The United States exports digital goods worth hundreds of billions of dollars across the Atlantic each year.  And both Silicon Valley and Hollywood do big business with Europe every year.  Differences in approaches to privacy have always made this relationship unsteady but the Snowden disclosures greatly complicated the prospects of a Transatlantic Trade and Investment Partnership.  In this paper Cameron Kerry examines that politics of transatlantic trade and the critical role that U.S. privacy policy plays in these conversations.

Kerry relies on his experience as the U.S.’s chief international negotiator for privacy and data regulation to provide an overview of key proposals related to privacy and data in Europe.  He addresses the possible development of a European Internet and the current regulatory regime known as Safe Harbor. Kerry argues that America and Europe have different approaches to protecting privacy both which have strengths and weaknesses.

To promote transatlantic trade the United states should:

• Not be defensive about its protection of privacy
• Provide clear information to the worldwide community about American law enforcement surveillance
• Strengthen its own privacy protection
• Focus on the importance of trade to the American and European economies

Downloads

• Download the paper

       

Sen. Rand Paul has just completed his nearly thirteen hour filibuster against John Brennan's nomination to head the CIA. Breaking off his filibuster (because, he inferred, he had to pee), Rand was heralded for bringing back the "talking filibuster." There was much written (and tweeted) about his filibuster, which began with Paul’s dramatic:

"I will speak until I can no longer speak…I will speak as long as it takes, until the alarm is sounded from coast to coast that our Constitution is important, that your rights to trial by jury are precious, that no American should be killed by a drone on American soil without first being charged with a crime, without first being found to be guilty by a court."

I thought I would add a few late-night thoughts in honor of this day spent with C-Span 2 humming in my ear.

First, I think Jon Bernstein’s reaction to the filibuster was right on the mark.  There’s been a lot of enthusiasm for the talking filibuster today, from Ezra Klein's "If more filibusters went like this, there’d be no reason to demand reform," to Josh Marshall’s, "This is a good example of why we should have the talking filibuster and just the talking filibuster." But Bernstein raises a critical point: "Today’s live filibuster shows again just how easy it is to hold the Senate floor for an extended period." The motivation of recent reformers has been to reduce filibustering by raising the costs of obstruction for the minority. In theory, making the filibuster more burdensome to the minority—while putting their views under the spotlight—should make filibusters more costly and more rare. (Paul did note in coming off the Senate floor tonight that his feet hurt…) But as Bernstein points out, Paul believes in his cause, and it plays well with his constituencies. On the physical front, the tag-team of GOP senators rallying to Paul's cause also lessened the burden on Paul (as would have a pair of filibuster-proof shoes). That said, today's filibuster was a little unusual. The majority seemed unfazed by giving up the day to Paul’s filibuster, perhaps because the rest of Washington was shutdown for a pseudo-snow storm. Moreover, the Brennan nomination had bipartisan support, with Reid believing there were 60 senators ready to invoke cloture.  In short, today's episode might not be a great test case for observing the potential consequences of reform.

Second, keep in mind that this was a double-filibuster day. The nomination of Caitlin Halligan for the DC Court of Appeals was blocked, failing for the second time to secure cloture. With 41 Republican senators voting to block an up or down confirmation vote on Halligan, an often-noted alternative reform (which would require 41 senators to block cloture instead of 60 senators to invoke it) would have made no difference to the outcome. And what if the minority had been required to launch a talking filibuster to block Halligan’s nomination? Reid might have been willing to forfeit the floor time to Paul today.  But Reid would unlikely have wanted to give up another day to Halligan’s opponents. As Steve Smith has argued, the burden of talking filibusters also falls on the majority, which typically wants to move on to other business. "Negotiating around the filibuster," Smith has argued, "would still be common."  On a day with two successful minority filibusters (at least in consuming floor time and deterring the majority from its agenda), we can see why the majority might be reticent to make senators talk.

Third, let's not lose sight of the target of Rand's filibuster: The head of the CIA.  Although the chief spook is not technically in the president’s cabinet, the position certainly falls within the ranks of nominations that have typically been protected from filibusters.  Granted, that norm was trampled with the Hagel filibuster for Secretary of Defense. But rather than seeing the potential upside of today's talking filibuster, I can't help but see the downside: In an age of intense policy and political differences between the parties, no corner of Senate business is immune to filibusters.

All that said, what's not to like about a mini demonstration of a real live filibuster?!  Perhaps Paul's late day Snickers break was cheating.  But it was a good C-Span type of day overall, for filibuster newbies to Franklin Burdette devotees. Even Dick Durbin well after midnight seemed to be enjoying the fray. Perhaps there’s a silver lining for talking filibusters after all.

       

On May 9, Filipinos elected a new president, Rodrigo Duterte. The long-time mayor of Davao City is the first Philippine president to hail from the southern islands of the archipelago. There, he established a “can-do” reputation on the back of brutal crackdown on crime, which won him the sobriquet “the Punisher.” During his controversial, profanity-laced campaign (his comments on rape, for instance, are truly regrettable), the tough-talking, cavalier eventual winner was described as the “Donald Trump of the Philippines.” He established that his priorities would be to confront crime, drugs, and corruption with a firm hand. Indeed, during a televised debate, Duterte claimed he was even prepared to kill his own children if they were involved in drugs.

Getting the Philippines out of its funk

Duterte’s success reflects a mood in Philippine society today. The Philippines has been a beacon of democracy in Southeast Asia for some time. Long before the Arab Spring or “Reformasi” (the massive social movement that brought down Suharto’s 32-year rule in Indonesia in 1998), the “People’s Revolution” against the Marcos regime in 1986 fired the imagination. 

Yet until very recently, the Philippines had not reaped any economic dividends from democratization. For many years following the “People’s Revolution,” the Philippine economy lurched along, plagued by endemic corruption and incompetent leadership. So deep was the malaise, the country became known as the new “sick man of Asia.” The lack of economic opportunity drove its women—among the most highly educated in the world—to seek employment abroad as housemaids and domestic helpers (remittances from these sources account for 10 percent of GDP). The issue is in fact a larger one, as there is a growing educated class frustrated with the lack of opportunity and upward social mobility. It is this mood that Duterte has tapped into.

[T]here is a growing educated class frustrated with the lack of opportunity and upward social mobility.

It remains to be seen though, now that he has won, if Duterte can “walk the talk.” The fact is that Duterte’s anti-establishment credentials and populist positions on poverty and corruption run sharply athwart an oligarchy that has long been an entrenched part of Philippine society. 

Despite impressive economic growth rates over the last few years under the Benigno Aquino III administration, the Philippines has been beset by a growing wealth disparity. To get at this problem, Duterte will have to have to leave behind his provincial mindset to govern at the national level, where these problems are amplified. Specifically, he will have to deal with a rent-seeking culture and a powerful aristocracy that controls huge chunks of the economy. It will take more than tough talk and populism to create a more equitable distribution of wealth and opportunity.

In the neighborhood

It is still too early to say, but indications are that foreign policy issues will probably not be a priority for Duterte, with two exceptions (neither of which are of his own choosing). Given his unpredictability, few would venture to say with any certainty how he might act on them. 

First, Duterte will have to handle the fallout from the arbitration tribunal rulings on the Philippine case against China’s massive claims in the South China Sea. Most observers agree that from the 15 items awaiting the tribunal’s decision, the majority will be ruled in favour of the Philippines. This would constitute a moral victory for Manila, but would also pose potential problems for the new government in terms of relations with China. Probably mindful of this, Duterte has already spoken of his readiness to engage in dialogue with China on the South China Sea. More to the point, given his likely emphasis on domestic economic issues, it is quite possible that Duterte will pursue a more pragmatic policy towards Beijing with an eye to Chinese investments in infrastructure development. On the other hand, true to character, Duterte also declared that he would set out on his own jet ski to the South China Sea to plant the Philippine flag. Populist posturing aside, at issue is whether Duterte’s unpredictability will jeopardize Manila’s current alignment with fellow ASEAN claimant, Vietnam, or its ongoing support for American efforts to exercise freedom of navigation rights in the South China Sea in response to China’s expansive claims.

Second, Duterte will be in office when the Philippines assumes the chairmanship of ASEAN in 2017. On the occasion of its 50th anniversary (ASEAN was formed in 1967), the Association would be looking to the Philippines, a founder-member, to demonstrate much-needed regional leadership. At stake is nothing less than the unity of ASEAN, which of late has come under increasing strain because of the South China Sea disputes. Duterte said very little about ASEAN during his campaign. Yet one thing should be clear. Given the complex challenges that the region is likely to face in the coming year, Duterte would be well-advised that the imperative of ASEAN unity will require more diplomatic nous and less saber-rattling bravado.

      

       

       

       

Editor's Note: The current U.S. presidential race demonstrates the deep political divisions that exist in our country. But what does it mean to be "liberal" or "conservative," "Republican" or "Democratic"? According to Shadi Hamid, certain values transcend political chasms. This post originally appeared on PBS NewsHour.

What does it mean to say that the Republican Party is on the “right”? The GOP, long defined (at least in theory) by its faith in an unbridled free market, the politics of personal responsibility, and a sort of Christian traditionalism, is no longer easily plotted on the traditional left-right spectrum of American politics. Under the stewardship of presidential nominee Donald Trump, the Republican Party appears to be morphing into a European-style ethnonationalist party. With Trump’s open disrespect for minority rights and the Bill of Rights, the GOP can no longer be considered classically “liberal” (not to be confused with capital-L American Liberalism). This is a new kind of party, an explicitly illiberal party.

These developments, of course, further constrain Republicans’ appeal to minority voters (I haven’t yet met an American Muslim willing to admit they’re voting for Trump, but they apparently exist). This makes it all the more important to distinguish between conservative values and those of this latest iteration of the Republican Party.

There are some aspects of Burkean conservative thought – including aspects of what might be called civic communitarianism – that could plausibly strike a chord in the current cultural landscape across “left” and “right,” categories which, in any case, are no longer as clearly distinguishable as they once were. (Take, for example, British Labour leader Jeremy Corbyn’s Euroskepticism and that of his opponents on the right, or the populist anti-elitism and trade protectionism that are now the province of both Republicans and Democrats).

Everyone seems angry or distrustful of government institutions, which, even when they provide much needed redistributive fiscal stimulus and services, are still blamed for being incompetent, inefficient, or otherwise encouraging a kind of undignified dependency. After the Brexit debacle, it seemed odd that some of the most Europhobic parts of Britain were the very ones that benefited most from EU subsidies. But this assumes that people are fundamentally motivated by material considerations and that they vote – or should vote – according to their economic interests.

If there’s one thing that the rise of Trump and Brexit – and the apparent scrambling of left-right divides – demonstrates, it’s that other things may matter more, and that it’s not a matter of people being too stupid to realize what’s good for them. As Will Davies put it in one of the more astute post-Brexit essays, what many Brexiteers craved was “the dignity of being self-sufficient, not necessarily in a neoliberal sense, but certainly in a communal, familial and fraternal sense.”

The communitarian instinct – the recognition that meaning ultimately comes from local communities rather than happiness-maximizing individuals or bloated nanny-states – transcends the Republican-Democratic or the Labour-Conservative chasm. In other words, an avowedly redistributive state is fine, at least from the standpoint of the left, but that shouldn’t mean neglecting the importance of local control and autonomy, and finding ways, perhaps through federal incentives, to encourage things like “local investment trusts.”

Setting up local investment trusts, expanding the child tax credit, or introducing a progressive consumption tax aren’t exactly a call-to-arms, and various traditionalist and communitarian-minded philosophers have, as might be expected from philosophers, tended to stay at the level of abstraction (authors armed with more policy proposals are more likely to be young conservative reformers like Ross Douthat, Reihan Salam, and Yuval Levin). Douthat and Salam want to use wide-ranging tax reform to alter incentives in the hope of strengthening families and communities. This is a worthy goal, but realizing such policies requires leadership on the federal level from the very legislators who we should presumably become less dependent on.

This is the reformer’s dilemma, regardless of whether you’re on the left or right. If your objective is to weaken a centralized, overbearing state and encourage mediating or “middle” institutions, then you first need recourse to that same overbearing state, otherwise the proposed changes are unlikely to have any significant impact on the aggregate, national level.

The fact that few people seem interested in talking about any of this in our national debate (we instead seem endlessly intrigued by Melania Trump’s copy-and-paste speechwriting) suggests that we’re likely to be stuck for some time to come. Incidentally, however, the Hillary Clinton campaign slogan of “Stronger Together” has an interesting communitarian tinge to it. I doubt that was the intent, and it’s only in writing this column that I even took a minute to think about what the slogan might actually mean. I, as it happens, have been much more interested in talking about – and worrying about – an unusually fascinating and frightening man named Donald Trump.

       

A recent blog suggested that CMS’ efforts to standardize assessment data was based on a goal of “….creating a functional measurement tool that could be used throughout the industry.” In fact, CMS has been working since 2005 to meet the Congressional directive to standardize assessment information at hospital discharge, and post-acute care (PAC) admission and discharge for payment and quality reporting purposes (Deficit Reduction Act of 2005). The CARE tool was developed as part of the national Post-Acute Care Payment Reform Demonstration (PAC PRD). The conceptual domains and items were selected with the input of the wide range of stakeholder communities working with PAC populations. Clinicians from acute hospitals and each of the four PAC settings, including long term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs) identified items to test in four areas: medical status, functional status, cognitive status, and some social support factors. Input was given by physicians, nurses, physical therapists, occupational therapists, speech and language pathologists, social workers and case managers working in each of the different levels of care. Initial item selection was based on a review of existing assessment items, including those in the three Federally-mandated instruments, (the IRF-PAI, MDS 2.0, and OASIS-B which were in effect at this time) and the input of each of the scientific communities working in these areas.

Developers of proprietary systems such as the UDS-MR©, Inter-RAI ©, and AM-PAC ©, as well as public domain items tested in clinical trials such as the PROMIS items, were all reviewed as part of this process. The selected items needed to be in the public domain so the measures could be modified as science advanced practice.

Over 200 providers participated nationwide to submit over 53,000 CARE assessments over the course of the PAC PRD. Participating clinicians also provided feedback during training and exit interviews. In general, positive feedback was provided on most items. Feedback showed that almost all items were commonly collected on existing instruments in hospitals and PAC providers, although some of the information may have been informally noted in charts rather than provided in the structured form of the CARE items.

The items were tested for reliability so they could be applied consistently across populations and settings. Most of the items were previously tested and found reliable in at least one of the five levels of care. Two types of reliability tests were conducted on the final CARE tool item set used in the PAC PRD. The results showed that most items when applied to the other four settings were at least as reliable as the existing Federal assessment items (Kappa scores of 0.6 or better) ensuring their reliable use in future quality measures or payment models would reach consistent results. Complete reports on item reliability and PAC PRD results can be found here.

Data standardization is critical to allow providers to exchange information as they follow the patient. The Deficit Reduction Act of 2005 directed CMS to use standardized assessment items at acute hospital discharge and PAC admission and discharge to allow for empirical comparisons of key questions arising out of changing incentives in the Medicare payment policies. The standardized CARE items are consensus-based versions of the items already collected by clinicians. These and additional items being incorporated into CMS’ assessment item library represent the “best in class.” The team developing the CARE item set represented the leading experts in each of the areas – Dr. Margaret Stineman of the University of Pennsylvania, developer of the function-related groups associated with the proprietary FIM©, Dr. Deborah Saliba, UCLA, lead developer of the MDS 3.0, and Dr. Chris Murtaugh of the Visiting Nurse Service of New York. Team members included Drs. Anne Deutsch and Trudy Mallinson of the Rehabilitation Institute of Chicago. Input was also given by Dr. David Hittle, of the University of Colorado who has worked closely with the OASIS tool, Dr. Samuel Markello, formerly of the UDS-MR©, and Dr. Patrick Murray of Case Western University.

The blog suggested that, “the early reviews of the CARE tool have been poor.” While this clearly is not true, it is worth pointing out that the author owns one of the key proprietary assessment instruments. The CARE items have been evaluated for reliability and they meet the national standards; they allow providers and others the opportunity to download the e-specification of the items without charge and to have the clinicians trained for free under CMS’ regular assessment training initiatives. CMS is currently developing quality measures using the “best in class” assessment items which all meet scientific standards. The quality measure development process already requires CMS to submit measures for endorsement by the National Quality Forum. The “loophole” identified by the UDS-MR© author is non-existent. The Measures Application Partnership is part of the existing NQF process included in the IMPACT legislation. Further, use of uniform data elements across settings, such as those used in the currently collected pressure ulcer measure, allows for exchangeability and improves communication across the system, finally creating a “data follows the person” system.

      

Event Information

Register for the Event

Many clinicians have terrific ideas for improving the quality and cost of health care, but often don’t know how to navigate the often baffling landscape of payment and delivery reform options. To address this need in clear, practical terms, we are pleased to announce the second MEDTalk event in the “Merkin Series on Innovations in Care Delivery.” The series is designed to support clinicians and policymakers who’ve always wondered how delivery reform occurs, but didn’t know where to begin. 

Our second case focused on the work of leaders from the New Mexico Cancer Center (NMCC), and their efforts to "Reinvent Patient-Centered Cancer Care." The event featured several brief “TED-style” talks that considered the challenges of delivering oncology care, while enhancing patient experience, improving coordination of care, and reducing costs. The agenda included firsthand experiences from patients, payers, policymakers, and NMCC's clinical leadership who explores sustainable improvement strategies, and the financial mechanisms available to encourage innovations in oncology.

Video

• A Day in the Life: The Patient Experience
• The Future of Oncology: Drugs, Genetic Testing and Personalized Medicine
• The Challenge of Delivering Cancer Care in a Triple Aim World
• What We're Learning from New Oncology Payment Models
• Supporting Care While Reducing Costs: What is Possible?
• The New Mexico Experience: Aligning Clinical Redesign and Payment Reform
• Sustaining Improvements in Patient-Centered Care
• Lessons Learned and the Path Forward
• MEDTalk: Reinventing Patient-Centered Cancer Care

Event Materials

• Oncology Case Study August 2014 FINAL WEB

      

Event Information

Register for the Event

Many clinicians have terrific ideas for improving the quality and cost of health care, but often don’t know how to navigate the frequently baffling landscape of payment and delivery reform options. To address this need in clear, practical terms, we are pleased to announce the third MEDTalk event in the “Merkin Series on Innovations in Care Delivery.” The series is designed to support clinicians and policymakers who’ve always wondered how delivery reform occurs, but didn’t know where to begin.

Our third case drew on the experiences of the Community Asthma Initiative, an enhanced pediatric asthma intervention, and their efforts in sustainability. The event featured seven brief “TED-style” talks that consider the challenges of delivering pediatric care, while tackling non-medical factors that drive suboptimal care, improving patient and family quality of life, and reducing costs. The agenda included firsthand experiences from patients, payers, policymakers, and clinical leadership from Massachusetts and Arkansas. Sustainable improvement strategies and the financial mechanisms available to encourage innovations in asthma were explored.

Video

• MEDTalk: Pediatric Asthma and Transforming Care for the Most Vulnerable
• A Day in the Life: The Patient Experience
• Challenge Accepted: Delivery of Asthma Care in a Triple Aim World
• The Community Asthma Initiative: A Case Study in Clinical Innovation
• Paying for Asthma Care: Options for Tackling Challenges
• State Medicaid Innovation: Opportunities and Barriers
• A Tale of Success: How to Get the Payer on Board
• Lessons Learned and the Path Forward
• Question and Answer Session

       

        

       

       

Federal departments and agencies received just above $133 billion in R&D funds in 2013. To put that figure in perspective, World Bank data for 2013 shows that, 130 countries had a GDP below that level; U.S. R&D is larger than the entire economy of 60 percent of all countries in the world.

The chart below shows how those funds are allocated among the most important federal departments and agencies in terms of R&D.

Those looking at these figures for the first time may be surprised to see that the Department of Defense takes about half of the pie. It should be noted however that not all federal R&D is destined to preserve U.S. military preeminence in the world. From non-defense research, 42 percent is destined to the much-needed research conducted by the National Institutes of Health, 17 percent to the research of the Department of Energy—owner of 17 celebrated national laboratories—16 percent for space exploration, and 8 percent for understanding the natural and social worlds at a fundamental level. The balance category is only lumped together for visual display not for its importance; it includes for instance the significant work of the National Oceanic and Atmospheric Administration and the National Institute of Standards and Technology.

Despite the impressive size of defense R&D, we hear little about it. While much of defense research and development is classified, in time, civilian applications find their way into mainstream commercial uses—the Internet and GPS emerged from research done at DARPA. Far more visible than defense R&D is biomedical research, clean energy research, or news about truly impressive discoveries either in distant galaxies or in the depths of our oceans.

What produces this asymmetry of visibility of federal R&D work?

In a recent Brookings paper, a colleague and I suggest that the answer lies in the prominence of R&D in the agencies’ accounting books. In short: How visible is R&D and how much the agency seeks to discuss it in public fora depends not on the relative importance, but on how large a portion of the agency’s budget is dedicated to R&D.

From a budget perspective, we identified two types of agencies performing R&D: those agencies whose main mission is to perform research and development, and those agencies that perform many functions in addition to R&D. For the former, the share of R&D in the discretionary budget is consistently high, while for the latter group, R&D is only a small part of their total budget (see the chart below). This distinction influences how agencies will argue for their R&D money, because they will make their case on the most important uses of their budget. If agencies have a low R&D share, they will keep it mixed with other functions and programs; for instance, research efforts will be justified only as supporting the main agency mission. In turn, agencies with a high R&D share must argue for their budgets highlighting the social outcomes of their work. These include three agencies whose primary mission is research (NASA, NSF, NIH), and a fourth (DoE) where research is a significant element of its mission.

There is little question that the four agencies with high R&D share produce greatly beneficial research for society. Their strategy of promoting their work publicly is not only smart budget politics but also civic and pedagogical in the sense of helping taxpayers understand that their tax dollars are well-spent. However, it is interesting to observe that other agencies may be producing research of equal social impact that flies under the public radar, mainly because those agencies prefer as a matter of good budget policy to keep a low profile for their R&D work.

One interesting conclusion for institutional design from this analysis is that promoting a research agency to the level of departments of government or its director to a cabinet rank position may bring prominence to its research, not because more and better research will necessarily get done but simply because that agency will seek public recognition for their work in order to justify its budget. Likewise, placing a research agency within a larger department may help conceal and protect their R&D funding; the politics of the department will focus on its main goals and R&D would recede to a concern of secondary interest in political battles.

In the Politics of Federal R&D we discuss in more detail the changing politics of budget and how R&D agencies can respond. The general strategies of concealment and self-promotion are likely to become more important for agencies to protect a steady growth of their research and development budgets.

Data sources: R&D data from the American Association for the Advancement of Sciences historical trends in Federal R&D. Total non-discretionary spending by federal agency from the Office of Management and Budget.

       

       

       

       

Israel apologized to Turkey today for the May 2010 incident on board the Mavi Marmara naval vessel, part of a flotilla to Gaza, in which nine Turks were killed from Israel Defense Forces fire. The apology came during a 30-minute telephone conversation between Israeli Prime Minister Benjamin Netanyahu and Turkish Prime Minister Recep Tayyip Erdogan, orchestrated by President Barack Obama, who was ending his 3 day visit to Israel and the Palestinian Authority. Erdogan accepted the Israeli apology, and the leaders agreed to begin a normalization process between Israel and Turkey, following the past three years, when relations were practically at a standstill. (Last December, I wrote about the beginnings of a Turkey-Israeli rapprochement, and discussed more of the policy implications here.)

This development allows the two countries to begin a new phase in their relationship, which has known crisis and tension, but also cooperation and a strong strategic partnership.

The U.S. administration played a key role behind the scenes in creating the conditions that paved the way for an Israeli apology and Turkish acceptance. Undoubtedly, a close relationship between Turkey and Israel-- two of America’s greatest allies in the region-- serves United States’ strategic interests globally and regionally. At a time when the Middle East political landscape is changing rapidly, it was imperative to end the long impasse between Ankara and Jerusalem.

Over the past year, Turkey and Israel have also come to realize that repairing their relationship and re-establishing a dialogue is at their best interest, as they face great challenges in their immediate vicinity (first and foremost, the Syrian civil war).

United States officials emphasized that this is the first step in a long process. Nevertheless, the parties will have to make a great effort to overcome years of distrust and suspicion if they want the relationship to work. No one is under the allusion that relations will go back to what they were in the “honeymoon” period of the 1990s but modest improvement can be made. It will not be an easy task, and for that to happen it is essential that the parties not only talk to each other, but also listen to one another and begin to respect each other’s sensitivities. In order for this rapprochement to be successful, United States will have to continue to oversee discussions between Turkey and Israel, and remain heavily engaged in this process.