Event Information

The year 2015 will be a milestone year, with the adoption of the Sustainable Development Goals (SDGs) and the post-2015 development agenda by world leaders in September; the Addis Ababa Accord on financing for development in July; and the conclusion of climate negotiations at COP21 in Paris in December. The draft Addis Ababa Accord, which focuses on the actions needed to attain the SDGs, highlights the key role envisaged for the multilateral development banks (MDBs) in the post-2015 agenda. Paragraph 65 of the draft accord notes: “We call on the international finance institutions to establish a process to examine the role, scale, and functioning of the multilateral and regional development finance institutions to make them more responsive to the sustainable development agenda.”          

Against this backdrop, on April 18, 2015, the Global Economy and Development program at Brookings held a private roundtable with the leaders of the MDBs and other key stakeholders to discuss the role of the MDBs in supporting the post-2015 development agenda.

The meeting focused on four questions:

1. What does the post-2015 development agenda and the ambitions of the Addis and Paris conferences imply for the MDBs?


Given the ability of the MDBs to leverage shareholder resources, they can be efficient and effective mechanisms for scaling up development cooperation, particularly with respect to the agenda on investing in people and to the financing of sustainable infrastructure. New roles, instruments and partnerships might be needed.

2. How can MDBs best take advantage of the political attention that is being paid to the various conferences in 2015?   


The World Bank and selected regional development banks have launched a series of initiatives to optimize their balance sheets, address other constraints and enhance their catalytic role in crowding in private finance. And new institutions and mechanisms are coming to the fore. But the responses are not coordinated to best take advantage of each MDB’s comparative advantage.

3. What are the key impediments to scaling up the role and engagement of the MDBs?


Views on constraints are likely to differ but discussions should cover policy dialogue, capacity building, capital, leverage, shareholder backing on volume, instruments on leverage and risk mitigation, safeguards, and governance. 

4. How should the MDBs respond to the proposal to establish a process to examine the role, scale and functioning of the multilateral and regional development finance institutions to make them more responsive to the sustainable development agenda?   


A proactive response and engagement on the part of the MDBs would facilitate a better understanding of the contribution that the MDBs can make and greater support among shareholders for a coherent and stepped-up role.

Event Materials

• Participant List
• MDB PostEvent Summary

So we’ve almost reached the end of the year 2015, which could go down in the history of global sustainable development efforts as one of the more significant years, with the trifecta of the approval of the Sustainable Development Goals (SDGs), the agreement on the Addis Agenda on Financing for Development (FfD) and the (shortly to be completed) Paris COP21 Climate Summit. Yet, all will depend on how the agreements with their ambitious targets are implemented on the ground.

Effective implementation will require a theory of change—a way to think about how we are to get from “here” in 2015 to “there” in 2030. The key problem is what has very appropriately been called by some “the missing middle,” i.e., the gap between the top-down global targets on the one hand and the bottom-up development initiatives, projects, and programs that are supported by governments, aid agencies, foundations, and social entrepreneurs.

One way to begin to close this gap is to aim for scaled-up global efforts in specific areas, as is pledged in the Addis Agenda, including efforts to fight global hunger and malnutrition, international tax cooperation and international cooperation to strengthen capacities of municipalities and other local authorities, investments and international coopera­tion to allow all children to complete free, equitable, inclusive and quality early childhood, primary and secondary education, and concessional and non-concessional financing.

Another way is to develop country-specific national targets and plans consistent with the SDG, Addis, and COP21 targets, as is currently being done with the assistance of the United Nations Development Program’s MAPS program. This can provide broad guidance on policy priorities and resource mobilization strategies to be pursued at the national level and can help national and international actors to prioritize their interventions in areas where a country’s needs are greatest.

However, calling for expanded global efforts in particular priority areas and defining national targets and plans is not enough. Individual development actors have to link their specific projects and programs with the national SDG, Addis, and COP21 targets. They systematically have to pursue a scaling-up strategy in their areas of engagement, i.e., to develop and pursue pathways from individual time-bound interventions to impact at a scale in a way that will help achieve the global and national targets. A recent paper I co-authored with Larry Cooley summarizes two complementary approaches of how one might design and implement such scaling-up pathways. The main point, however, is that only the pursuit of such scaling-up pathways constitutes a meaningful theory of change that offers hope for effective implementation of the new global sustainable development targets.

Fortunately, over the last decade, development analysts and agencies have increasingly focused on the question of how to scale up impact of successful development interventions. Leading the charge, the World Bank in 2004, under its president Jim Wolfensohn, organized a high-level international conference in Shanghai in cooperation with the Chinese authorities on the topic of scaling up development impact and published the associated analytical work. However, with changes in the leadership at the World Bank, the initiative passed to others in the mid-2000s, including the Brookings Institution, ExpandNet (a group of academics working with the World Health Organization), Management Systems International (MSI), and Stanford University. They developed analytical frameworks for systematically assessing scalability of development initiatives and innovations, analyzed the experience with more or less successful scaling-up initiatives, including in fragile and conflict-affected states, and established networks that bring together development experts and practitioners to share knowledge.

By now, many international development agencies (including GIZ, JICA, USAID, African Development Bank, IFAD and UNDP), foundations (including the Bill & Melinda Gates Foundation and Rockefeller Foundation) and leading development NGOs (including Heifer International, Save the Children and the World Resources Institute), among others, have focused on how best to scale up development impact, while the OECD recently introduced a prize for the most successful scaling-up development initiatives. The International Fund for Agricultural Development (IFAD) is perhaps the most advanced among the agencies, having developed a systematic operational approach to the innovation-learning-scaling-up cycle. In a collaborative effort with the Brookings Institution, IFAD reviewed its operational practices and experience and then prepared operational design and evaluation guidelines, which can serve as a good example for other development agencies. The World Bank, while yet to develop a systematic institution-wide approach to the scaling-up agenda, is exploring in specific areas how best to pursue scaled-up impact, such as in the areas of mother and child health, social enterprise innovation, and the “science of delivery.”

Now that the international community has agreed on the SDGs and the Addis Agenda, and is closing in on an agreement in Paris on how to respond to climate change, it is the right time to bridge the “missing middle” by linking the sustainable development and climate targets with effective scaling-up methodologies and practices among the development actors. In practical terms, this requires the following steps:

• Developing shared definitions, analytical frameworks, and operational approaches to scaling up among development experts;
• Developing sectoral and sub-sectoral strategies at country level that link short- and medium-term programs and interventions through scaling-up pathways with the longer-term SDG and climate targets;
• Introducing effective operational policies and practices in the development agencies in country strategies, project design, and monitoring and evaluation;
• Developing multi-stakeholder partnerships around key development interventions with the shared goal of pursuing well-identified scaling-up pathways focused on the achievement of the SDGs and climate targets;
• Developing incentive schemes based on the growing experience with “challenge funds” that focus not only on innovation, but also on scaling up, such as the recently established Global Innovation Fund; and
• Further building up expert and institutional networks to share experience and approaches, such as the Community of Practice on Scaling Up, recently set up by MSI and the Results for Development Institute.

Editor's Note: : We’re hosting a conversation on Markaz on the Iranian nuclear talks, debating the merits of a deal, as well as the broader issues at stake for the United States and the region. This piece originally appeared in The Huffington Post.

As we near what may be the endgame of the current negotiations with Iran, I am reminded of the place where President Obama announced the overarching strategy that helped produce this moment: Prague. After stating his readiness to speak to Iran in a Democratic primary debate in 2007, and following that up postelection in 2009 with a series of initial statements directed to the Iranians, the president chose the Czech capital to lay out his vision of dealing with the dangers of nuclear weapons in April 2009. That included emphasizing that Iran would not be permitted to obtain a nuclear weapon on his watch: "Rules must be binding. Violations must be punished. Words must mean something. The world must stand together to prevent the spread of these weapons."

As a result of that 2009 speech, the president's nuclear strategy became known as the Prague Agenda. I had the privilege to travel with President Obama back to Prague in April 2010 to witness the signing of a major accomplishment in another area under the Prague Agenda, namely the New START treaty. By the following year, April 2011, I was in Prague as U.S. ambassador. That year, and in the each year that followed, we held an annual Prague Agenda conference to assess the steps that had been taken and the challenges that lay ahead.

In the years since, there has been steady progress in each of the four main areas the president laid out on that spring day in Prague in 2009. New START was a step forward on his first objective, to reduce the risks posed by existing nuclear weapons. Another goal, preventing nuclear terror by safeguarding materials and improving safety, has since been the subject of a series of successful Nuclear Security Summits in Washington, Seoul, and The Hague.

I saw first-hand the president's personal commitment to a third objective articulated in Prague: to promote the peaceful use of nuclear energy. I was, for example, present in the Oval Office in October 2011 when the president and the Czech prime minister met. President Obama advocated for the use of civil nuclear power as a part of the Czech energy mix (and also to achieve energy independence from Russia). That approach has been replicated in administration policy supporting civil nuclear energy in the United States and around the world.

Now, with the possible Iran deal, progress under the Prague Agenda's final prong is in reach: holding to account a state which had violated its nuclear obligations under international treaties. I am not of the school that believes the president needs to secure an Iran deal to build his legacy. That was never the case; having known him for almost a quarter of a century, since we were law students together, and having worked for him for six years, first in the White House and then as ambassador, I can attest that those kinds of considerations do not enter into critical decisions like this one. Even the president's strongest critics have to admit that legacy is, as a matter of logic, much less of a consideration after the recent breakthroughs on the Affordable Care Act and on Trade Promotion Authority.

Instead, as the comprehensive nature of the Prague Agenda itself suggests, President Obama is pursuing a deal out of principle. He is acting from his conviction that a good agreement with Iran represents another step toward making the U.S., our allies, and the world safe from nuclear terror. It is that ambition that has driven the president's formulation and consistent pursuit of each of the four elements of the Prague Agenda, the obscure aspects just as much as the headline-making ones.

Of course, as the president himself has repeatedly emphasized, the deal must be a good one. That is why I recently joined a bipartisan group of experts convened by the Washington Institute for Near East Policy in signing a statement laying out criteria for what any deal with Iran must at a minimum contain in five core areas: monitoring and verification; possible military dimensions; advanced centrifuges; sanctions relief; and consequences of violations. We also agreed on the importance of complementing any agreement with a strong deterrence policy and a comprehensive regional strategy. I have been encouraged by the warm reception for our statement from all corners, and by the strong tone struck by the American negotiators in Vienna this week. They recognize that willingness to walk away is the surest path to securing a good deal. If such a deal can be struck that meets the criteria in our bipartisan statement, that will be another stride forward under the Prague Agenda — perhaps the biggest yet.

This week marks the release of the 2015 Brown Center Report on American Education, the fourteenth issue of the series.  One of the three studies in the report, “Girls, Boys, and Reading,” examines the gender gap in reading.  Girls consistently outscore boys on reading assessments.  They have for a long time.  A 1942 study in Iowa discovered that girls were superior to boys on tests of reading comprehension, vocabulary, and basic language skills.^[i]  Girls have outscored boys on the National Assessment of Educational Progress (NAEP) reading assessments since the first NAEP was administered in 1971. 

I hope you’ll read the full study—and the other studies in the report—but allow me to summarize the main findings of the gender gap study here.

Eight assessments generate valid estimates of U.S. national reading performance: the Main NAEP, given at three grades (fourth, eighth, and 12^th grades); the NAEP Long Term Trend (NAEP-LTT), given at three ages (ages nine, 13, and 17); the Progress in International Reading Literacy Study (PIRLS), an international assessment given at fourth grade; and the Program for International Student Assessment (PISA), an international assessment given to 15-year-olds.  Females outscore males on the most recent administration of all eight tests.  And the gaps are statistically significant.  Expressed in standard deviation units, they range from 0.13 on the NAEP-LTT at age nine to 0.34 on the PISA at age 15.

The gaps are shrinking.  At age nine, the gap on the NAEP-LTT declined from 13 scale score points in 1971 to five points in 2012.  During the same time period, the gap at age 13 shrank from 11 points to eight points, and at age 17, from 12 points to eight points.  Only the decline at age nine is statistically significant, but at ages 13 and 17, declines since the gaps peaked in the 1990s are also statistically significant.  At all three ages, gaps are shrinking because of males making larger gains on NAEP than females.  In 2012, seventeen-year-old females scored the same on the NAEP reading test as they did in 1971.  Otherwise, males and females of all ages registered gains on the NAEP reading test from 1971-2012, with males’ gains outpacing those of females.

The gap is worldwide.  On the 2012 PISA, 15-year-old females outperformed males in all sixty-five participating countries.  Surprisingly, Finland, a nation known for both equity and excellence because of its performance on PISA, evidenced the widest gap.  Girls scored 556 and boys scored 494, producing an astonishing gap of 62 points (about 0.66 standard deviations—or more than one and a half years of schooling).   Finland also had one of the world’s largest gender gaps on the 2000 PISA, and since then it has widened.  Both girls’ and boys’ reading scores declined, but boys’ declined more (26 points vs. 16 points).  To put the 2012 scores in perspective, consider that the OECD average on the reading test is 496.  Finland’s strong showing on PISA is completely dependent on the superior performance of its young women.

The gap seems to disappear by adulthood.  Tests of adult reading ability show no U.S. gender gap in reading by 25 years of age.  Scores even tilt toward men in later years. 

The words “seems to disappear” are used on purpose.  One must be careful with cross-sectional data not to assume that differences across age groups indicate an age-based trend.  A recent Gallup poll, for example, asked several different age groups how optimistic they were about finding jobs as adults.  Optimism fell from 68% in grade five to 48% in grade 12.  The authors concluded that “optimism about future job pursuits declines over time.”  The data do not support that conclusion.  The data were collected at a single point in time and cannot speak to what optimism may have been before or after that point.  Perhaps today’s 12^th graders were even more pessimistic several years ago when they were in fifth grade.  Perhaps the 12^th-graders are old enough to remember when unemployment spiked during the Great Recession and the fifth-graders are not.   Perhaps 12^th-graders are simply savvier about job prospects and the pitfalls of seeking employment, topics on which fifth-graders are basically clueless.

At least with the data cited above we can track measures of the same cohorts’ gender gap in reading over time.  By analyzing multiple cross-sections—data collected at several different points in time—we can look at real change.  Those cohorts of nine-year-olds in the 1970s, 1980s, and 1990s, are—respectively—today in their 50s, 40s, and 30s.  Girls were better readers than boys when these cohorts were children, but as grown ups, women are not appreciably better readers than men.

Care must be taken nevertheless in drawing firm conclusions.  There exists what are known as cohort effects that can bias measurements.  I mentioned the Great Recession.   Experiencing great historical cataclysms, especially war or economic chaos, may bias a particular cohort’s responses to survey questions or even its performance on tests.  American generations who experienced the Great Depression, World War II, and the Vietnam War—and more recently, the digital revolution, the Great Recession, and the Iraq War—lived through events that uniquely shape their outlook on many aspects of life. 

The gender gap is large, worldwide, and persistent through the K-12 years. What should be done about it?  Maybe nothing.  As just noted, the gap seems to dissipate by adulthood.  Moreover, crafting an effective remedy for the gender gap is made more difficult because we don’t definitely know its cause. Enjoyment of reading is a good example.  Many commentators argue that schools should make a concerted effort to get boys to enjoy reading more.  Enjoyment of reading is statistically correlated with reading performance, and the hope is that making reading more enjoyable would get boys to read more, thereby raising reading skills.

It makes sense, but I’m skeptical.  The fact that better readers enjoy reading more than poor readers—and that the relationship stands up even after boatloads of covariates are poured into a regression equation—is unpersuasive evidence of causality.  As I stated earlier, PISA produces data collected at a single point in time.  It isn’t designed to test causal theories.  Reverse causality is a profound problem.  Getting kids to enjoy reading more may in fact boost reading ability.  But the causal relationship might be flowing in the opposite direction, with enhanced skill leading to enjoyment.   The correlation could simply be indicating that people enjoy activities that they’re good at—a relationship that probably exists in sports, music, and many human endeavors, including reading.

A key question for policymakers is whether boosting boys’ enjoyment of reading would help make boys better readers.  I investigate by analyzing national changes in PISA reading scores from 2000, when the test was first given, to 2102.  PISA creates an Index of Reading Enjoyment based on several responses to a student questionnaire.  Enjoyment of reading has increased among males in some countries and decreased in others.  Is there any relationship between changes in boys’ enjoyment and changes in PISA reading scores? 

There is not.  The correlation coefficient for the two phenomena is -0.01.  Nations such as Germany raised boys’ enjoyment of reading and increased their reading scores by about 10 points on the PISA scale.  France, on the other hand, also raised boys’ enjoyment of reading, but French males’ reading scores declined by 15 points.  Ireland increased how much boys enjoy reading by a little bit but the boys’ scores fell a whopping 37 points. Poland’s males actually enjoyed reading less in 2012 than in 2000, but their scores went up more than 14 points.  No relationship.

How should policymakers proceed?  Large, cross-sectional assessments are good for measuring academic performance at one point in time.  They are useful for generating hypotheses based on observed relationships, but they are not designed to confirm or reject causality.  To do that, randomized control trials should be conducted of programs purporting to boost reading enjoyment.  Also, consider that it ultimately may not matter whether enjoying reading leads to more proficient readers.  Enjoyment of reading may be an end worthy of attainment irrespective of its relationship to achievement.  In that case, RCTs should carefully evaluate the impact of interventions on both enjoyment of reading and reading achievement, whether the two are related or not.  

Hypocrisy is not scarce in the world of politics. But the current House and Senate budget resolutions set new lows. Each proposes to cut about $5 trillion from government spending over the next decade in pursuit of a balanced budget. Whatever one may think of putting the goal of reducing spending when the ratio of the debt-to-GDP is projected to be stable above investing in the nation’s future, you would think that deficit-reduction hawks wouldn’t cut spending that has been proven to lower the deficit.

Yes, there are expenditures that actually lower the deficit, typically by many dollars for each dollar spent. In this category are outlays on ‘program integrity’ to find and punish fraud, tax evasion, and plain old bureaucratic mistakes. You might suppose that those outlays would be spared. Guess again. Consider the following:

Medicare. Roughly 10% of Medicare’s $600 billion budget goes for what officials delicately call ‘improper payments, according to the 2014 financial report of the Department of Health and Human Services. Some are improper merely because providers ‘up-code’ legitimate services to boost their incomes. Some payments go for services that serve no valid purpose. And some go for phantom services that were never provided. Whatever the cause, approximately $60 billion of improper payments is not ‘chump change.’

Medicare tries to root out these improper payments, but it lacks sufficient staff to do the job. What it does spend on ‘program integrity’ yields an estimated $14.40? for each dollar spent, about $10 billion a year in total. That number counts only directly measurable savings, such as recoveries and claim denials. A full reckoning of savings would add in the hard-to-measure ‘policeman on the beat’ effect that discourages violations by would-be cheats.

Fat targets remain. A recent report from the Institute of Medicine presented findings that veritably scream ‘fraud.’ Per person spending on durable medical equipment and home health care is ten times higher in Miami-Dade County, Florida than the national average. Such equipment and home health accounts for nearly three-quarters of the geographical variation in per person Medicare spending. Yet, only 4% of current recoveries of improper payments come from audits of these two items and little from the highest spending locations.

Why doesn’t Medicare spend more and go after the remaining overpayments, you may wonder? The simple answer is that Congress gives Medicare too little money for administration. Direct overhead expenses of Medicare amount to only about 1.5% of program outlays—6% if one includes the internal administrative costs of private health plans that serve Medicare enrollees. Medicare doesn’t need to spend as much on administration as the average of 19% spent by private insurers, because for example, Medicare need not pay dividends to private shareholders or advertise.

But spending more on Medicare administration would both pay for itself—$2 for each added dollar spent, according to the conservative estimate in the President’s most recent budget—and improve the quality of care. With more staff, Medicare could stop more improper payments and reduce the use of approved therapies in unapproved ways that do no good and may cause harm.

Taxes. Compare two numbers: $540 billion and $468 billion. The first number is the amount of taxes owed but not paid. The second number is the projected federal budget deficit for 2015, according to the Congressional Budget Office.

Collecting all taxes legally owed but not paid is an impossibility. It just isn’t worth going after every violation. But current enforcement falls far short of practical limits. Expenditures on enforcement directly yields $4 to $6 for each dollar spent on enforcement. Indirect savings are many times larger—the cop-on-the-beat effect again. So, in an era of ostentatious concern about budget deficits, you would expect fiscal fretting in Congress to lead to increased efforts to collect what the law says people owe in taxes.

Wrong again. Between 2010 and 2014, the IRS budget was cut in real terms by 20%. At the same time, the agency had to shoulder new tasks under health reform, as well as process an avalanche of applications for tax exemptions unleashed by the 2010 Supreme Court decision in the Citizens United case. With less money to spend and more to do, enforcement staff dropped by 15% and inflation adjusted collections dropped 13%.

One should acknowledge that enforcement will not do away with most avoidance and evasion. Needlessly complex tax laws are the root cause of most tax underpayment. Tax reform would do even more than improved administration to increase the ratio of taxes paid to taxes due. But until that glorious day when Congress finds the wit and will to make the tax system simpler and fairer, it would behoove a nation trying to make ends meet to spend $2 billion to $3 billion more each year to directly collect $10 billion to 15 billion a year more of legally owed taxes and, almost certainly, raise far more than that by frightening borderline scoff-laws.

Disability Insurance. Thirteen million people with disabling conditions who are judged incapable of engaging in substantial gainful activity received $161 billion in disability insurance in 2013. If the disabling conditions improve enough so that beneficiaries can return to work, benefits are supposed to be stopped. Such improvement is rare. But when administrators believe that there is some chance, the law requires them to check. They may ask beneficiaries to fill out a questionnaire or, in some cases, undergo a new medical exam at government expense. Each dollar spent in these ways generated an estimated $16 in savings in 2013.

Still, the Social Security Administration is so understaffed that SSA has a backlog of 1.3 million disability reviews. Current estimates indicate that spending a little over $1 billion a year more on such reviews over the next decade would save $43 billion. Rather than giving Social Security the staff and spending authority to work down this backlog and realize those savings, Congress has been cutting the agency’s administrative budget and sequestration threatens further cuts.

Claiming that better administration will balance the budget would be wrong. But it would help. And it would stop some people from shirking their legal responsibilities and lighten the burdens of those who shoulder theirs. The failure of Congress to provide enough staff to run programs costing hundreds of billions of dollars a year as efficiently and honestly as possible is about as good a definition of criminal negligence as one can find.

SUMMARY:
With the U.S. poverty rate stuck at around 15 percent for years, it’s clear that something needs to change, and candidates need to focus on three pillars of economic advancement-- education, work, family -- to increase economic mobility, according to Brookings Senior Fellow Isabel Sawhill and Senior Research Assistant Edward Rodrigue.

“Economic success requires people’s initiative, but it also requires us, as a society, to untangle the web of disadvantages that make following the sequence difficult for some Americans. There are no silver bullets. Government cannot do this alone. But government has a role to play in motivating individuals and facilitating their climb up the economic ladder,” they write.

The pillar of work is the most urgent, they assert, with every candidate needing to have concrete jobs proposals. Closing the jobs gap (the difference in work rates between lower and higher income households) has a huge effect on the number of people in poverty, even if the new workers hold low-wage jobs. Work connects people to mainstream institutions, helps them learn new skills, provides structure to their lives, and provides a sense of self-sufficiency and self-respect, while at the aggregate level, it is one of the most important engines of economic growth. Specifically, the authors advocate for making work pay (EITC), a second-earner deduction, childcare assistance and paid leave, and transitional job programs. On the education front, they suggest investment in children at all stages of life: home visiting, early childhood education, new efforts in the primary grades, new kinds of high schools, and fresh policies aimed at helping students from poor families attend and graduate from post-secondary institutions. And for the third prong, stable families, Sawhill and Rodrique suggest changing social norms around the importance of responsible, two-person parenthood, as well as making the most effective forms of birth control (IUDs and implants) more widely available at no cost to women.

“Many of our proposals would not only improve the life prospects of less advantaged children; they would pay for themselves in higher taxes and less social spending. The candidates may have their own blend of responses, but we need to hear less rhetoric and more substantive proposals from all of them,” they conclude.

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Far too many people reach their advanced years without planning for how they want their lives to end. The result too often is needless suffering, reduced dignity and autonomy, and agonizing decisions for family members.

Addressing these end-of-life issues is difficult. Most of us don’t want to confront them for ourselves or our family members. And until recently, many people resisted the idea of reimbursing doctors for end-of-life counselling sessions. In 2009, Sarah Palin labelled such sessions as the first step in establishing “death panels.” Although no such thing was contemplated when Representative Earl Blumenauer (D- Oregon) proposed such reimbursement, the majority of the public believed that death panels and euthanasia were just around the corner. Even the Obama Administration subsequently backed away from efforts to allow such reimbursement.

Fortunately, this is now history. In the past year or two the tenor of the debate has shifted toward greater acceptance of the need to deal openly with these issues. At least three developments illustrate the shift.

First, talk of “death panels” has receded, and new regulations, approved in late 2015 to take effect in January of this year, now allow Medicare reimbursement for end of life counselling. The comment period leading up to this decision was, according to most accounts, relatively free of the divisive rhetoric characterizing earlier debates. Both the American Medical Association and the American Hospital Association have signaled their support.

Second, physicians are increasingly recognizing that the objective of extending life must be balanced against the expressed priorities of their patients which often include the quality and not just the length of remaining life. Atal Gwande’s best-selling book, Being Mortal, beautifully illustrates the challenges for both doctors and patients. With well-grounded and persuasive logic, Gwande speaks of the need to de-medicalize death and dying.

The third development is perhaps the most surprising. It is a bold proposal advanced by Governor Jeb Bush before he bowed out of the Presidential race, suggesting that eligibility for Medicare be conditioned on having an advanced directive. His interest in these issues goes back to the time when as governor of Florida he became embroiled in a dispute about the removal of a feeding tube from a comatose Terry Schiavo. Ms. Schiavo’s husband and parents were at odds about what to do, her husband favoring removal and her parents wishing to sustain life. In the end, although the Governor sided with the parents, the courts decided in favor of the husband and allowed her to die. If an advanced directive had existed, the family disagreement along with a long and contentious court battle could have been avoided.

The point of such directives is not to pressure people into choosing one option over another but simply to insure that they consider their own preferences while they are still able. Making this a requirement for receipt of Medicare would almost surely encourage more people to think seriously about the type of care they would like toward the end of life and to talk with both their doctors and their family about these views. However, for many others, it would be a step too far and might reverse the new openness to advanced planning. A softer version nudging Medicare applicants to address these issues might be more acceptable. They would be asked to review several advance directive protocols, to choose one (or substitute their own). If they felt strongly that such planning was inappropriate, they could opt out of the process entirely and still receive their benefits.

Advanced care planning should not be linked only to Medicare. We should encourage people to make these decisions earlier in their lives and provide opportunities for them to revisit their initial decisions. This could be accomplished by implementing a similar nudge-like process for Medicaid recipients and those covered by private insurance.

Right now too few people are well informed about their end-of-life options, have talked to their doctors or their family members, or have created the necessary documents. Only about half of all of those who have reached the age of 60 have an advanced directive such as a living will or a power of attorney specifying their wishes. Individual preferences will naturally vary. Some will want every possible treatment to forestall death even if it comes with some suffering and only a small hope of recovery; others will want to avoid this by being allowed to die sooner or in greater comfort. Research suggests that when given a choice, most people will choose comfort care over extended life.

In the absence of advance planning, the choice of how one dies is often left to doctors, hospitals, and relatives whose wishes may or may not represent the preferences of the individual in their care. For example, most people would prefer to die at home but the majority do not. Physicians are committed to saving lives and relatives often feel guilty about letting a loved one “go.”

The costs of prolonging life when there is little point in doing so can be high. The average Medicare patient in their last year of life costs the government $33,000 with spending in that final year accounting for 25 percent of all Medicare spending. Granted no one knows in advance which year is “their last” so these data exaggerate the savings that better advance planning might yield, but even if it is 10% that represents over $50 billion a year. Dr. Ezekiel Emanuel, an expert in this area, notes that hospice care can reduce costs by 10 to 20 percent for cancer patients but warns that little or no savings have accompanied palliative care for heart failure or emphysema patients, for example. This could reflect the late use of palliative care in such cases or the fact that palliative care is more expensive than assumed.

In the end, Dr. Emanuel concludes, and I heartily agree, that a call for better advance planning should not be based primarily on its potential cost savings but rather on the respect it affords the individual to die in dignity and in accordance with their own preferences.

Editor's note: This piece originally appeared in Inside Sources.

Today marks Equal Pay Day. How are we doing? We have come a long way since I wrote my doctoral dissertation on the pay gap back in the late 1960s. From earning 59 percent of what men made in 1974 to earning 79 percent in 2015 (among year-round, full-time workers), women have broken a lot of barriers. 

There is no reason why the remaining gap can’t be closed. The gap could easily move in favor of women. After all, they are now better educated than men. They earn 60 percent of all bachelor’s degrees and the majority of graduate degrees. Adjusting for educational attainment, the current earnings gap widens, with the biggest relative gaps at the highest levels of education:

If we want to encourage people to get more education, we can't discriminate against the best educated just because they are women.

One source of the current gap is the fact that women still take more time off from work to care for their families. These family responsibilities may also affect the kinds of work they choose. Harvard professor Claudia Goldin notes that they are more likely to work in occupations where it is easier to combine work and family life. These divided work-family loyalties are holding women back more than pay discrimination per se. This should change when men are more willing to share equally on the home front, as Richard Reeves and I have argued elsewhere.  

But there is much to be done while waiting for this more egalitarian world to arrive. Paid family leave and more support for early child care and education would go a long way toward relieving families, and women in particular, of the dual burden they now face. In the process, the pay gap should shrink or even move in favor of women. 

The Economic Policy Institute (EPI) has just released a very informative report on these issues. They call for an aggressive expansion of both early childhood education and child care subsidies for low and moderate income families. Specifically, they propose to cap child care expenses at 10 percent of income, which would provide an average subsidy of $3,272 to working families with children and much more than this to lower-income families. 

The EPI authors argue that child care subsidies would provide needed in-kind benefits to lower income families (check!), boost women’s labor force participation in a way that would benefit the overall economy (check!), and reduce the gender pay gap (check!). In short, childcare subsidies are a win-win-win.

For present purposes I want to focus on the likely effects on the pay gap. In the mid-1990s, the U.S. had the highest rate of female labor force participation compared to Germany, Canada, and Japan. Now we have the lowest. One reason is because other advanced countries have expanded paid leave and child care support for employed mothers while the U.S. has not:

If we want to eliminate the pay gap and perhaps even reverse it, the primary focus must be on women’s continuing difficulties in balancing work and family life. We should certainly attend to any remaining instances of pay discrimination in the workplace, as called for in the Paycheck Fairness Act. But the biggest source of the problem is not employer discrimination; it is women’s continued double burden.

On Tuesday, October 28, 2014, tens of thousands of citizens of Burkina Faso gathered in its capital city, Ouagadougou, and its second biggest city, Bobo Dioulasso, to protest proposed changes to its constitution regarding term limits. A vote was planned for Thursday, on whether to extend the current limit of two terms to three. This vote is extremely controversial:  Current President Blaise Compaoré, who came to power in a coup in 1987, has ruled the country for 27 years. Allowing him to run for election in November 2015 could extend his reign for another five years. In Ouagadougou on Wednesday, citizens angry over the possibility that parliament might make it possible for Campaoré to stay in power indefinitely set fire to the parliament and forced legislators to postpone the vote that had been set for Thursday, October 30, 2014 to decide the constitutional issue.

The West African country has been plagued by dictators, autocracies and coups in the past. At independence on August 5, 1960, Maurice Yaméogo, leader of the Voltaic Democratic Union (Union démocratique voltaïque), became the country’s first president. Shortly after assuming power, Yaméogo banned all political opposition, forcing mass riots and demonstrations that only came to an end after the military intervened in 1966. Lt. Col. Sangoulé Lamizana and a collection of military elites took control of the government and subsequently dissolved the National Assembly as well as suspended the constitution. Lamizana stayed in power until November 1980 when the military overthrew the government and installed Col. Saye Zerbo as the new president. Two years later, Col. Zerbo’s government was overthrown by Maj. Dr. Jean-Baptiste Ouédraogo and the Council of Popular Salvation (CSP—Conseil du salut du peuple). Although it promised to transition the country to civilian rule and provide a new constitution, the Ouédraogo regime banned all political organizations, including opposition parties. There soon arose a political struggle within the CSP. The radicals, led by Captain Thomas Sankara, eventually overthrew the government in August 1983, and Capt. Sankara emerged as the country’s new leader. In 1984, the Sankara government changed the country’s name from Upper Volta to Burkina Faso and introduced many institutional reforms that effectively aligned the country with Marxist ideals.

On October 15, 1987, Capt. Blaise Compaoré, a former colleague of Sankara’s, killed Sankara and several of his confidants in a successful coup d’état. In 1991, Campaoré was elected president in an election in which only 25 percent of the electorate participated because of a boycott movement organized and carried out by opposition parties. In 1998, he won reelection for another seven-year term. As president, Campaoré reversed all the progressive policies that Sankara had implemented.

In 2000, the country’s post-Cold War 1991 constitution was amended to impose a limit of two five-year consecutive terms on the presidency. However, Campaoré’s supporters argued that because he was in office when the amendments went into effect, they did not apply to him and, hence, he was qualified to run for re-election in 2005. Despite the fact that the opposition fielded several candidates, Campoaré won 80.35 percent of the votes cast in the 2005 presidential election. And, in the presidential elections held in November 2010, he captured 80.2 percent of votes.

Over more than a quarter century in power, Campaoré has used an unusual formula to achieve relative stability in Burkina Faso—authoritarianism mixed with traces of democracy. The complex governance system has relied primarily on Campaoré’s dominant and charismatic political power and has failed to build sustainable institutions—specifically, those capable of maintaining the rule of law and enhancing peaceful coexistence in his absence.

Constitutionally mandated presidential term limits strengthen the rule of law and provide a significant level of stability and predictability to the country’s governance institutions. In response to the efforts by Burkinabé members of parliament to change the constitution to enable Compaoré to secure another term in office, U.S. government officials have recently stated that “democratic institutions are strengthened when established rules are adhered to with consistency.” On his part, Campaoré has proclaimed that his main and immediate concern “is not to build a future for myself—but to see how the future of this country will take shape.” If this is indeed true, then he should exit gracefully from the Burkinabé political scene and henceforth serve as an elder statesman, providing his country’s new leadership with the advice and support that they need to deepen and institutionalize democracy, as well as enhance economic, social, political and human development.

Insisting, as President Campoaré has done, that the constitution be changed so that he can seek an additional term in power not only destroys the country’s fragile stability but also sends the wrong message to citizens about the rule of law—while citizens must be law-abiding, the president does not have to abide by the country’s settled law; if the law stands in the way of the president’s personal ambitions, he can simply change the law to provide him with the wherewithal to achieve those objectives. Such behavior from the country’s chief executive does not augur well for deepening the country’s democracy, an objective that is dear to many Burkinabé. The question to ask President Campoaré is: How do you want history to remember you? As a self-serving political opportunist who used his public position to accumulate personal power and wealth, at the expense of fellow citizens, or as a public servant who led and directed his country’s transformation into a peaceful, safe and productive society?