensify its support for Italian authorities engaged in the establishment and management of so-called migrant hot spots. Indeed, while Rome has fulfilled most of its obligations by setting up new headquarters and boosting its processing rates, its European partners are struggling to make available specialized personnel for the hot spots and to relocate migrants already in Italy.

The ideas above are only a short-term interim solution, however. In the medium to long term, the international community needs to address the tremendous underlying challenges producing chaos in Libya. The newly established Government of National Accord must secure the support of all ethnic groups and major tribes. Having done that, the Islamic State must be rooted out through a very high-intensity but hopefully brief and localized conflict. Finally, a minimum degree of administrative capacity must be re-established beyond Tripoli.

All of the above require meaningful engagement with Libya on the part of Europe that will probably take years to reap benefits. Until that is forthcoming, an interim solution must be found, for the sake of the hundreds of thousands of lives at risk.

The piece was originally published in Foreign Policy. 

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

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

Customer-Facing Changes:

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

Service Provider Changes:

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

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

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

Pathway One: Through Big Data

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

Pathway Two: Through local Businesses

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

Pathway Three: Through Socio-Financial Networks

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

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

Editors’ Note: Terrorist groups don’t emerge out of nowhere, and wars are perhaps the richest soil for seeding and growing violent groups of all stripes, writes Dan Byman. This post originally appeared in the Washington Post.

Study after study has found no common profile of a terrorist. It is hard to explain why, say, almost four times as many recruits leave Sweden to fight with the Islamic State as from neighboring Norway, though Sweden’s population is only twice Norway’s. Pundits and politicians alike speculate on why individuals might embrace terrorism, but such a question risks missing one obvious point: Having a terrorist group around in the first place is one of the most important factors in influencing an individual’s choice to join.

Terrorist groups don’t emerge out of nowhere, and wars are perhaps the richest soil for seeding and growing violent groups of all stripes. Without the wars in the Middle East there would be no Islamic State, and it is not the only one: al-Qaida, Hezbollah, and other extremist groups all emerged out of regional civil wars. The formation of such groups is a political phenomenon, and so, too, is the radicalization of foreign fighters from the West.

Terrorist groups are rarely the cause of civil wars. Iraq’s civil war began in 2003 after the U.S. invasion and occupation; Syria’s civil war began with peaceful protests against a brutal dictator in 2011; and Libya’s strife came after a terrorist-supporting dictator was toppled in the same year.

Rather, such wars beget and foster terrorism in several ways. Terror itself is often a tool in war, used to sow an atmosphere of fear and undermine governments. Assassinations of rival political leaders, bombs for police and military recruits and random violence against civilians—these are all methods learned from Insurgency 101.

Groups such as al-Qaida and now the Islamic State exploit new wars wherever they can. Terrorist groups linked to civil wars seek supporters in the United States, Europe, and other areas outside the theater for reasons both obvious and obscure—and these factors generate more terrorists. This pull is especially strong when identities cross borders—as does a religious identity like Islam—and when local ties are weak or the community as a whole is poorly integrated, as the Muslim community is in many European countries.

Foreigners might join these groups for altruistic reasons, to help the genuinely oppressed (the Syrian people facing Bashar al-Assad, or the Afghans facing the Soviets). Yet often the oppression is a myth, or at least greatly exaggerated: One powerful narrative of the Islamic State is that Sunni Muslims are facing a global Shiite conspiracy led by Iran and Hezbollah.

Still others join because they are true believers and want to live the dream. In different ways, the war takes them out of their humdrum or depressing present, giving them a new life: “I’m the most content I have ever been in my life,” tweeted one young American woman who had gone to live in the Islamic State, ending the tweet with a heart emoji. Many are merely thugs who spent time in jail or otherwise led delinquent lives: Joining the Islamic State or a similar group gives them a license to kill and torture.

Because there is no single profile, terrorist groups such as the Islamic State seek to appeal to many different ones. Propaganda stresses the good life in the caliphate, the glory of fighting for God, the oppression the community is facing, and glorified ultra-violence. Religion matters, but only as a badge of meaning and belonging rather than for its specific ideological content. By professing religious beliefs, a young Muslim male can go from marginalized and alienated in his home country to part of God’s army, defending his people with his own sex slaves to boot. Yet one study of the European foreign fighters found that most were theologically illiterate. Omar Mateen, the Orlando shooter, may not have understood the difference between the theologies espoused by the Islamic State, al-Qaida and Hezbollah.

As long as these wars rage, the problems they generate will not stay confined to the Middle East. Only a fraction of a fraction end up fighting, and even fewer engage in terrorism, but only a small number need to respond for the problem to be serious.

Editors’ Note: The phenomenon Donald Trump has created has become something larger than him, and something far more dangerous, writes Bob Kagan. This phenomenon has arisen in other democratic and quasi-democratic countries over the past century, and it has generally been called “fascism.” This piece originally appeared in The Washington Post.

The Republican Party’s attempt to treat Donald Trump as a normal political candidate would be laughable were it not so perilous to the republic. If only he would mouth the party’s “conservative” principles, all would be well.

But of course the entire Trump phenomenon has nothing to do with policy or ideology. It has nothing to do with the Republican Party, either, except in its historic role as incubator of this singular threat to our democracy. Trump has transcended the party that produced him. His growing army of supporters no longer cares about the party. Because it did not immediately and fully embrace Trump, because a dwindling number of its political and intellectual leaders still resist him, the party is regarded with suspicion and even hostility by his followers. Their allegiance is to him and him alone.

And the source of allegiance? We’re supposed to believe that Trump’s support stems from economic stagnation or dislocation. Maybe some of it does. But what Trump offers his followers are not economic remedies—his proposals change daily. What he offers is an attitude, an aura of crude strength and machismo, a boasting disrespect for the niceties of the democratic culture that he claims, and his followers believe, has produced national weakness and incompetence. His incoherent and contradictory utterances have one thing in common: They provoke and play on feelings of resentment and disdain, intermingled with bits of fear, hatred and anger. His public discourse consists of attacking or ridiculing a wide range of “others”—Muslims, Hispanics, women, Chinese, Mexicans, Europeans, Arabs, immigrants, refugees—whom he depicts either as threats or as objects of derision. His program, such as it is, consists chiefly of promises to get tough with foreigners and people of nonwhite complexion. He will deport them, bar them, get them to knuckle under, make them pay up or make them shut up.

That this tough-guy, get-mad-and-get-even approach has gained him an increasingly large and enthusiastic following has probably surprised Trump as much as it has everyone else. Trump himself is simply and quite literally an egomaniac. But the phenomenon he has created and now leads has become something larger than him, and something far more dangerous.

[T]he phenomenon he has created and now leads has become something larger than him, and something far more dangerous.

Republican politicians marvel at how he has “tapped into” a hitherto unknown swath of the voting public. But what he has tapped into is what the founders most feared when they established the democratic republic: the popular passions unleashed, the “mobocracy.” Conservatives have been warning for decades about government suffocating liberty. But here is the other threat to liberty that Alexis de Tocqueville and the ancient philosophers warned about: that the people in a democracy, excited, angry and unconstrained, might run roughshod over even the institutions created to preserve their freedoms. As Alexander Hamilton watched the French Revolution unfold, he feared in America what he saw play out in France—that the unleashing of popular passions would lead not to greater democracy but to the arrival of a tyrant, riding to power on the shoulders of the people.

This phenomenon has arisen in other democratic and quasi-democratic countries over the past century, and it has generally been called “fascism.” Fascist movements, too, had no coherent ideology, no clear set of prescriptions for what ailed society. “National socialism” was a bundle of contradictions, united chiefly by what, and who, it opposed; fascism in Italy was anti-liberal, anti-democratic, anti-Marxist, anti-capitalist and anti-clerical. Successful fascism was not about policies but about the strongman, the leader (Il Duce, Der Fuhrer), in whom could be entrusted the fate of the nation. Whatever the problem, he could fix it. Whatever the threat, internal or external, he could vanquish it, and it was unnecessary for him to explain how. Today, there is Putinism, which also has nothing to do with belief or policy but is about the tough man who singlehandedly defends his people against all threats, foreign and domestic.

Successful fascism was not about policies but about the strongman, the leader (Il Duce, Der Fuhrer), in whom could be entrusted the fate of the nation.

To understand how such movements take over a democracy, one only has to watch the Republican Party today. These movements play on all the fears, vanities, ambitions and insecurities that make up the human psyche. In democracies, at least for politicians, the only thing that matters is what the voters say they want—vox populi vox dei. A mass political movement is thus a powerful and, to those who would oppose it, frightening weapon. When controlled and directed by a single leader, it can be aimed at whomever the leader chooses. If someone criticizes or opposes the leader, it doesn’t matter how popular or admired that person has been. He might be a famous war hero, but if the leader derides and ridicules his heroism, the followers laugh and jeer. He might be the highest-ranking elected guardian of the party’s most cherished principles. But if he hesitates to support the leader, he faces political death.

In such an environment, every political figure confronts a stark choice: Get right with the leader and his mass following or get run over. The human race in such circumstances breaks down into predictable categories—and democratic politicians are the most predictable. There are those whose ambition leads them to jump on the bandwagon. They praise the leader’s incoherent speeches as the beginning of wisdom, hoping he will reward them with a plum post in the new order. There are those who merely hope to survive. Their consciences won’t let them curry favor so shamelessly, so they mumble their pledges of support, like the victims in Stalin’s show trials, perhaps not realizing that the leader and his followers will get them in the end anyway.

A great number will simply kid themselves, refusing to admit that something very different from the usual politics is afoot.

A great number will simply kid themselves, refusing to admit that something very different from the usual politics is afoot. Let the storm pass, they insist, and then we can pick up the pieces, rebuild and get back to normal. Meanwhile, don’t alienate the leader’s mass following. After all, they are voters and will need to brought back into the fold. As for Trump himself, let’s shape him, advise him, steer him in the right direction and, not incidentally, save our political skins.

What these people do not or will not see is that, once in power, Trump will owe them and their party nothing. He will have ridden to power despite the party, catapulted into the White House by a mass following devoted only to him. By then that following will have grown dramatically. Today, less than 5 percent of eligible voters have voted for Trump. But if he wins the election, his legions will comprise a majority of the nation. Imagine the power he would wield then. In addition to all that comes from being the leader of a mass following, he would also have the immense powers of the American presidency at his command: the Justice Department, the FBI, the intelligence services, the military. Who would dare to oppose him then? Certainly not a Republican Party that laid down before him even when he was comparatively weak. And is a man like Trump, with infinitely greater power in his hands, likely to become more humble, more judicious, more generous, less vengeful than he is today, than he has been his whole life? Does vast power un-corrupt?

This is how fascism comes to America, not with jackboots and salutes (although there have been salutes, and a whiff of violence) but with a television huckster, a phony billionaire, a textbook egomaniac “tapping into” popular resentments and insecurities, and with an entire national political party—out of ambition or blind party loyalty, or simply out of fear—falling into line behind him.

There will always be winners and losers as the global economy shifts and evolves. For a long period in the mid- to late 20th century, those losers were cities. Across the developed world, suburbanization shrank inner-city populations just as the industrial base that had once fueled growth succumbed to globalization.

At the end of the 20th century, as global cities such as New York and London pulled themselves out of the malaise of the 1970s, economic growth still eluded many smaller, formerly industrial cities across the United States and Europe. Catalyzing recovery in those older industrial areas was the focus of a decade-long effort of the London School of Economics and the Brookings Institution. As is clear in Cities for a Small Continent, a new book from Anne Power at LSE, the potential in these cities is greater now than ever. In our contribution to the volume, we examine the why and the how of economic transformation in several U.S. cities. 

There has been a lot of focus on the shift in location preferences that is bringing people back to cities. Significant shares of millennials as well as empty nesters are voting for urban communities where they can live, work, and play. At least as important is the restructuring of the U.S. economy—from a closed innovation system where corporations operated isolated research facilities, to an open, networked economy where corporations innovate in collaboration with universities, researchers, entrepreneurs, and investors. Innovation is critical, because as Antoine van Agtmael and Fred Bakker assert in The Smartest Places on Earth, “the era of cheap [in manufacturing] is over; the era of smart has begun.”

These shifts in social preferences and market forces revalue cities and “cityness”—proximity, density, vibrancy, authenticity, and diversity. In particular, population and employment growth is occurring in downtowns and midtowns that have key institutions and assets: universities, medical campuses, cultural venues, historic buildings, walkable streets, and transit connectivity.

This regeneration is being delivered through a new localism in U.S. governance. Every day brings new bottom-up, city-led approaches to the training of workers, the education of children, the mitigation of climate change, the financing of infrastructure, and the development of affordable housing for our workers and quality places for our young and elderly populations.

Across this wide range of activity are some common characteristics.

Cities are harnessing the power of networks of government, business, civic, philanthropic, university, and community institutions and leaders rather than relying on public-sector solutions alone. The focus of the new American localism on unlocking the latent capacity and creativity of public, private, and civic networks differs markedly from the focus of traditional federalism on relationships between levels of government, particularly the federal government and the states.

Cities and metropolitan areas are also deploying capital from an array of public, private, and civic sources at the local, national, and even global levels. With federal investment dwindling, financing of critical projects will increasingly come from public-private collaboration and require experimentation around new forms of innovative finance.

Our chapter highlights four cities in the United States—Pittsburgh, Philadelphia, Cleveland, and Detroit—where this new localism has delivered tangible results. Though each city is at a different point of recovery, all have experienced growth in their cores that has been enabled and co-led by anchor institutions, major philanthropies, private-sector leaders, and civic groups. The biggest investments and decisions in these places have been the results of collaborative processes—proof that cities and the institutions that invest in them can be a source of long-term, strategic thinking that ultimately leads to healthier and more prosperous urban economies.

Similar efforts are spreading across the United Kingdom and Europe, though the systems there tend more toward public-sector leadership. In Sheffield, England, a concerted effort by business and academic institutions to “upskill” the manufacturing base, enabled by the flexibility of a “city deal” from the central government, has made the city a global center of advanced manufacturing. Bilbao, Spain evolved from a manufacturing base to a vibrant urban cultural hub by leveraging the value of publicly owned land and other assets for regeneration purposes. Stories such as these are featured throughout Cities for a Small Continent, as well as in a new series of seven case studies from LSE.

We are still in the early stages of this rebalancing of growth. Cities and metropolitan areas experienced decades of population and employment decentralization, poverty concentration, racial separation, and de-industrialization. Such patterns do not get changed overnight. But they are changing. As cities innovate, those solutions must be captured and codified and then replicated across the world.

Watch the May 24, 2016 LSE launch event for Cities for a Small Continent here: 

Five years ago, my mother needed an orthopedic surgeon for a knee replacement. Unable to find any data, we went with an academic doctor that was recommended to us (she suffered surgical complications). Last month, we were again looking for an orthopedic surgeon- this time hoping that a steroid injection in her spine might allay the need for invasive back surgery. This time, thanks to a recent data dump from CMS, I was able to analyze some information about Medicare providers in her area and determine the most experienced doctor for the job.  Of 453 orthopedic surgeons in Maryland, only a handful had been paid by Medicare for the procedure more than 10 times.  The leading surgeon had done 263- as many as the next 10 combined. We figured he might be the best person to go to, and we were right- the procedure went like clockwork.

Had it been a month prior to the CMS data release, I wouldn’t have had the data at my fingertips. And I certainly wouldn’t have found the most experienced hand in less than 10 minutes.

It’s been a couple of month since the release of Medicare data by the Centers for Medicare and Medicaid (CMS) on the volume and cost of services billed by healthcare providers, and despite the whiff of scandal surrounding the highest paid providers (including the now-famous Florida ophthalmologist that received $21 million) the analyses so far have been somewhat unsurprising. This week, coinciding with the fifth Health DataPalooza, is a good time to take stock of the utility of this data, its limitations, and what the future may hold.

The millions of lines of data was exactly as advertised: charges and paid services under traditional Medicare “fee-for-service,” including the billing provider’s ID and the costs to Medicare. The initial headlines touting “Medicare Millionaires” relied on some basic arithmetic and some sorting.  And the cautions piled up: the data could reflect multiple providers billing under a single ID; payments are not the same as a provider’s actual take home income; it’s not complete information as it doesn’t contain information about other insurers, or even Medicare Advantage, and so on.

But perhaps most damning was how little insight the data seemed to provide on the quality or value of care provided, as opposed to volume of services.  As Lisa Rosenbaum wrote in the New Yorker, “So much of that good isn’t captured by these numbers. You don’t bill for talking to a patient about how he wants to die. There’s no code for providing reassurance rather than ordering a test.”

Where is the value in the data?

Data bear witness to the fundamental flaw of the payment system that generates them. The absence of information on quality, safety, appropriateness, or outcomes appears to have been a genuine revelation to many, but it is in fact exactly the type of output that we should expect from this volume-based system that we have built. This is not a critique of the data release. It is an indictment of our payment system.

Data is revealing important trends in how we pay doctors differently. Not all physician payments are created equal, and the data certainly shows the disparities across specialties, primary care, and others. For example, the average total annual Medicare payment to geriatricians was less than $100,000, while dermatologists and radiation oncologists (who presumably also see non-elderly patients) received on average $200,000 and $360,000 respectively. The important question will be why and should it continue?

Figure 1: Distribution of Total Medicare Pay by Provider Type, 2012 

Source: Author's calculations based on Medicare data released in April 2014

Data is revealing important indicators of cost and pricing – a major contributor to rising health care costs. Why is it that a brief visit with a geriatrician is worth $13; a 45-minute visit with a geriatrician sorting through medications, educating family members, and developing a quality of life plan with a terminal cancer patient is worth $79; and a dermatologist treating suspected skin cancer can earn upwards of $600 for a procedure that takes them minutes?

Data sheds light on practice patterns. The data is also revealing important variances in utilization of drugs and treatments. For example, a block apart on Park Avenue, two ophalmologists differ significantly in their use of treatments for macular degeneration. One uses expensive injectable drugs and gets paid over $10,000 per injection, while the other receives less than $500 for the lower-cost equivalent.

A CBS News report looked at spinal fusion surgeries—a procedure where there is almost no evidence demonstrating a net benefit to patients compared to other conservative therapies. They observed that “while the average spine surgeon performed them on 7 percent of patients they saw, some did so on 35 percent.”

At the extremes, outlier “practice pattern” begins to raise questions of potential improper billing or outright fraud and abuse. For example, simply looking at the frequency and volume of services provided to individual beneficiaries can identify concerning outliers. This laboratory company billed for 28,954 blood glucose reagent strips in 2012- for 88 patients. And yes, that’s highly unusual.

Figure 2: "Outlier" Medicare Billing for Blood Glucose Reagent Strips, 2012

Source: Author's calculations based on Medicare data released in April 2014

One clinical social worker billed for 1,697 separate days of service on 28 patients (the size of the bubble is proportional to the total amount of reimbursement by Medicare in 2012).

Figure 3: "Outlier" Medicare Billing for Days of Service, 2012

Source: Author's calculations based on Medicare data released in April 2014

The most extreme outlier, Dr. Gary Ordog, was named by NPR and ProPublica in their examination of providers who are outliers on their pattern of coding for the highest intensity office. Ordog had previously lost the right to bill California’s state Medicaid program, and yet continued to charge Medicare for over $500,000 in billing in 2012. It’s important to caution however, that even in these extreme outliers, statistics alone cannot provide definitive evidence of abuse. There is a need for formal investigation.

Medicare and law enforcement officials will need to create new processes for dealing with a potential flood of outlier reports from amateur sleuths like me.

What's Next for Medicare Data?

Data can be trended. Updates of data releases can begin to show us not just snapshots, but moving pictures of our healthcare system as it undergoes rapid changes. The New York Times reported on the increase in charges for certain frequent causes of hospitalization between 2011 and 2012. It will be interesting to see whether the data release itself, and the Steven Brill landmark Time article on hospital charges, have an impact on reversing these trends.  

Data can be “mashed up”.  The value of open data is hugely greater than the sum of its parts. As more and more data becomes available, the files can be cross-linked and “mashed up” to be able to answer questions no one database could have.  ProPublica linked together cobbled together data on state actions and sanctions on physicians with the Medicare data release to ask why these physicians are still being paid by Medicare.

What does the future hold? Correlations with drug prescribing data, meaningful use, and referral patterns are possible today, Sunshine Act disclosures and quality reporting, and much more is soon to come.

As we get comfortable with the data, analysts can move past the basics of arithmetic and sorting, we have an opportunity to make more ‘meaningful use’ of this data. We can begin to identify practice patterns, overuse, variations in geography or demographics, and potentially even fraud and abuse. As more and more data becomes available, the files can be cross-linked and “mashed up” to be able to answer questions no one database could have addressed. What will determine the value of the Medicare data release will be the creativity of those data scientists, epidemiologists, and health services researchers (amateur as well as professional) who can ask the challenging questions that must be answered.

Contributors: Alice M. Rivlin and Christine Dang-Vu

Recent data suggest that Accountable Care Organizations (ACOs) are improving important aspects of care and some are achieving early cost savings, but there is a long way to go. Not all ACOs will be successful at meeting the quality and cost aims of accountable care. The private sector has to date allowed more flexibility in terms of varying risk arrangements—there are now over 250 accountable care arrangements with private payers in all parts of the country—with notable success in some cases, particularly in ACOs that have been able to move farther away from fee-for-service payments. Future growth of the Medicare ACO program will depend on providers having the incentives to become an ACO and the flexibility to assume different levels of risk, ranging from exclusively upside arrangements to partial or fully capitated payment models.

Given that the first three year cycle of Medicare ACOs ends in 2015 and more providers will be entering accountable care in the coming years, the Centers for Medicare and Medicaid Services (CMS) has indicated that they intend to release a Notice of Proposed Rulemaking (NPRM) affecting the Medicare ACO program.

In anticipation of these coming changes, the Engelberg Center for Health Care Reform has identified the "Top Eight ACO Challenges" that warrant further discussion and considerations for ensuring the continued success of ACOs across the country. To support that discussion, we also present some potential alternatives to current Medicare policies that address these concerns. These findings build on the experiences of the Engelberg Center’s ACO Learning Network members and other stakeholders implementing accountable care across the country.  In some cases, the alternatives might have short-term costs, but could also improve the predictability and feasibility of Medicare ACOs, potentially leading to bigger impacts on improving care and reducing costs over time.  In other cases, the alternatives could lead to more savings even in the short term. In every case, thoughtful discussion and debate about these issues will help lead to a more effective Medicare ACO program.

Top Eight ACO Challenges

1. Make technical adjustments to benchmarks and payments
2. Transition to more person-based payments
3. Increase beneficiary engagement
4. Enhance and improve alignment of performance measures
5. Enable better and more consistent supporting data
6. Link to additional value-based payment reforms
7. Develop bonus payments and other incentives to participate
8. Support clinical transformation

Downloads

• Issue Brief: Improving the Medicare ACO Program