In the developing world, more than 200 million children under the age of five years are at risk of not reaching their full development potential because they suffer from the negative consequences of poverty, nutritional deficiencies and inadequate learning opportunities. Overall, 165 million children (one in four) are stunted, and 90 percent of these children live in Africa and Asia. And though some progress has been made globally, child malnutrition remains a serious public health problem with enormous human and economic costs. Worldwide, only about 50 percent of children are enrolled in preprimary education, and in low-income countries a mere 17 percent. And though more and more children are going to school, millions have little to show for it. By some accounts, 250 million children of primary school age cannot read even part of a sentence. Some of these children have never been to school (58 million); but more often, they perform poorly despite having spent several years in school, which reflects not only the poor quality of many schools but also the multiple disadvantages that characterize their early life.

Ensuring that all children—regardless of their place of birth and parental income or education level—have access to opportunities that will allow them to reach their full potential requires investing early in their development. To develop their cognitive, linguistic, socioemotional and physical skills and abilities, children need good nutrition and health, opportunities for play, nurture and learning with caregivers, early stimulation and protection from violence and neglect.

The Case for Early Interventions 

The arguments for investing in children early are simple and convincing. Early investment makes sense scientifically. The brain is almost fully developed by age three, providing a prime opportunity to achieve high gains. We know that the rapid rate of development of the brain’s neural pathways is responsible for an individual’s cognitive, social and emotional development, and there is solid evidence that nutrition and stimulation during the first 1,000 days of life are linked to brain development. 

Early investment makes sense in terms of equity. The playing field has the highest chances of being leveled early on, and we know that programs have a higher impact for young children from poorer families. In the United States, for example, increasing preschool enrollment to 100 percent for low-income children would reduce disparities in school readiness by 24 percent between black and white children and by 35 percent between Hispanic and white children. We also know that equalizing initial endowments through early childhood development (ECD) programs is far more cost-effective than compensating for differences in outcomes later in life. 

Early investment makes sense economically. Investing early prevents higher costs down the road, and interventions yield a high return on investment. There is evidence of the benefits for the individual and for society more broadly. For instance, at the level of the individual, in Jamaica children participating in an early childhood stimulation program were found to have 25 percent higher earnings 20 years later compared with children who did not participate. At the economy-wide level, eliminating malnutrition is estimated to increase gross domestic product by 1 to 2 percentage points annually, while countries with school systems that have a 10-percentage-point advantage in the proportion of students

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We will likely look back on 2015 as a consequential year in China’s evolving global strategy. The September crash of the stock market in Shanghai marks the first contemporary occasion when China’s internal difficulties have had global consequences. In November, China will take over the leadership of the G-20 and have an opportunity to put its stamp on the evolving tools of global governance. And on September 28, President Xi Jinping will address the world during the 70th anniversary of the only global body in which China already has full powers—the United Nations.

A rising power, cut from different cloth

But with greater consequence comes greater responsibility. President Xi’s job at the U.N. in 2015 will be harder than in recent years. For the past several years the international community has been transfixed by the narrative of the rising powers, and of American, or at least Western, decline. Now, America’s economic recovery, its energy revolution, its leadership on Ebola, and its re-engagement around the Islamic State (or ISIS)—however partial—has gutted the “American decline” narrative. 

And Xi’s putative allies in the forging of a post-American order—Russia, Brazil, and India—won’t be nearly the help to China they have often been presumed to be. President Vladimir Putin will speak against the backdrop of Russia’s aggressive strategy in Ukraine and now Syria; Brazil’s President Dilma Roussef against the backdrop of a deep recession and a huge corruption scandal; and while President Narendra Modi is still riding relatively high internationally, he’s hardly riding in a pro-China direction. 

China is more consequential than any of these other three, of course. But it faces its own challenge to its narrative as it doubles down on its assertive posture in the South China Sea and as its handling of the stock market collapse shows serious cracks in the narrative of the “Beijing model.” As Chinese growth has slowed, especially in the manufacturing sector, so has its consumption of global commodities—and the knock-on effect has been slower growth in dozens of developing countries that had ridden China’s boom. China isn’t quite the alternative “pole” to the West it has been hyped to be. 

Still, China is now clearly the number two economy in the world; the number two defense spender; the dominant force in politics and economic integration in East Asia; and an increasingly important voice on global issues. So hype and narrative aside, the world will be listening closely to what President Xi has to say at the U.N.—as they will when he takes the reigns of the G-20. 

In what direction is Chinese leadership heading?

At a 700-person-strong gala dinner in Seattle on Tuesday, President Xi rehearsed the arguments. China is committed to a peaceful rise. China has learned the lesson of the Second World War, and recognizes that military hegemony is not an option. China is committed to the multilateral order, and the U.N. Charter. He even teased the international relations scholarly community: “There is no Thucydides trap,” he said, referring to the idea that the growth of Chinese power will cause fear in the United States and lead to war. He stressed his theme about forging a “new kind of great power relations” that eschewed military competition for more creative approaches to cooperation on win/win issues. 

All these would be welcome messages at the U.N., and if he means it, they are profoundly important messages. But if Xi wants these messages to be believed, if he wants to gain credibility at the global level, he’s going to have to do more than just talk a good game. 

First, China is going to have to start acknowledging that leadership is less about abusing the privileges of power and more about absorbing costs. The world may be hungry for leadership, but it’s not hungry for leadership of the abusive kind. It’s hungry for actors capable and willing to set a direction and bear the lion’s share of the costs of action—because that’s the only thing that’s ever overcome the collective action challenges that otherwise bedevil cooperation at the international level. 

China is going to have to start acknowledging that leadership is less about abusing the privileges of power and more about absorbing costs.

Second, he has to put his strategy where his principles are. He could start with the U.N. Charter. It’s an essential document of the international order, but only if the great powers abide by its essential principles (not by every detail.) The most essential of these are the prohibition against the acquisition of territory by force and the assertion of non-interference in sovereign affairs (except with the backing of the Security Council). The United States has violated these principles, notably in Iraq—its violation was of a temporary nature, of course, but had huge consequences. Russia has violated these principles—its violation in Crimea is modest in scale but notionally permanent and a fundamental violation of the foundational principles of the U.N.

China’s actions in the South China Sea have been more subtle than these, but no less invidious or injurious to the notion of a stable international order. If China wants others to believe that it still intends for its rise to be peaceful, it needs urgently to shift strategy in the South China Sea—and it would be in a strong position, then, to call on the other great powers to recommit themselves to the principle of the non-use of force and respect for sovereignty. 

[Xi] has to put his strategy where his principles are. He could start with the U.N. Charter.

I’m reasonably optimistic about the first idea. China was among the most neuralgic of countries when it came to the global response to SARS a decade ago; it’s learned its lesson and was far more forward leaning on Ebola. It chipped in, albeit not to scale, on the eurocrisis. It’s made financial contributions to the counter-ISIS campaign. And it’s made commitments that, if kept, will make a vital difference on the climate. These efforts represent a serious start, and if President Xi expands China’s role in this kind of leadership it could position him well on global issues—especially during his G-20 presidency. 

I’m not so optimistic about the second. China shows every sign of being locked in an assertive-tilting-to-aggressive strategy in the South China Sea, consequences be damned. And with Russia also seemingly locked into a “wrong-foot the West” strategy, the United States and its allies will increasingly be pulled into an escalatory response—creating exactly the kind of Thucydidean trap President Xi ostensibly wants to avoid. (The United States bears responsibility here too, and it can also take steps to lower tensions in Asia.) 

The problem is, the further out we go along the pathway of security tensions in Asia, the more we undermine the prospects for win-win cooperation on global challenges like terrorism and climate. For now, these twin strands of strategy are in roughly equal balance—both rivalry and restraint are leitmotifs of Xi’s worldview, and of America’s. But 2015 is going to be an important testing time for the viability of this dual-strand approach. If Xi wants to start tilting the balance to win/win approaches, his speech at the U.N. is a good place to start. But even that would only be a beginning.

I write this as I learn of the beating death of an Azerbaijani journalist Rasim Aliyev. His “crime” was to post a Facebook item about football. What follows seems insignificant compared to his murder.

Two articles have appeared in prominent Western outlets in the past month addressing developments in the South Caucasus and the need for adjustments in U.S. (and Western) policy toward the region. The first was an excellent, in-depth Brookings report titled "Retracing the Caucasian Circle—Considerations and Constraints for U.S., EU, and Turkish Engagement in the South Caucasus"; the second was a shorter essay that Bill Courtney, Denis Corboy, and I penned for Newsweek on the need to reboot policy toward Armenia, Azerbaijan, and Georgia. Both reflected the difficulty of writing about the “South Caucasus” as if the three countries had common interests and objectives. Increasingly these interests and objectives are diverging, except for a growing unhappiness with the United States and the West for not paying attention to—or doing enough to support—the region. In the case of Azerbaijan, the frustration stems from U.S. leaders paying too much attention to the appalling human rights situation in the country.

What’s making the Azerbaijanis so upset with the West?

The authors of the Brookings report point to elite cynicism over Western disinterest and policy failures in the region as sources of Azerbaijani leaders’ unhappiness. This, in their view, is causing Armenia, Georgia, and Azerbaijan—for different reasons and in different ways—to tack toward Russia.

We have a different take in our Newsweek piece. We argue that the unhappiness results from governing elites recognizing that U.S. and Western policy regarding human rights, democracy building, corruption, and conflict resolution (especially the Nagorno-Karabakh conflict) threaten regime stability. Therefore, the tacking toward Russia is a conscious choice to avoid pressure and the transparency that closer association with the United States and Europe would involve.

The new orientation of these countries requires serious adjustment in Western policies. There are four new drivers prompting change (beyond the role of Russia): the regional consequences of the Iran nuclear agreement; the growing economic crisis, which is affecting the South Caucasian states in different ways; the threat of renewed military conflict between Armenia and Azerbaijan; and the internal security implications of suppression of human rights. While each country responds to these drivers in different ways, they are the source of a new dynamic in the South Caucasus that requires a fresh Western policy approach.

Three wild cards will shape these drivers and the Western approach to them: First, how hard will Russian President Vladimir Putin push his objective of rolling back the degree of Western influence achieved since the fall of the Soviet Union? Second, how well will Iran play the nuclear agreement card, especially regarding its reentry into global energy markets? Third, how distracting will Turkey’s military response to the Islamic State and the Kurdistan Workers’ Party (PKK) be for Turkey’s interests in the South Caucasus and its objective of becoming a regional energy hub?

The shortcomings of soft regionalism

What is to be done? Faced with such a challenging situation, the default policy response is to provide more assistance (economic and military), dispatch senior officials from Western capitals to visit the region, and indulge (rather than criticize) democracy and human rights abuses, all in the name of developing a strategic partnership. In other words: Show more love.

That business-as-usual approach is inappropriate for these challenging times. In the case of Azerbaijan, it is an inappropriate response to the continued violations by the Baku regime of basic human rights and freedom of expression.

The Brookings paper suggests a multilateral approach (involving the United States, EU, and Turkey) based on soft regionalism. I do not believe that soft regionalism will work. The best we can hope for is parallel bilateral engagement on the basis of common interests (e.g. conflict prevention) and shared values (e.g. democratic evolution, observance of human rights). We need to treat the energy issue in the region as a commercial rather than geopolitical one. Changes in the global energy market have undermined the geopolitical significance of Caspian energy resources compared to two decades ago. With low energy prices likely the norm for the near future, energy no longer plays a strategic role for the region. Among other weaknesses, the soft regionalism prescription implies coordinated interests with Turkey—this will be difficult absent an opening in Turkish-Armenian relations.

Who needs who more?

The burden of choice in this relationship with the West must shift from the outside parties to the South Caucasian states themselves. The outsiders should stop talking about “strategic” partnerships, trans-Caspian pipelines and Silk Roads because this perpetuates a “you-need-us-more-than-we-need-you” starting point. Rather, the time has come for Armenia, Azerbaijan, and Georgia to decide on their own where their interests coincide with those of the West. That’s where we and they can begin to develop meaningful relationships, rather than trying to invent a veneer to cover differences—as in the case of Azerbaijan’s record on human rights.

Another recent article in Newsweek, by Theodore Gerber and Jane Zavisca, raised questions about promoting democracy and human rights where populations and elites are skeptical of U.S. motivations in promoting these issues. Fairly, the article questions the effectiveness of the traditional instruments of promoting opposition political parties and local NGOs as a way of winning “hearts and minds” in the former Soviet Union. Unfortunately, these traditional instruments tend to emphasize the attractiveness of the “American way of life” through student and scientific exchanges. This offers a variant on the soft regionalism theme advanced in the Brookings paper. Both require a receptivity to change that both elites and populations increasingly find threatening. Developing a values-based relationship is difficult when values diverge.

To the extent our interests do not coincide, then the Western policy focus must be transactional and rest exclusively on conflict prevention and/or amelioration. It also should not shy away from pressing all three South Caucasian states on their obligations to observe international standards regarding human rights, democracy, and freedom of expression.

Totaling more than $111,000,000.00, the 2014 North Carolina Senate contest between Kay Hagan and Thom Tillis is the most expensive Senate election in the nation’s history (not adjusted for inflation). As we investigated earlier this week, outside money has been flowing into American politics in the wake of the Supreme Court’s Citizens United decision in 2010.

When candidate and independent spending are combined, 2014 ranks among the most expensive, if not the most expensive, in history. However, understanding campaign spending takes more than a simple examination of total dollars. Spending differences across states can occur for a variety of reasons, including geographic size, population size, and the expense of media markets.

As a result, a more useful metric for understanding the magnitude of campaign activity is spending per voter, and 2014 offers an interesting case: Alaska. This year, Alaska saw a highly competitive Senate race in which both outside groups and candidates spend substantial amounts of money. Alaska ranks 47th in population with just over 700,000 residents and an estimated 503,000 eligible voters. After adjusting spending (both candidate and independent expenditures) for each state's estimated voting eligible population, Alaska's 2014 Senate race, unsurprisingly, ranks as the most expensive in US history.

Alaska originally ranked 6^th most expensive in 2014, with about $60 million spent total. But it jumps to first place in dollars spent per voter. Candidates and outside groups spent roughly $120 per voter in Alaska this year, about double the next most-expensive race, Montana 2012, where candidates and outside groups spent $66.5 per voter. By comparison, the $111 million Senate race in North Carolina—with a voting-eligible population of about 6,826,610—equaled only $16.25 per voter. That’s still far above the median spending per race for all three cycles ($7.3 per voter) but certainly serves to put the spending in context.

Relative to 2012 and 2014, in terms of both combined and per-voter spending, 2010 could be considered one of the cheaper cycles for Senate races thus far.

These data lend some support to the observation that, since Citizens (and more recently McCutcheon v. FEC) independent expenditures are quickly outpacing contributions to candidates. But given changes in reporting requirements and limited data, there is still a lot about outside spending we still don’t know.

All in all, candidate and outside group spending totaled just over a billion dollars in Senate races in 2014. The fact that North Carolina alone accounted for more than ten percent of that spending is astonishing, but no less remarkable is the intensity of spending per voter in Alaska. But if spending continues to grow as it has the last three election cycles, both of those records will likely be shattered in 2016.

Campaign finance is a key issue for the quality of democracy. As we noted in a recently-published book of which we are co-authors, and which we had the honor to present in the Hall of Former Presidents of the Legislative Assembly last February 11 (El costo de la Democracia: Ensayos sobre el financiamiento político en América Latina, UNAM, Mexico City, 2015), it is important because of an inescapable fact: While democracy has no price, it does have an operating cost. The use of economic resources is an essential element for democratic competition. More than a pathology of democracy, political financing, when well-regulated, is a normal part of democratic life.

Yet it is undeniable that money is capable of introducing distortions in the democratic process. Its unequal distribution impacts, first, on the real possibilities enjoyed by the parties and the candidates to take their message to the voters. Second, having money gives individuals and social groups a differentiated possibility of participating in elections and exercizing their influence over the candidates through their contributions. This is vital for democracy. When political power is simply a reflection of economic power, the principle of “one person, one vote” loses meaning. Third, fundraising efforts offer obvious opportunities for the articulation of exchanges between donors and those who make decisions on public affairs, or at least for the continual appearance of conflicts of interest. This can be very problematic in the case of Latin America, where there is a risk of money from organized crime penetrating the campaigns.

And so it is not surprising that the issue is on the political agenda in many countries of the region, just as it has been for a long time in Costa Rica. Costa Rica introduced public financing for political parties in 1956, making it the second country in the world to do so, after Uruguay. Nonetheless, the generosity of the government contribution did not avoid a long succession of scandals associated with the issue, a history that includes figures ranging from Robert Vesco and Manuel Antonio Noriega to Carlos Hank González and the illegal donations from the government of Taiwan. 

The wounds left by each of these episodes gave way to worthy yet incomplete regulatory efforts. Most important has been the reform of the Electoral Code approved in 2009, which among many necessary changes prohibited corporate contributions to the political parties. And not only legislative action has made a difference. The Constitutional Chamber of the Supreme Court has also made a difference by lifting bank secrecy on financing, a very important decision that has been pointed to internationally.

Each of these steps has been moving the country in the right direction. This is worth underscoring: At a time when it is so easy to revile the Costa Rican political system, it should be recognized that in terms of political financing the country is, in general, better situated than it was 20 or 30 years ago. All the evidence we have indicates that private contributions today are less important in our campaigns than one generation ago. We can state with great certainty that our parties are financing more than 80% of the cost of their campaigns with the state contribution. That is good news.

However, the current regulatory framework presents problems such as:

a) It continues to be a regulatory system that is somehow upside down: It meticulously keeps tabs on the use of the state contribution by the parties, which does not give rise to conflicts of interest, while it is much less effective when it comes to verifying the truth of the information the parties provide about their private sources of financing, which do have the potential to compromise the autonomy of the political system. Correcting this imbalance, getting the Supreme Electoral Tribunal to prioritize monitoring private financing and to devote more resources to it, would not only be a way to straighten out its priorities, but frankly, all the parties would also breathe a sigh of relief.

b) The system of advances on the state contribution continues to be very limited (only 15% of the subsidy is disbursed before the presidential election and nothing in the case of municipal elections). It is time to admit that eliminating the system whereby the contributions were distributed in advance payments, which existed from 1971 to 1991 (when 50% was disbursed in advances), caused grave prejudice to the political system. The weakness of the advanced disbursement has ended up leaving the parties at the mercy of banks and lenders during the campaigns. Worse still, today the possibility of a party receiving loans during the campaign against its electoral expectations depends entirely on the fickle behavior of the opinion polls. This is unfair and risky, as the OAS electoral observation missions have noted.

c) The legal framework does little to limit parties’ spending on advertising, one of the most effective ways to reduce outlays during campaigns and to bring about fairness in electoral competition, which is one of the most important objectives in improving the current system. One must evaluate the advisability of adopting a system of advertising slots (provided free of charge by those holding concessions for the radio spectrum or purchased by the Supreme Electoral Tribunal and then made available to the parties) as has been done, with a positive outcome, by other democracies in the region such as Argentina, Brazil, Chile, Ecuador, and Mexico.

d) The current regulatory framework has serious vulnerabilities at the local level. Requiring the parties to file a single financial report with the contribution they receive nationwide (the same system that exists for the presidential election) is insufficient when in practice there are 81 local elections in which each candidate raises and spends money autonomously. Let’s be clear: Relatively little is known about who finances the campaigns at the local level in Costa Rica. This would not matter much except that the experience of other countries – from Mexico to Colombia – shows that local campaigns are the preferred point of entry for organized crime to penetrate the electoral structures. Reinforcing the financial controls on municipal elections is one of the country’s most urgent tasks in relation to campaign finance.

Costa Rica has made major strides in regulating political financing. Yet there is an urgent need to address the weaknesses in the current regulatory framework. There are bills in the legislative pipeline, such as No. 18,739, introduced by the Supreme Electoral Tribunal in April 2013, that incorporate almost all the reforms suggested here and that provide an excellent basis for moving this inevitable discussion forward. 

We will have to address the problems in the current regulatory framework sooner or later. The question is whether we will do so before or after the next scandal. Let’s hope that, for once, we act on time.

This piece was originally published by International IDEA. 

Missouri's population is spreading out, adding to the costs of providing services and infrastructure across the state, according to a new study released today by the Brookings Institution Center on Urban and Metropolitan Policy.

The 84-page study, Growth in the Heartland: Challenges and Opportunities for Missouri, reports that Missouri's population is quickly dispersing, with smaller metropolitan areas experiencing some of the state's fastest growth and residency in unincorporated areas on the rise. Though new residents and jobs fueled prosperity in the 1990s, the report finds that growth has slowed in the past year, and suggests that the state's highly decentralized development patterns could become troublesome as Missouri contends with a slowing economy and serious budget deficits.

Sponsored by the Ewing Marion Kauffman Foundation, Growth in the Heartland provides the most comprehensive and up-to-date body of research and statistics yet assembled analyzing the direction, scope, and implications of development in Missouri. In addition to assessing the consequences of those trends for the state's fiscal health, economic competitiveness, and quality of life, the report addresses the potential role of state and local policy in shaping those trends in the future. Specific findings of the report conclude that:

• Growth in the Columbia, Springfield, Joplin, and St. Joseph metropolitan areas strongly outpaced that of the Kansas City and St. Louis metropolitan areas in the 1990s. Altogether the four smaller areas captured fully one-quarter of the state's growth and doubled the growth rate of the Kansas City and St. Louis areas.
  
  
• Population and job growth also moved beyond the smaller metro areas and towns into the state's vast unincorporated areas. Overall, residency in these often-outlying areas grew by 12.3 percent in the 1990s—a rate 50 percent faster than the 8.1 percent growth of towns and cities.
  
  
• Most rural counties reversed decades of decline in the 1990s, with eight in ten rural counties experiencing population growth and nine in ten adding new jobs. By 2000, more rural citizens lived outside of cities and towns than in them, as more than 70 percent of new growth occurred in unincorporated areas.

"Missouri experienced tremendous gains during the last decade, but the decentralized nature of growth across the state poses significant fiscal challenges for the future," said Bruce Katz, vice president of Brookings and director of the policy center. "The challenge for Missouri is to give communities the tools, incentives, and opportunities to grow in more efficient and fiscally responsible ways."

The Brookings Institution Center on Urban and Metropolitan Policy is committed to shaping a new generation of policies that will help build strong neighborhoods, cities, and metropolitan regions. By informing the deliberations of state and federal policymakers with expert knowledge and practical experience, the center promotes integrated approaches and practical solutions to the challenges confronting metropolitan communities. Learn more at www.brookings.edu/urban.

Editor's note: This article appears in the April 2015 issue of Global Forum. Click here to view the full publication.

Since passage of the Affordable Care Act in 2010, the last several years have seen a groundswell in physician payment and delivery reforms designed to achieve higher value health care through incentivizing higher quality care and lower overall costs. Accountable care models, for example, are achieving marked progress by realigning provider incentives toward greater risk-sharing and increased payments and shared savings with measured improvements in quality and cost containment. Medical homes are introducing greater care coordination and team-based care management, while the use of episode-based or bundled payments is removing perverse incentives that reward volume and intensity.

These reforms are coming just as the number of highly targeted, highly priced treatments continues to expand. The U.S. Food and Drug Administration (FDA) approved a decade-high 41 novel new drugs in 2014, many of them targeted therapies approved on the basis of increasingly sophisticated progress in genomics and the understanding of disease progression. In areas like oncology, such targeted treatments have grown as a percentage of global oncology market size from 11% in 2003 to 46% in 2013. New brand specialty drug spending in the U.S. is estimated to have been $7.5 billion in 2013, or 69% of total new drug spending. The growing prevalence of these drugs and their cost to the health system are setting the stage for significant flashpoints between industry, payers, and providers, seen most clearly in the debate over hepatitis C treatment costs that roiled stakeholder interactions for most of the past year. 

More of these targeted treatments are in the development pipeline, and a growing number of public policy efforts taking shape in 2015 are focused on accelerating their availability. The House of Representatives' 21st Century Cures Initiative, for example, has released a slew of legislative proposals aimed at promoting breakthrough innovation by increasing the efficiency of drug development and regulatory review. These efforts have significant downstream implications for the pace at which targeted and specialty therapies will become available, their associated costs, and the growing importance of demonstrating value in the postmarket setting.

As payers and providers continue their push toward increased value-based care, more innovative models for connecting such reforms to drug development are needed. Earlier collaboration with industry could enable more efficient identification of unmet need, opportunities to add value through drug development, and clearer input on the value proposition and evidentiary thresholds needed for coverage. Equally important will be unique public-private collaborations that invest in developing a better postmarket data infrastructure that can more effectively identify high value uses of new treatments and support achieving value through new payment reforms.

Stronger collaboration could also improve evidence development and the coverage determination process after a targeted  treatment has gained regulatory approval. Facilitated drug access programs like those proposed by the Medicare Administrative Contractor Palmetto GBA create access points for patients to receive targeted anti-cancer agents off-label while payers and industry gather important additional outcomes data in patient registries. More systematic and efficient use of policies like Medicare's Coverage with Evidence Development (CED), which allows for provisional coverage for promising technologies or treatments while evidence continues to be collected, could enable industry and payers to work together to learn about a medical product's performance in patient populations not typically represented in clinical studies. A CED-type model could be especially useful for certain specialty drugs: data collected as a condition of payment could help payers and providers develop evidence from actual practice to improve treatment algorithms, increase adherence, and improve outcomes. 

Finally, collaborations that support stronger postmarket data collection can also support novel drug payment models that further reward value. Bundled payments that include physician-administered drugs, for example, could encourage providers to increase quality while also incentivizing manufacturers to help promote evidence-based drug use and lower costs for uses that generate low value. Outcomes-based purchasing contracts that tie price paid to a medical product's performance could be another promising approach for high-expense treatment with clearly defined and feasibly measured outcomes.

Many of these ideas are not new, but as manufacturers, payers, providers, and patients move into an increasingly value-focused era of health care, it is clear that they must work together to find new ways to both promote development of promising new treatments while also making good on the promise of value-based health care reforms.

The Centers for Medicare and Medicaid Services (CMS) recently reported more optimistic news about the Medicare Accountable Care (ACO) Program, which began in 2012.  CMS released final first year financial and quality results for the Medicare Shared Savings Program (MSSP) ACOs and preliminary year two financial and quality results for the Pioneer ACO Model (Pioneer ACOs).

Financial Results: To date, the two programs have generated savings of $817 million—$372 million of which has been saved by Medicare and another $445 that has been returned to the ACOs through shared savings. While these savings are not final calculations, they suggest that both programs have produced modest savings in the first two years with some variability across ACOs.

Pioneer ACOs: Pioneers, generally considered more advanced ACOs, were able to generate more total program savings in year two than in year one ($96 million vs. $87 million), while also qualifying for shared savings payments of $68 million. The Medicare Trust Fund saved approximately $41 million in year two of the Pioneer program. In total, Pioneer ACOs were able to achieve an approximately 1% lower spending trend overall for the Medicare population than fee-for-service (1.4 vs. 0.45 percent lower per capita growth). Seventeen of the 23 Pioneer ACOs had positive or neutral financial performance, eleven of which were able to slow health spending enough to share in savings. On average, those ACOs saved $4.2 million in 2013, up from $2.7 million in 2012; shared savings grew from $1.2 million to $13 million. Six Pioneers generated losses, three of which were significant enough to require those Pioneer ACOs to share in the losses. While remaining Pioneers have been able to attain bigger savings in year two of the program, almost a third of original participants have left the program—some have moved to the lower risk MSSP, while others have focused on commercial ACO contracts or higher levels of risk in MA programs.

MSSP ACOs: MSSP ACOs were likewise able to reduce overall cost trend by slightly less than 1 percent. Of the 220 MSSP ACOs that started in 2012 or 2013, roughly one-quarter (53) were able to reduce spending enough to qualify for total shared savings of over $300 million. An additional 52 ACOs reduced spending compared to their benchmarks, but not enough to qualify for shared savings. One ACO that opted for track two (two-sided financial risk) overspent its benchmark by $10 million and owed shared savings of $4 million. MSSP ACOs as a whole were able to reduce spending by $652 million below their financial benchmarks and saved the Medicare Trust Fund $345 million, including repayment for the track 2 ACO losses.

Quality Results
Medicare ACOs continue to improve significantly on overall quality scores.  Both Pioneer ACOs and MSSPs have been able to attain higher average performance than quality benchmarks and better performance than Medicare fee-for-service on measures with data, such as colorectal screening, tobacco cessation, and depression screening.

Pioneer ACOs: All 23 Pioneer ACOs that remain in the program out of the initial 32 successfully reported their quality measures in their first two years.  The mean quality scores for Pioneer ACOs increased by 19 percent, from 71.8 percent in 2012 to 85.2% in 2013. Pioneer ACOs increased average improvement by 14.8 percent across all quality measures and overall improvement on 28 of 33 quality measures. Patients also report a positive experience receiving care from Pioneer ACOs—the ACOs improved average performance scores for patient and caregiver experience across 6 out of 7 measures.

MSSP ACOs: MSSP ACOs, as a group, posted even more improvement in quality scores than the Pioneer ACOs. MSSP ACOs starting in 2012 and 2013 were able to improve 30 of 33 quality measures, including measures such as patients’ rating of clinicians’ communication, beneficiaries rating of doctors, health promotion and education, screening for tobacco use and cessation, and screening for high blood pressure. In total, MSSP ACOs are experiencing higher CAHPS patient experience survey scores than Medicare fee-for-service, suggesting that patients are engaged and satisfied with being a part of an ACO. Additionally, MSSP ACOs achieved higher average performance rates on 17 of 22 Group Practice Reporting Option (GPRO) Web Interface measures reported by other large physician group fee-for-service providers.  Over 125,000 eligible providers or supplier members of ACOs qualified for incentive payments through PQRS (Physician Quality Reporting System) in 2013. Unfortunately, nine MSSP ACOs failed to successfully report their quality scores, four of which would have otherwise qualified for shared savings.

Digging Deeper into the Results
While program level analysis of financial performance is meaningful, a deeper analysis of the data and organizational characteristics of those MSSP ACOs that earned shared savings reveals some interesting trends. A little over half of those earning shared savings were physician-led ACOs (26/49) and more than a third of these physician led ACOs operate in Florida (10/26). The continued success of physician-led ACOs is consistent with previous findings that these ACOs may be better positioned than institutionally-based ACO to reduce overall costs. In addition, analysis by The Center for Medicare and Medicaid Innovation (CMMI) found that there is no relationship between savings/loss performances and whether the ACO included a hospital. Hospital-led ACOs were overall less likely to share in savings than physician-led ACOs. These two findings together suggest that ACOs can experience success even without an official hospital affiliation, paving the way for more physician practices to join and excel at accountable care.

Interesting regional trends are beginning to emerge from the data. Florida and Texas had the highest concentration of ACOs sharing in savings. Of the 30 Florida-based MSSP ACOs, more than a third (11) were able to share in savings, while almost half (7/15) Texas-based MSSP ACOs qualified for shared savings. Furthermore, the top two earning MSSP ACOs were from Texas (Memorial Herman with $28.34 million) and Florida (Palm Beach ACO with $19.34 million), respectively. The concentration of shared savings in these two states raises important questions about what is driving the high level performance. Are these MSSPs more likely to succeed because of a higher financial benchmark based on disproportionately greater regional Medicare spending? Do these ACOs have a leg up from the start because of their patient population and historical spending trend? Are physician ACOs more likely to form and succeed in these higher-cost areas? The success of these programs should not be understated, but further analysis may be needed to better understand performance drivers so appropriate program adjustments may be considered to level the playing field among MSSP ACOs across all regions.

Next Steps
While these latest Medicare ACO results are encouraging, more work needs to be done. The Pioneer Program recently lost its tenth program participant, Sharp Healthcare, bringing the total number of Pioneers down to 22. Like some other Pioneers that have exited the program, Sharp was dissatisfied with the benchmark and payment methodology and was no longer willing to assume financial risk that they felt was too great. This is just one among many policy and implementation issues with which Medicare ACOs are struggling. In June, we published a set of recommendations to ensure the long-term sustainability of the Medicare ACO program by addressing eight major ACO challenges. These results seem to reinforce the need for several of these recommendations for change in the Medicare ACO Program.

CMMI, which administers the Pioneer ACO Program, has recognized some of these challenges and has begun giving ACOs some greater flexibility in operating within the program. These changes include allowing them to move to population-based payments, waiving the 3-day hospitalization rule to allow ACOs to directly admit qualified patients to skilled nursing facilities, and experimenting with “voluntary alignment” to allow beneficiaries to attest to a primary care physician to offset some of the limitations of the existing attribution process. These are moves in the right direction; however CMS must continue to engage providers across the country to make sure the program remains viable.

Meanwhile, the MSSP will add another round of participants in January 2015 and CMS is expected to release a notice of proposed rulemaking that will amend the current operating requirements for the MSSP program later this year. The scope and nature of changes could dramatically impact the interest of new organization, as well as the continued participation of current MSSP and Pioneer ACOs.  Medicare ACOs will likely be encouraged to continue innovating to improve quality and reduce costs in the Medicare program, but the Medicare ACO program must continue to evolve to meet provider and beneficiary needs to ensure continued success.

Note: This blog has been corrected since its original posting on September 22 to reflect more accurate data.

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ABSTRACT

This study analyzes the willingness to pay for health insurance and hence the potential market for new low-cost health insurance product in Namibia, using the double bounded contingent valuation (DBCV) method. The findings suggest that 87 percent of the uninsured respondents are willing to join the proposed health insurance scheme and on average are willing to insure 3.2 individuals (around 90 percent of the average family size). On average respondents are willing to pay NAD 48 per capita per month and respondents in the poorest income quintile are willing to pay up to 11.4 percent of their income. This implies that private voluntary health insurance schemes, in addition to the potential for protecting the poor against the negative financial shock of illness, may be able to serve as a reliable income flow for health care providers in this setting.

Read the full paper on ScienceDirect »

In the developing world, more than 200 million children under the age of five years are at risk of not reaching their full development potential because they suffer from the negative consequences of poverty, nutritional deficiencies and inadequate learning opportunities. Overall, 165 million children (one in four) are stunted, and 90 percent of these children live in Africa and Asia. And though some progress has been made globally, child malnutrition remains a serious public health problem with enormous human and economic costs. Worldwide, only about 50 percent of children are enrolled in preprimary education, and in low-income countries a mere 17 percent. And though more and more children are going to school, millions have little to show for it. By some accounts, 250 million children of primary school age cannot read even part of a sentence. Some of these children have never been to school (58 million); but more often, they perform poorly despite having spent several years in school, which reflects not only the poor quality of many schools but also the multiple disadvantages that characterize their early life.

Ensuring that all children—regardless of their place of birth and parental income or education level—have access to opportunities that will allow them to reach their full potential requires investing early in their development. To develop their cognitive, linguistic, socioemotional and physical skills and abilities, children need good nutrition and health, opportunities for play, nurture and learning with caregivers, early stimulation and protection from violence and neglect.

The Case for Early Interventions 

The arguments for investing in children early are simple and convincing. Early investment makes sense scientifically. The brain is almost fully developed by age three, providing a prime opportunity to achieve high gains. We know that the rapid rate of development of the brain’s neural pathways is responsible for an individual’s cognitive, social and emotional development, and there is solid evidence that nutrition and stimulation during the first 1,000 days of life are linked to brain development. 

Early investment makes sense in terms of equity. The playing field has the highest chances of being leveled early on, and we know that programs have a higher impact for young children from poorer families. In the United States, for example, increasing preschool enrollment to 100 percent for low-income children would reduce disparities in school readiness by 24 percent between black and white children and by 35 percent between Hispanic and white children. We also know that equalizing initial endowments through early childhood development (ECD) programs is far more cost-effective than compensating for differences in outcomes later in life. 

Early investment makes sense economically. Investing early prevents higher costs down the road, and interventions yield a high return on investment. There is evidence of the benefits for the individual and for society more broadly. For instance, at the level of the individual, in Jamaica children participating in an early childhood stimulation program were found to have 25 percent higher earnings 20 years later compared with children who did not participate. At the economy-wide level, eliminating malnutrition is estimated to increase gross domestic product by 1 to 2 percentage points annually, while countries with school systems that have a 10-percentage-point advantage in the proportion of students

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In the developing world, more than 200 million children under the age of five years are at risk of not reaching their full human potential because they suffer from the negative consequences of poverty, nutritional deficiencies and inadequate learning opportunities. Given these risks, there is a strong case for early childhood development (ECD) interventions in nutrition, health, education and social protection, which can produce long-lasting benefits throughout the life cycle. The results from the 2012 round of the Program for International Student Assessment (PISA)—an international, large-scale assessment that measures 15-year-olds’ performance in mathematics, reading and science literacy—demonstrate the benefits of ECD: Students in the countries that belong to the Organization for Economic Cooperation and Development (OECD) who had the benefit of being enrolled for more than one year in preprimary school scored 53 points higher in mathematics (the equivalent of more than one year of schooling), compared with students who had not attended preprimary school. Although there is much evidence that ECD programs have a great impact and are less costly than educational interventions later in life, very few ECD initiatives are being scaled up in developing countries. For example, in 2010, only 15 percent of children in low-income countries—compared with 48 percent worldwide—were enrolled in preprimary education programs. Furthermore, even though the literature points to larger beneficial effects of ECD for poorer children, within developing countries, disadvantaged families are even less likely to be among those enrolled in ECD programs. For instance, in Ghana, children from wealthy families are four times more likely than children from poor households to be enrolled in preschool programs.

One of the major barriers to scaling up ECD interventions is financing. In order to address financing issues, both policymakers and practitioners need a better understanding of what is currently being spent on ECD interventions, what high-quality interventions cost, and what outcomes these interventions can produce. If stakeholder groups are made more aware of the costs of ECD interventions, they may be able to support decisionmaking on investments in ECD, to better estimate gaps in financing, and to work toward securing stable funding for scaling up service provision and for quality enhancement. One of the weakest areas of ECD policy planning is in the realm of financial planning.6 Good data are scarce on ECD spending and the costs of ECD interventions that are useful for program budgeting and planning; but these data are valuable for a number of reasons, including the fact that they support analyses of what different inputs cost and thus can facilitate considering various alternative modalities for service delivery. In this paper, we focus on what data are available to gain a clearer picture of what is being spent on ECD and what it costs to deliver basic ECD interventions in developing countries.

ECD interventions come in many varieties, and therefore we first define the package of ECD interventions that have been deemed essential. Then we outline a framework for better understanding ECD financing, which combines a top-down approach analyzing expenditures and a bottom-up approach analyzing the costs of delivering individual interventions. We comment on the general methodological issues stemming from these approaches and the limitations of the data that have been produced. Next, we delve into the available data and discuss the different funding sources and financing mechanisms that countries utilize to deliver ECD services and what patterns exist in spending. We provide a brief overview of how many public and private resources in both developed and developing countries are invested in young children, and in which specific subsectors. Although these data on spending illustrate the flows and help us understand how much is being allocated and by whom, the data are limited, and this top-down approach still leaves us with many unanswered questions. Therefore, we turn our attention to the actual costs of individual ECD interventions, which help us further understand what ECD spending can “buy” in different countries. We identify some trends in the actual costs of delivering these services, although there are a number of methodological issues vis-à-vis costing and the services delivered, which lead to wide variations between and within countries and make it difficult to compare programs over time.

Finally, we look at a number of initiatives that are currently under way to collect better data on ECD costs and expenditures, which will be useful for countries in planning programs and identifying funding sources. These initiatives are sponsored by organizations such as UNICEF, Save the Children, the World Bank and the Inter-American Development Bank. Given the gaps in the available data that we identify and the interventions currently under way, we conclude with recommendations for increasing the knowledge base in this area for use in policymaking and planning.

Voters and policy makers bemoan our crumbling roads, airports, and public transit systems, but few jurisdictions do much about it. The odd thing is that historically low interest rates now make it cheap to fix or improve our public facilities. The mystery is why decision makers have passed on this opportunity.

The sorry state of the nation’s roads, bridges, and public infrastructure has been widely reported. Every few years the American Society of Civil Engineers draws up a report card on U.S. infrastructure, highlighting its strengths and shortcomings in a variety of areas—drinking water systems, wastewater, dams, roads, bridges, inland waterways, ports. The report card spotlights areas where spending on maintenance falls short of the amount needed to keep our infrastructure functioning efficiently. For many kinds of infrastructure, a bigger population and heavier utilization require us to invest in brand new facilities. In its latest report card, the ASCE awards our public infrastructure a grade of D+.

It’s hard to think of a time more attractive for public investment than years when total demand for goods and services is depressed. The Treasury’s borrowing cost for investment funds is near historical lows. Since 2011, the interest rate on 10-year government bonds has averaged 2.3 percent. Savers buying inflation-protected bonds have been willing to lend funds to the federal government at a real interest rate of just 0.22 percent.

So long as there is excess unemployment, especially in the building trades, the labor resources needed to fix or improve public facilities should be abundant and relatively inexpensive. Employment in the construction industry has rebounded as home building and business investment have improved. Nonetheless, construction employment has recovered only half the loss it experienced between its pre-recession peak in 2006 and its post-recession low in 2011. Skilled labor is not nearly as abundant as it was in 2011, but the trend in wage inflation does not suggest employers are bidding up worker salaries.

The federal government’s failure to use fiscal policy and, in particular, public investment policy to bring the nation closer to full employment represents a notable lapse in policymaking, perhaps the most grievous lapse since the crisis began. It unnecessarily prolonged the suffering of the nation’s long-term unemployed and it wasted a rare opportunity to rebuild the nation’s public infrastructure at relatively low cost.

Why did this failure occur? One reason is that policy makers were too optimistic when the financial crisis took place back in 2008. Most public and private forecasts at the time understated the severity of the economic fallout from the bank meltdown. Decision makers in Congress and the Administration may have believed infrastructure investment would be unhelpful in the recovery. Well-conceived infrastructure projects take many months to design and many years to complete. Policy makers may have believed the economic crisis would be over by the time federally infrastructure spending reached its peak.

When forecasters and Democratic policy makers recognized their error, voters had elected a Congress that supported only one kind of fiscal policy to deal with the crisis—big tax cuts focused on high-income tax payers. Whether or not such a policy could have been effective, it would not make additional funds available for infrastructure projects.

Harvard’s Lawrence Summers and Rachel Lipset recently pointed to another reason voters have failed to back a big program to boost infrastructure investment—government ineptitude. In the Boston Globe they documented the painfully slow progress of the Massachusetts Department of Transportation in overhauling a bridge across the Charles River. The bridge, which was built over 11 months back in 1912, has so far required four years for its reconstruction. No end date is in sight. In addition to the over-budget cost of the project, the overhaul has also caused massive and highly visible inconvenience for drivers, cyclists, and pedestrians trying to move between Boston and Cambridge.

Few readers can be under the illusion Boston’s experience is exceptional. Many of us pass near or use public facilities that are being rebuilt or repaired. We often see bafflingly little progress over a span of months or even years. As Summers and Lipset note, the conspicuous failure of public managers to complete capital projects speedily and on budget undermines voters’ confidence that infrastructure projects can be worthwhile.

Despite wide agreement the nation’s infrastructure needs to be modernized, we have made little progress toward that goal. On the contrary, government capital spending has shrunk significantly as a share of the economy. In 2014, net government investment spending on items other than defense dipped to a 60-year low when spending is measured as a percent of GDP. Using this indicator, net government investment has shrunk almost half compared with its level in the first decade of the century. For many reasons this is a good time to fix our public infrastructure. It is also an excellent time to overhaul public management of government capital projects.

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

Universities cash handsome awards on infringement cases

Last month, a jury found Apple Inc. guilty of infringing a patent of the University of Wisconsin-Madison (UW) and ordered the tech giant to pay $234 million. The university scored a big financial victory, but this hardly meant any gain for the good name of the university.

The plaintiffs argued successfully in court that Apple infringed their 1998 patent on a predictor circuit that greatly improved the efficiency of microchips used in the popular iPhone 5s, 6, and 6 Plus. Apple first responded by challenging the validity of the patent, but the US Patent and Trademark Office ruled in favor of the university. Apple plans to appeal, but the appellate court is not likely to reverse the lower court’s decision.

This is not the first time this university has asserted its patents rights (UW sued Intel in 2008 for this exact same patent and reportedly settled for $110 million). Nor is this the first time universities in general have taken infringers to court. Prominent cases in recent memory include Boston University, which sued several companies for infringement of a patent for blue light-emitting diodes and settled out of court with most of them, and Carnegie Mellon, who was awarded $237 million by the federal appellate court on its infringement suit against Marvell, a semiconductor company, for its use of an enhanced detector of data in hard drives called Kavcic detectors.

Means not always aligned with aims in patent law

When university inventions emerge from federal research grants, universities can also sue the infringers, but in those cases they would be testing the accepted interpretations of current patent law.

The Bayh-Dole Act of 1980 extended patent law and gave small-business and universities the right to take title to patents from federal grants—later it was amended to extend the right to all federal grantees regardless of size. The ostensible aim of this act is to “to promote the utilization of inventions arising from federally supported research or development.” Under the law, a condition for universities to keep their exclusive rights on those patents is that they or their licensees take “effective steps to achieve practical application” of those patents. Bayh-Dole was not designed to create a new source of revenue for universities. If companies are effectively using university technologies, Bayh-Dole’s purpose is served without need of the patents.

To understand this point, consider a counterfactual: What if the text of Bayh-Dole had been originally composed to grant a conditional right to patents for federal research grantees? The condition could be stated like this: “This policy seeks to promote the commercialization of federally funded research and to this end it will use the patent system. Grantees may take title to patents if and only if other mechanisms for disseminating and developing those inventions into useful applications prove unsuccessful.” Under this imagined text, the universities could still take title to patents on their inventions if they or the U.S. Patent and Trademark Office were not aware that the technologies were being used in manufactures.

But no court would find their infringement claim meritorious if the accused companies could demonstrate that, absent of willful infringement, they had in fact used the technologies covered by university patents in their commercial products. In this case, other mechanisms for disseminating and developing the technologies would have proven successful indeed. The reality that Bayh-Dole did not mandate such a contingent assignation of rights creates a contradiction between its aims and the means chosen to advance those aims for the subset of patents that were already in use by industry.

I should clarify that the predictor circuit, the blue-light diode, and the Kavcic detectors are not in that subset of patents. But even in they were, there is no indication that the University of Wisconsin-Madison would have exercised its patent rights with any less vigor just because the original research was funded by public funds. Today, it is fully expected from universities to aggressively assert their patent rights regardless of the source of funding for the original research.

You can have an answer for every question and still lose the debate

It is this litigious attitude that puts off many observers. While the law may very well allow universities to be litigious, universities could still refuse to exercise their rights under circumstances in which those rights are not easily reconciled with the public mission of the university.

Universities administrators, tech transfer personnel, and particularly the legal teams winning infringement cases have legitimate reasons to wonder why universities are publicly scorned. After all, they are acting within the law and simply protecting their patent rights; they are doing what any rational person would do. They may be really surprised when critics accuse universities of becoming allies of patent trolls, or of aiding and abetting their actions. Such accusations are unwarranted. Trolls are truants; the universities are venerable institutions. Patent trolls would exploit the ambiguities of patent law and the burdens of due process to their own benefit and to the detriment of truly productive businesses and persons. In stark contrast, universities are long established partners of democracy, respected beyond ideological divides for their abundant contributions to society.

The critics may not be fully considering the intricacies of patent law. Or they may forget that universities are in need of additional revenue—higher education has not seen public financial support increase in recent years, with federal grants roughly stagnated and state funding falling drastically in some states. Critics may also ignore that revenues collected from licensing of patents, favorable court rulings, and out-of-court settlements, are to a large extent (usually two thirds of the total) plugged back into the research enterprise.

University attorneys may have an answer for every point that critics raise, but the overall concern of critics should not be dismissed outright. Given that many if not most university patents can be traced back to research funded by tax dollars, there is a legitimate reason for observers to expect universities to manage their patents with a degree of restraint. There is also a legitimate reason for public disappointment when universities do not seem to endeavor to balance the tensions between their rights and duties.

Substantive steps to improve the universities’ public image

Universities can become more responsive to public expectations about their character not only by promoting their good work, but also by taking substantive steps to correct misperceptions.

First, when universities discover a case of proven infringement, they should take companies to court as a measure of last resort. If a particular company refuses to negotiate in good faith and an infringement case ends up in court, the universities should be prepared to demonstrate to the court of public opinion that they have tried, with sufficient insistence and time, to negotiate a license and even made concessions in pricing the license. In the case of the predictor circuit patent, it seems that the University of Wisconsin-Madison tried to license the technology and Apple refused, but the university would be in a much better position if it could demonstrate that the licensing deals offered to Apple would have turned to be far less expensive for the tech company.

Second, universities would be well advised not to join any efforts to lobby Congress for stronger patent protection. At least two reasons substantiate this suggestion. First, as a matter of principle, the dogmatic belief that without patents there is no innovation is wrong. Second, as a matter of material interest, universities as a group do not have a financial interest in patenting. It’s worth elaborating these points a bit more.

Neither historians nor social science researchers have settled the question about the net effects of patents on innovation. While there is evidence of social benefits from patent-based innovation, there is also evidence of social costs associated with patent-monopolies, and even more evidence of momentous innovations that required no patents. What’s more, the net social benefit varies across industries and over time. Research shows economic areas in which patents do spur innovation and economic sectors where it actually hinders them. This research explains, for instance, why some computer and Internet giants lobby Congress in the opposite direction to the biotech and big pharma industries. Rigorous industrial surveys of the 1980s and 1990s found that companies in most economic sectors did not use patents as their primary tool to protect their R&D investments.

Yet patenting has increased rapidly over the past four decades. This increase includes industries that once were uninterested in patents. Economic analyses have shown that this new patenting is a business strategy against patent litigation. Companies are building patent portfolios as a defensive strategy, not because they are innovating more. The university’s public position on patent policy should acknowledge that the debate on the impact of patents on innovation is not settled and that this impact cannot be observed in the aggregate, but must be considered in the context of each specific economic sector, industry, or even market. From this vantage point, universities could then turn up or down the intensity with which they negotiate licenses and pursue compensation for infringement. Universities would better assert their commitment to their public mission if they compute on a case by case basis the balance between social benefits and costs for each of its controversial patents.

As to the material interest in patents, it is understandable that some patent attorneys or the biotech lobby publicly espouse the dogma of patents, that there is no innovation without patents. After all, their livelihood depends on it. However, research universities as a group do not have any significant financial interest in stronger patent protection. As I have shown in a previous Brookings paper, the vast majority of research universities earn very little from their patent portfolios and about 87% of tech transfer offices operate in the red. Universities as a group receive so little income from licensing and asserting their patents relative to the generous federal support (below 3%), that if the federal government were to declare that grant reviewers should give a preference to universities that do not patent, all research universities would stop the practice at once. It is true that a few universities (like the University of Wisconsin-Madison) raise significant revenue from their patent portfolio, and they will continue to do so regardless of public protestations. But the majority of universities do not have a material interest in patenting.

Time to get it right on anti-troll legislation

Last year, the House of Representative passed legislation closing loopholes and introducing disincentives for patent trolls. Just as mirror legislation was about to be considered in the Senate, Sen. Patrick Leahy withdrew it from the Judiciary Committee. It was reported that Sen. Harry Reid forced the hand of Mr. Leahy to kill the bill in committee. In the public sphere, the shrewd lobbying efforts to derail the bill were perceived to be pro-troll interests. The lobbying came from pharmaceutical companies, biotech companies, patent attorneys, and, to the surprise of everyone, universities.  Little wonder that critics overreacted and suggested universities were in partnership with trolls: even if they were wrong, these accusations stung.

University associations took that position out of a sincere belief in the dogma of patents and out of fear that the proposed anti-troll legislation limited their ability to sue patent infringers. However, their convictions stand on shaky ground and their material interests are not those of the vast majority of universities.

A reversal of that position is not only possible, but would be timely. When anti-troll legislation is again introduced in Congress, universities should distance themselves from efforts to protect the policy status quo that so benefits patent trolls. It is not altogether improbable that Congress sees fit to exempt universities from some of the requirements that the law would impose. University associations could show Congress the merit of such exemptions in consideration of the universities’ constant and significant contributions to states, regions, and the nation. However, no such concessions could ever be expected if the universities continue to place themselves in the company of those who profit from patent management.

No asset is more valuable for universities than their prestige. It is the ample recognition of their value in society that guarantees tax dollars will continue to flow into universities. While acting legally to protect their patent rights, universities are nevertheless toying with their own legitimacy. Let those universities that stand to gain from litigation act in their self-interest, but do not let them speak for all universities. When university associations advocate for stronger patent protection, they do the majority of universities a disservice. These associations should better represent the interests of all their members by advocating a more neutral position about patent reform, by publicly praising universities’ restraint on patent litigation, and by promoting a culture and readiness in technology transfer offices to appraise each patent not by its market value but by its social value. At the same time, the majority of universities that obtain neither private nor social benefits from patenting should press their political representatives to adopt a more balanced approach to policy advocacy, lest they squander the reputation of the entire university system.

This post originally appeared on the Center for Technology Innovation’s TechTank blog.

Universities cash handsome awards on infringement cases

This October, a jury found Apple Inc. guilty of infringing a patent of the University of Wisconsin-Madison (UW) and ordered the tech giant to pay $234 million. The university scored a big financial victory, but this hardly meant any gain for the good name of the university.

The plaintiffs argued successfully in court that Apple infringed their 1998 patent on a predictor circuit that greatly improved the efficiency of microchips used in the popular iPhone 5s, 6, and 6 Plus. Apple first responded by challenging the validity of the patent, but the US Patent and Trademark Office ruled in favor of the university. Apple plans to appeal, but the appellate court is not likely to reverse the lower court’s decision.

This is not the first time this university has asserted its patents rights (UW sued Intel in 2008 for this exact same patent and reportedly settled for $110 million). Nor is this the first time universities in general have taken infringers to court. Prominent cases in recent memory include Boston University, which sued several companies for infringement of a patent for blue light-emitting diodes and settled out of court with most of them, and Carnegie Mellon, who was awarded $237 million by the federal appellate court on its infringement suit against Marvell, a semiconductor company, for its use of an enhanced detector of data in hard drives called Kavcic detectors.

Means not always aligned with aims in patent law

When university patented inventions emerge from federal research grants, infringement suits test the accepted interpretations of current patent law.

The Bayh-Dole Act of 1980 extended patent law and gave small-business and universities the right to take title to patents from federal research grants—later it was amended to extend the right to all federal grantees regardless of size. The ostensible aim of this act is to “to promote the utilization of inventions arising from federally supported research or development.” Under the law, a condition for universities (or any other government research performers) to keep their exclusive rights on those patents is that they or their licensees take “effective steps to achieve practical application” of those patents. Bayh-Dole was not designed to create a new source of revenue for universities. If companies are effectively using university technologies, Bayh-Dole’s purpose is served without need of patents.

To understand this point, consider a counterfactual: What if the text of Bayh-Dole had been originally composed to grant a conditional right to patents for federal research grantees? The condition could be stated like this: “This policy seeks to promote the commercialization of federally funded research and to this end it will use the patent system. Grantees may take title to patents if and only if other mechanisms for disseminating and developing those inventions into useful applications prove unsuccessful.” Under this imagined text, the universities could still take title to patents on their inventions if they or the U.S. Patent and Trademark Office were not aware that the technologies were being used in manufactures.

But no court would find their infringement claim meritorious if the accused companies could demonstrate that, absent of willful infringement, they had in fact used the technologies covered by university patents in their commercial products. In this case, other mechanisms for disseminating and developing the technologies would have proven successful indeed. The reality that Bayh-Dole did not mandate such a contingent assignation of rights creates a contradiction between its aims and the means chosen to advance those aims for the subset of patents that were already in use by industry.

I should remark that UW’s predictor circuit resulted from grants from NSF and DARPA and there is no indication that the university exercised its patent rights with any less vigor just because the original research was funded by public funds. In fact, it is fully expected from universities to aggressively assert their patent rights regardless of the source of funding for the original research.

You can have an answer for every question and still lose the debate

It is this litigious attitude that puts off many observers. While the law may very well allow universities to be litigious, universities could still refuse to exercise their rights under circumstances in which those rights are not easily reconciled with the public mission of the university.

Universities administrators, tech transfer personnel, and particularly the legal teams winning infringement cases have legitimate reasons to wonder why universities are publicly scorned. After all, they are acting within the law and simply protecting their patent rights; they are doing what any rational person would do. They may be really surprised when critics accuse universities of becoming allies of patent trolls, or of aiding and abetting their actions. Such accusations are unwarranted. Trolls are truants; the universities are venerable institutions. Patent trolls would exploit the ambiguities of patent law and the burdens of due process to their own benefit and to the detriment of truly productive businesses and persons. In stark contrast, universities are long established partners of democracy, respected beyond ideological divides for their abundant contributions to society.

The critics may not be fully considering the intricacies of patent law. Or they may forget that universities are in need of additional revenue—higher education has not seen public financial support increase in recent years, with federal grants roughly stagnated and state funding falling drastically in some states. Critics may also ignore that revenues collected from licensing of patents, favorable court rulings, and out-of-court settlements, are to a large extent (usually two thirds of the total) plugged back into the research enterprise.

University attorneys may have an answer for every point that critics raise, but the overall concern of critics should not be dismissed outright. Given that many if not most university patents can be traced back to research funded by tax dollars, there is a legitimate reason for observers to expect universities to manage their patents with a degree of restraint. There is also a legitimate reason for public disappointment when universities do not seem to endeavor to balance the tensions between their rights and duties.

Substantive steps to improve the universities’ public image

Universities can become more responsive to public expectations about their character not only by promoting their good work, but also by taking substantive steps to correct misperceptions.

First, when universities discover a case of proven infringement, they should take companies to court as a measure of last resort. If a particular company refuses to negotiate in good faith and an infringement case ends up in court, the universities should be prepared to demonstrate to the court of public opinion that they have tried, with sufficient insistence and time, to negotiate a license and even made concessions in pricing the license. In the case of the predictor circuit patent, it seems that the University of Wisconsin-Madison tried to license the technology and Apple refused, but the university would be in a much better position if it could demonstrate that the licensing deals offered to Apple would have turned to be far less expensive for the tech company.

Second, universities would be well advised not to join any efforts to lobby Congress for stronger patent protection. At least two reasons substantiate this suggestion. First, as a matter of principle, the dogmatic belief that without patents there is no innovation is wrong. Second, as a matter of material interest, universities as a group do not have a financial interest in patenting. It’s worth elaborating these points a bit more.

Neither historians nor social science researchers have settled the question about the net effects of patents on innovation. While there is evidence of social benefits from patent-based innovation, there is also evidence of social costs associated with patent-monopolies, and even more evidence of momentous innovations that required no patents. What’s more, the net social benefit varies across industries and over time. Research shows economic areas in which patents do spur innovation and economic sectors where it actually hinders them. This research explains, for instance, why some computer and Internet giants lobby Congress in the opposite direction to the biotech and big pharma industries. Rigorous industrial surveys of the 1980s and 1990s found that companies in most economic sectors did not use patents as their primary tool to protect their R&D investments.

Yet patenting has increased rapidly over the past four decades. This increase includes industries that once were uninterested in patents. Economic analyses have shown that this new patenting is a business strategy against patent litigation. Companies are building patent portfolios as a defensive strategy, not because they are innovating more. The university’s public position on patent policy should acknowledge that the debate on the impact of patents on innovation is not settled and that this impact cannot be observed in the aggregate, but must be considered in the context of each specific economic sector, industry, or even market. From this vantage point, universities could then turn up or down the intensity with which they negotiate licenses and pursue compensation for infringement. Universities would better assert their commitment to their public mission if they compute on a case by case basis the balance between social benefits and costs for each of its controversial patents.

As to the material interest in patents, it is understandable that some patent attorneys or the biotech lobby publicly espouse the dogma of patents, that there is no innovation without patents. After all, their livelihood depends on it. However, research universities as a group do not have any significant financial interest in stronger patent protection. As I have shown in a previous Brookings paper, the vast majority of research universities earn very little from their patent portfolios and about 87% of tech transfer offices operate in the red. Universities as a group receive so little income from licensing and asserting their patents relative to the generous federal support (below 3%), that if the federal government were to declare that grant reviewers should give a preference to universities that do not patent, all research universities would stop the practice at once. It is true that a few universities (like the University of Wisconsin-Madison) raise significant revenue from their patent portfolio, and they will continue to do so regardless of public protestations. But the majority of universities do not have a material interest in patenting.

Time to get it right on anti-troll legislation

Last year, the House of Representative passed legislation closing loopholes and introducing disincentives for patent trolls. Just as mirror legislation was about to be considered in the Senate, Sen. Patrick Leahy withdrew it from the Judiciary Committee. It was reported that Sen. Harry Reid forced the hand of Mr. Leahy to kill the bill in committee. In the public sphere, the shrewd lobbying efforts to derail the bill were perceived to be pro-troll interests. The lobbying came from pharmaceutical companies, biotech companies, patent attorneys, and, to the surprise of everyone, universities.  Little wonder that critics overreacted and suggested universities were in partnership with trolls: even if they were wrong, these accusations stung.

University associations took that position out of a sincere belief in the dogma of patents and out of fear that the proposed anti-troll legislation limited the universities’ ability to sue patent infringers. However, their convictions stand on shaky ground and only a few universities sue for infringement. In taking that policy position, university associations are representing neither the interests nor the beliefs of the vast majority of universities.

A reversal of that position is not only possible, but would be timely. When anti-troll legislation is again introduced in Congress, universities should distance themselves from efforts to protect the policy status quo that so benefits patent trolls. It is not altogether improbable that Congress sees fit to exempt universities from some of the requirements that the law would impose. University associations could show Congress the merit of such exemptions in consideration of the universities’ constant and significant contributions to states, regions, and the nation. However, no such concessions could ever be expected if the universities continue to place themselves in the company of those who profit from patent management.

No asset is more valuable for universities than their prestige. It is the ample recognition of their value in society that guarantees tax dollars will continue to flow into universities. While acting legally to protect their patent rights, universities are nevertheless toying with their own legitimacy. Let those universities that stand to gain from litigation act in their self-interest, but do not let them speak for all universities. When university associations advocate for stronger patent protection, they do the majority of universities a disservice. These associations should better represent the interests of all their members by advocating a more neutral position about patent reform, by publicly praising universities’ restraint on patent litigation, and by promoting a culture and readiness in technology transfer offices to appraise each patent not by its market value but by its social value. At the same time, the majority of universities that obtain neither private nor social benefits from patenting should press their political representatives to adopt a more balanced approach to policy advocacy, lest they squander the reputation of the entire university system.

Editor's Note: The post was corrected to state that UW’s predictor circuit did originate from federally funded research.