With violent protests following the second anniversary of the Egyptian revolution, and calls for a new unified government amid dire comments about the stability of Egypt, the world’s attention is again on President Morsi and his country. This follows a tumultuous period last month, when Egyptians went to the polls and ratified a new constitution. The document, criticized as hurried, incomplete, and lacking in consensus is enormously contentious.

In the Saban Center’s newest Middle East Memo, The View From a Distance: Egypt’s Contentious New Constitution, nonresident fellow Mirette F. Mabrouk gives a broad overview of the new constitution, and provides context and analysis for specific sections.

Mabrouk outlines several ways in which, she argues, the document is shaky on the protection of freedoms and rights, particularly those of women, some religious minorities and minors. Mabrouk also encourages analysts to stop viewing this situation as an Islamist/ secular divide, arguing that idea is too simplistic, and lacks the context for greater understanding of Egypt’s domestic politics.

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Fee-for-service payments encourage high-volume services rather than high-quality care. Alternative payment models (APMs) aim to realign financing to support high-value services.

The 2 main components of gastroenterologic care, procedures and chronic care management, call for a range of APMs. The first step for gastroenterologists is to identify the most important conditions and opportunities to improve care and reduce waste that do not require financial support.

We describe examples of delivery reforms and emerging APMs to accomplish these care improvements. A bundled payment for an episode of care, in which a provider is given a lump sum payment to cover the cost of services provided during the defined episode, can support better care for a discrete procedure such as a colonoscopy. Improved management of chronic conditions can be supported through a per-member, per-month (PMPM) payment to offer extended services and care coordination.

For complex chronic conditions such as inflammatory bowel disease, in which the gastroenterologist is the principal care coordinator, the PMPM payment could be given to a gastroenterology medical home. For conditions in which the gastroenterologist acts primarily as a consultant for primary care, such as noncomplex gastroesophageal reflux or hepatitis C, a PMPM payment can support effective care coordination in a medical neighborhood delivery model. Each APM can be supplemented with a shared savings component.

Gastroenterologists must engage with and be early leaders of these redesign discussions to be prepared for a time when APMs may be more prevalent and no longer voluntary.

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The Center for Medicare and Medicaid Innovation (CMMI, or “the Innovation Center”) recently announced an initiative called Comprehensive Primary Care Plus (CPC+). It evolved from the Comprehensive Primary Care (CPC) initiative, which began in 2012 and runs through the end of this year. Both initiatives are designed to promote and support primary care physicians in organizing their practices to deliver comprehensive primary care services. Comprehensive Primary Care Plus has some very promising components, but also misses some compelling opportunities to further advance payment for primary care services.

The earlier initiative, CPC, paid qualified primary care practices a monthly fee per Medicare beneficiary to support practices in making changes in the way they deliver care, centered on five comprehensive primary care functions: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver engagement; and, (5) planned care and population health. For all other care, regular fee-for-service (FFS) payment continued. The initiative was limited to seven regions where CMMI could reach agreements with key private insurers and the Medicaid program to pursue a parallel approach. The evaluation funded by CMMI found quality improvements and expenditure reductions, but savings did not cover the extra payments to practices.

Comprehensive Primary Care Plus uses the same strategy of conducting the experiment in regions where key payers are pursuing parallel efforts. In these regions, qualifying primary care practices can choose one of two tracks. Track 1 is very similar to CPC. The monthly care management fee per beneficiary remains the same, but an extra $2.50 is paid in advance, subject to refund to the government if a practice does not meet quality and utilization performance thresholds.

The Promise Of CPC+

Track 2, the more interesting part of the initiative, is for practices that are already capable of carrying out the primary care functions and are ready to increase their comprehensiveness. In addition to a higher monthly care management fee ($28), practices receive Comprehensive Primary Care Payments. These include a portion of the expected reimbursements for Evaluation and Management services, paid in advance, and reduced regular fee-for-service payments. Track 2 also includes larger rewards than does Track 1 for meeting performance thresholds.

The combination of larger per beneficiary monthly payments and lower payments for services is the most important part of the initiative. By blending capitation (monthly payments not tied to service volume) and FFS, this approach might achieve the best of both worlds.

Even when FFS payment rates are calibrated correctly (discussed below), the rates are pegged to the average costs across practices. But since a large part of practice cost is fixed, it means that the marginal cost of providing additional services is lower than the average cost, leading to incentives to increase volume under FFS. The lower payments reduce or eliminate these incentives. Fixed costs, which must also be covered, are addressed through the Comprehensive Primary Care Payments. By involving multiple payers, practices are put in a better position to pursue these changes.

An advantage of any program that increases payments to primary care practices is that it can partially compensate for a flaw in the relative value scale behind the Medicare physician fee schedule. This flaw leads to underpayment for primary care services. Although the initial relative value scale implemented in 1992 led to substantial redistribution in favor of evaluation and management services and to physicians who provide the bulk of them, a flawed update process has eroded these gains over the years to a substantial degree.

In response to legislation, the Centers for Medicare and Medicaid Services are working correct these problems, but progress is likely to come slowly. Higher payments for primary care practices through the CPC+ can help slow the degree to which physicians are leaving primary care until more fundamental fixes are made to the fee schedule. Indeed, years of interviews with private insurance executives have convinced us that concern about loss of the primary care physician workforce has been a key motivation for offering higher payment to primary care physicians in practices certified as patient centered medical homes.

Two Downsides

But there are two downsides to the CPC+.

One concerns the lack of incentives for primary care physicians to take steps to reduce costs for services beyond those delivered by their practices. These include referring their patients to efficient specialists and hospitals, as well as limiting hospital admissions. There are rewards in CPC+ for lower overall utilization by attributed beneficiaries and higher quality, but they are very small.

We had hoped that CMMI might have been inspired by the promising initiatives of CareFirst Blue Cross Blue Shield and the Arkansas Health Care Improvement initiative, which includes the Arkansas Medicaid program and Arkansas Blue Cross Blue Shield. Under those programs, primary care physicians are offered substantial bonuses for keeping spending for all services under trend for their panel of patients; there is no downside risk, which is understandable given the small percentage of spending accounted for by primary care. The private and public payers also support the primary care practices with care managers and with data on all of the services used by their patients and on the efficiency of providers they might refer to. These programs appear to be popular with physicians and have had promising early results.

The second downside concerns the inability of physicians participating in CPC+ to participate in accountable care organizations (ACOs). One of CMMI’s challenges in pursuing a wide variety of payment innovations is apportioning responsibility across the programs for beneficiaries who are attributed to multiple payment reforms. As an example, if a beneficiary attributed to an ACO has a knee replacement under one of Medicare’s a bundled payment initiatives, to avoid overpayment of shared savings, gains or losses are credited to the providers involved in the bundled payment and not to the ACO. As a result, ACOs are no longer rewarded for using certain tools to address overall spending, such as steering attributed beneficiaries to efficient providers for an episode of care or encouraging primary care physicians to increase the comprehensiveness of the care they deliver.

Keeping the physician participants in CPC+ out of ACOs altogether seems to be another step to undermine the potential of ACOs in favor of other payment approaches. This is not wise. The Innovation Center has appropriately not established a priority ranking for its various initiatives, but some of its actions have implicitly put ACOs at the bottom of the rankings. Recently, Mostashari, Kocher, and McClellan proposed addressing this issue by adding a CPC+ACO option to this initiative.

In an update to its FAQ published May 27, 2016 (after out blog was put into final form), CMMI eased its restriction somewhat by allowing up to 1,500 of the 5000 practices expected to participate in CPC+ to also participate in Medicare Shared Savings Program (MSSP) ACOs. But the prohibition continues to apply to Next Gen ACOs, the model that has created the most enthusiasm in the field. If demand for these positions in MSSP ACOs exceeds 1,500, a lottery will be held. This change is welcome but does not really address the issue of disadvantaging ACOs in situations where a beneficiary is attributed to two or more payment reform models. CMMI is sending a signal that CPC+, notwithstanding its lack of incentives concerning spending outside of primary care, is a powerful enough reform that diverting practices away from ACOs is not a problem. ACOs are completely dependent on primary care physician membership to function, meaning that any physician practices beyond 1,500 that enroll in CPC+ will reduce the size and the impact of the ACO program. CMMI has never published a priority ranking of reform models, but its actions keep indicating that ACOs are at the bottom.

The Innovation Center should be lauded for continuing to support improved payment models for primary care. Its blending of substantial monthly payments with lower payments per service is promising. But the highest potential rewards come from broadening primary care physicians’ incentives to include the cost and quality of services by other providers. CMMI should pursue this approach.

Editor's note: This piece originally appeared in Health Affairs Blog.

In advance of President Obama’s trip to Panama later this week, Brookings experts Richard Feinberg, Ted Piccone, and Harold Trinkunas discuss expectations for the Seventh Summit of the Americas. Obama will arrive holding a strong hand given recent policy changes that have addressed historic obstacles, such as relations with Cuba. However, a slowing regional economy and U.S.-Venezuela tensions may yet cast a shadow over the proceedings.

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Improved United States-Latin America relations

“The United States is going into this next Summit of the Americas in a somewhat improved position compared to the summits in both Cartagena in 2012 and in Trinidad in 2009, where there was a considerable amount of friction among the countries on issues related to Cuba, to counter narcotics policy, to immigration policy. Broadly speaking, I think the Obama administration has done something incredible on each of these fronts, which the countries will recognize and which will help clear the air.”  —Harold Trinkunas

Friction with Venezuela?

“There are 35 countries. At any given time, there's going to be some friction. At the last summit, the Argentines raised the Malvinas issue.  At previous summits, the Bolivians raised the outlets of the sea issue. So there's always a little bit of this. But whether or not [Venezuela] dominates the summit is an issue largely for the Latin Americans to decide. And my guess is the Latin Americans in general will not want to follow Maduro over the cliff. I don't even think that the Cubans will want Maduro to take the summit over the cliff. So therefore, I think we have this sort of tremendous irony in which the country that adds -- that dampens the dissident voices of ALBA will actually be Cuba, because Cuba wanted to demonstrate that it can be a constructive voice in regional diplomacy, that they're not just the force of disruption and therefore, the U.S. all these years was right to keep them out because they would just be disruptive if you let them in. They've already demonstrated they're a mature country that can engage constructively.”  —Richard Feinberg

Dialogue with Cuba

“It's in our interest, U.S. national interest, to have this dialogue process with our close neighbor, Cuba. And to, frankly, bring them back towards the inter-American community, where they've been missing for all these years. [The U.S. rapprochement with Cuba] is also going to raise the question of shifting attention to the role of the rest of the region vis-à-vis Cuba; that it's not just the United States. It's actually the other countries in the hemisphere that could help Cuba come along, as I said, modernize, update its economy, and hopefully at some point, engage more formally in the inter-American system.”  —Ted Piccone

Sub-regional groupings

“This is a much more diverse hemisphere than we saw 20 years ago... In fact, we may see that there's sort of a broad agreement on general themes and then much more sub-regional groupings that work on issues like the Northern Triangle, for example, or Caribbean Energy Security, which was an initiative of the vice president last year.”  —Harold Trinkunas

Summit side events with the private sector and civil society

“You have the leaders representing the executive branches of their governments, but you also have the CEO Summit. Seven hundred corporate executives will be there. There will be interaction between the leaders and the corporate executives...It's indicative of the rise of the private sector and the corporate sector in Latin America as part of a dynamic growing region economically.

Throughout the hemisphere, the acceptance of Civil Society as a concept, as an actor, adds depth to democracy. Democracy is not just elections or that's important, but an active, vibrant Civil Society. And that's what you'll see at the Civil Society meeting. And President Obama personally we're told will interact with Civil Society leaders, as will other leaders present there.”  —Richard Feinberg

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On April 10th and 11th, the heads of state and government from nearly every state in the Americas will meet in Panama City for the Seventh Summit of the Americas. The leaders present in Panama preside over a region that has advanced far and fast on key political and economic indicators since the first of these meetings was held in Miami in 1994. At the Miami Summit, the legacy of the Cold War was very much present, and the specter of war, military dictatorship, armed revolution, financial crises, and political instability still hung in the air. 

In 2015, the region is by and large more democratic, economically prosperous, free from war, and the last insurgency in the region—Colombia’s—is winding down as peace is discussed between the government and its opponents at talks hosted by Havana. The beginning of a rapprochement between the United States and Cuba in December 2014 broke down one of the last remaining obstacles to an event that is truly inclusive of every country in the Western Hemisphere. 

In comparison to the rest of the world—where in the past year we have witnessed terrorist attacks in Paris, war in Ukraine, insurgency in Yemen, and saber-rattling around the South China Sea—the Western Hemisphere appears to be relatively better off. While there are a small number of countries that face challenging circumstances, especially among the fragile states of the Caribbean basin, these problems mostly threaten local rather than regional order. Given this picture, what lessons can we learn from the Western Hemisphere, and from U.S. policy towards the region, as we contemplate how best to improve global order?

Drawing the right lessons from history

The Americas have a long history of developing regional norms that promote the peaceful resolution of conflicts. Since the founding of the Panamerican Union in 1890, which transformed into the Organization of American States (OAS) in 1948, the countries of the hemisphere have embedded these norms of peace into their multilateral institutions. While frequently criticized, it is important to remember that the OAS has presided over the elimination of inter-state conflict in the Americas. 

Today, Latin American states resolve territorial disputes at the International Court of Justice rather than on the battlefield. The last war in the region, between Peru and Ecuador in 1995, occurred two decades ago. Given how rare militarized disputes are at home, Latin American soldiers frequently serve as peacekeepers in United Nations missions around the world. Latin Americans have become good at peacemaking and peacekeeping, something that other regions of the world would do well to emulate.

When it comes to domestic politics, most leaders in the region now understand the political and economic principles that contribute to stability. Governments have become much better about economic governance, which means that as South America’s economy cools off this year, fiscal problems will be manageable and localized rather than region-wide and existential, a sharp contrast with the 1980s and 1990s. 

Leaders in the region have learned that promoting polarization for short-term political advantage is all too likely to produce instability, coups, and revolution. To minimize the risk that domestic political violence might reoccur in the future, states in the region have self-consciously examined the legacy of their authoritarian pasts, using innovative processes such as truth and reconciliation commissions—initially in Argentina in 1983—but also drawing on traditional courts to prosecute perpetrators of past abuses.  

In the 21st century, successful coups d’état have become rare, and when they do occur, as was the case in Honduras in 2009, the region collaborates to ensure a return to democracy. Here again is an area where Latin America has led the way through policies that reduce the likelihood of domestic conflicts that threaten internal stability or global order.

The importance of revisiting unworkable U.S. policies 

At this Summit in Panama, President Barack Obama will be able to credibly claim that he has listened to his Latin American counterparts and has begun to change policies that had become obstacles to improving regional order. At the 2009 and 2012 Summits (they occur every three years), U.S. policies on drugs, immigration, and Cuba had made President Obama the target of growing criticism from other leaders. In fact, many governments had made it clear that they would not attend the 2015 Summit if Cuba was not invited. 

Since 2012, the Obama administration has taken steps to address these concerns. It has taken executive action to reform immigration policy, signaled greater openness to drug policy liberalization by states such as Uruguay, and initiated a historic normalization of relations with Cuba. In each of these areas, the United States has shifted from policies that were largely unilateral towards its neighbors to policies that emphasize collaboration and partnership. This reflects U.S. learning that unilateralism produces blowback, strengthens its political adversaries in the region, and undermines its interests in the long run. This is a lesson worth considering as we think about our policies towards troubled regions of the world.

The risk of forgetting lessons learned

Yet not all countries and all politicians have remembered these lessons, and some of them have learned the wrong ones. In Argentina, macroeconomic stability is at risk due to a feud between the government and its international creditors. The result is a country cut off from international capital markets at a time when its economy is suffering the effect of declining commodity prices. Venezuela faces a deep crisis that has at its heart the highly polarizing politics practiced by the governing party and an unreasoning attachment to an unworkable economic model. Key countries such as Brazil have lost interest in hemisphere-wide institutions, as indicated by their refusal to appoint an ambassador to the OAS or pay their membership dues. And the region as a whole has become so attached to multilateralism and politics by consensus that is has forgotten how to work together when individual member states deviate from regional norms of democracy and human rights, as is occurring today in Venezuela.

So while the recent history of the Americas offers insights into policies that contribute to a peaceful and stable regional order, it also illustrates that these achievements are not irreversible. Let us hope that future generations do not have the relearn these lessons anew. At this and future Summits, there must be a commitment to preserving the gains made in peace, democracy, human rights, and economic prosperity, but also a new emphasis on developing workable mechanisms to address deviations from the norms and practices that have contributed to making the Americas a relative safe and orderly region of the world.

For more information, check out Emily Miller's post on U.S. priorities at the Seventh Summit of the Americas.

President Obama’s emphasis on “smart power” diplomacy has thrust the need for international volunteer service into the global spotlight. On June 23, Global Economy and Development at Brookings and Washington University’s Center for Social Development (CSD) will host a forum examining how international volunteer service can address multiple global challenges simultaneously and build international cooperation. The forum will frame international service as an effective tool for increasing international social capital as well as building sustainable cross-cultural bridges.

This event begins with an address by service champion, Ambassador Elizabeth Frawley Bagley, who leads the Department of State’s Global Partnerships Initiative. Bagley is well poised to foster innovative public-private partnerships, an approach she describes as “Ubuntu Diplomacy: where all sectors belong as partners, where we all participate as stakeholders, and where we all succeed together, not incrementally but exponentially.” The need for multilateral approaches to development has been analyzed by Brookings scholars Jane Nelson and Noam Unger, who explore how the U.S. foreign assistance system works in the new market-oriented and locally-driven global development arena.

This spirit of cross-sector collaboration will carry the June 23^rd forum, beginning with a research panel releasing beneficiary outcome data from a Peace Corps survey completed with over 800 host country nationals, including community members, direct beneficiaries, and collaborators. Peace Corps colleagues, Dr. Susan Jenkins and Janet Kerley, will present preliminary findings from this multi-year study measuring the achievement of “helping the people of interested countries in meeting their need for trained men and women” and “promoting a better understanding of Americans on the part of the peoples served”. Aggregate data about respondents’ views of Americans before and after their interaction with the Peace Corps will be discussed.

This work complements the release of new data on the impact of international service on volunteers, which is supported with funding from the Ford Foundation and a joint Brookings-Washington University academic venture capital fund. Washington University’s CSD has studied international service over the last decade. The current research, first in a series from the quasi-experimental study, compares international volunteers’ perceived outcomes to a matched group who did not volunteer internationally: volunteers are more likely to report increased international awareness, international social capital, and international career intentions.

Building on the demonstrated potential of international service, policymakers and sector leaders will then discuss options for enhancing international service, and provide recommendations for bringing international service to the forefront of American foreign policy initiatives. This policy plenary will introduce and discuss the Service World policy platform: a collaborative movement led by the Building Bridges Coalition, National Peace Corps Association and the International Volunteering Initiative at Brookings. This powerhouse of sector leaders aims to scale international service to the levels of domestic volunteer service with increased impact through smart power policy proposals. What Service Nation did to unite Americans around domestic service as a core ideal and problem-solving strategy in American society, Service World hopes to do on a global scale.

Next week in New York City, the Points of Light Institute and the Corporation for National and Community Service will convene to further spotlight the Service World Platform at the 2010 National Conference on Volunteering and Service. This event will bring together more than 5,000 volunteer service leaders and social entrepreneurs from around the world, including local host Mayor Bloomberg. Michelle Nunn, CEO of Points of Light Institute noted in Huffington Post that “demand, idealism and presidential impact are leading American volunteerism to its…most important stage – the movement of service to a central role in our nation’s priorities.”

Nunn’s statement illustrates the momentum and power that make the voluntary sector a unique instrument in the “smart power” toolbox. According to successive polling from Terror Free Tomorrow, American assistance, particularly medical service, is a leading factor in favorable opinions toward the United States. A 2006 survey conducted in Indonesia and Bangladesh showed a 63 percent favorable response among Indonesian respondents to the humanitarian medical mission of “Mercy,” a United States’ Navel Ship, and a 95 percent favorable response among Bangladeshi respondents.

Personifying the diplomatic potential of medical service abroad is Edward O’Neil’s work with OmniMed. In the Mukono District of Uganda, OmniMed has partnered with the U.S. Peace Corps and the Ugandan Ministry of Health as well as local community-based organizations to implement evidence-based health trainings with local village health workers. Dr. O’Neil is now working with Brookings International Volunteering Initiative and Washington University’s CSD on a new wave of rigorous research: a randomized, prospective clinical trial measuring the direct impact of over 400 trained village health workers on the health of tens of thousands of villagers. 

In the words of Peace Corps architect and former U.S. Senator Harris Wofford, the pairing of new data and policy proposals on June 23^rd will support a “quantum leap” in the scale and impact of international service, advancing bipartisan calls to service from President Kennedy to Bush 41, Bush 43, Clinton and Obama.

For nearly fifteen hours between Wednesday morning and early Thursday, Senator Chris Murphy (D-CT), along with his Connecticut colleague Senator Richard Blumenthal (D) and Senator Cory Booker (D-NJ), led a filibuster on the floor of the Senate aimed at addressing gun control issues in the aftermath of last weekend’s mass shooting in Orlando. Other than learning that Wednesday is pizza night in the Murphy household, what else should we take away from this Mr. Smith Goes to Washington­-style exercise? Here are three lessons:

1. The real meaning of “I” in “I hold the floor until I yield the floor.”

Anyone who tuned into yesterday’s filibuster joined Senate procedure wonks (and faithful viewers of the West Wing) in the knowledge that a senator who holds the floor can yield to another senator for a question without yielding the floor. Indeed, 38 of Murphy’s 45 Democratic colleagues (as well as two Republicans, Senators Ben Sasse (R-NE) and Pat Toomey (R-PA)), came to the chamber yesterday to ask “questions.” In many cases, these were lengthy speeches—Senator Tammy Baldwin (D-WI), for example, read brief biographies of all 49 Orlando victims—in which the speaker satisfied the question requirement with a conclusion that asked Murphy for his reactions to their statement.

This kind of teamwork on extended speech-making is not unusual. When Senator Ted Cruz (R-TX) took the floor to talk for 21 hours about the Affordable Care Act in 2013, he took questions from nine fellow Republicans (as well as two Democrats). Last May, Senator Rand Paul (R-KY) got an assist from ten colleagues, including seven Democrats, during his filibuster of a bill extending the PATRIOT Act. The depth of Murphy’s bench not only reduced the energy he had to expend speaking, but also helped guarantee that the entire discussion was on-message and focused on the topic at hand; Murphy did not have to resort to reading the phone book to fill the hours.

2. In policy terms, it’s hard to know if the filibuster was a success…

When Murphy left the floor early Thursday morning, it was reported that Senate leaders had agreed to consider two gun control amendments: one that would address the ability of suspected terrorists to purchase guns and a second that would expand background checks for gun purchases. Details of the deal ensuring consideration are still emerging, but it is difficult to know if Murphy’s filibuster caused Senate leaders to agree to hold votes on them. It is possible that, had Democrats simply threatened to object to the motion to proceed to debate on the underlying spending bill, Republican leaders would have been forced to agree to consider the amendments for which Murphy and his allies were pushing. In the contemporary Senate, this is often how obstruction proceeds: without extended speeches and off the floor, with the two sides negotiating behind the scenes.

3. …but the political victory is perhaps more important

As my colleague Sarah Binder and her co-author Steve Smith wrote in their 1997 book on the filibuster, “encouragement from external groups…has given senators an incentive to exploit their procedural rights, sometimes leading them to block legislation with the filibuster or with holds and at other times leading them to use procedural prerogatives to force the Senate to consider issues of importance to parochial, partisan, or national constituencies.” On these grounds, Murphy’s filibuster was unequivocally a success in the eyes of its supporters. As the filibuster neared its end, Murphy reported that his office had received 10,000 phone calls supporting his efforts, and the hashtag #filibuster was trending on Twitter for much of the day. Even if the underlying amendments are not adopted—a real possibility that Murphy acknowledged in one of his final speeches of the evening—the visibility of the exercise is likely to pay political dividends for Democrats in the coming weeks.

Stephen was still a teenager on the north side of St. Louis when his dad, a police officer, was killed during a robbery in their neighborhood. Despite the trauma, Stephen later joined the police force to continue his dad’s legacy and commitment to safe and inclusive neighborhoods. But even before the fatal shooting of Michael Brown in Ferguson in 2014, Stephen (not his real name) yearned to right local wrongs through broader approaches. “The darkest forces weren’t necessarily the ones getting arrested,” he observed. “So I retired from the police force after 22 years, essentially to chase after a different type of perpetrator.” Wanting to focus on policies at multiple levels of government that “were causing the disparities that fueled increasing crime and violence in St. Louis,” Stephen pivoted to civil rights enforcement, tracking policy violations and innovations at a government agency in the St. Louis region.

I met Stephen in February while in St. Louis for a conference his agency organized on HUD’s recently strengthened Affirmatively Furthering Fair Housing (AFFH ) rule, which increases local accountability in promoting residential integration. He wasn’t a speaker at the event, but hearing his story reinforced the importance of combating the deeply entrenched and often invisible causes of segregation.

Recent events and new academic research, including landmark findings by Raj Chetty and colleagues testifying to the benefits of low-poverty neighborhoods for low-income kids, the updated AFFH rule, and the Supreme Court’s disparate impact decision upholding other tools to fight segregation have brought renewed attention to these challenges. Meanwhile, underlying these developments, poverty has failed to decline since the recession and, as recent Brookings research shows, has become more concentrated in neighborhoods of extreme poverty.

How can regional leaders and practitioners respond to these challenges? I was in St. Louis to discuss one part of the solution—advancing more mixed-income neighborhoods. In the Chicago region, our housing and community development-focused firm, BRicK Partners, is collaborating with the Chicago Metropolitan Agency for Planning (CMAP), the Illinois Housing Development Authority (IHDA), and 10 metropolitan Chicago public housing authorities, with support and leadership from HUD, to develop and operate the Regional Housing Initiative (RHI)

RHI is a small, systemic, and potentially scalable “work around” of a very specific set of programs and policies that contribute inadvertently to regional inequities. A flexible and regional pool of resources working across the many traditional public housing authority (PHA) and municipal jurisdictions in the Chicago region, RHI increases quality rental housing in neighborhoods with good jobs, schools, and transit access and provides more housing options to households on Housing Choice Voucher (HCV) waiting lists. Recognizing that the federal formulas allocating HCVs to each individual PHA are not responsive to population, employment, or poverty trends, RHI partners convert and pool a small portion of their HCVs to provide place-based operating subsidies in support of development activity that advances local and regional priorities. RHI supports both opportunity areas with strong markets and quality amenities as well as revitalization areas where public and private sector partners are planning and investing toward that end. In both cases, the bulk of RHI investments are in the suburbs, where the PHAs are smaller and the rental stock more limited. 

RHI has committed over 550 RHI subsidies to nearly 40 mixed-income and supportive housing developments across Chicagoland, supporting more than 2,200 total apartments, over half of which are in opportunity areas. The pooling and transferring of subsidies has allowed RHI to support proposals that local jurisdictions wouldn’t be able to undertake otherwise.

Although a number of innovative programs around the country provide assistance to households moving to opportunity areas, RHI is unique its focus on increasing the supply of housing in opportunity areas regionwide. Its approach is consistent with lessons learned from Brookings’ work on Confronting Suburban Poverty in America: With CMAP as a strong quarterback, RHI has addressed the shortage of rental housing in the suburbs by working across jurisdictions, developing shared priorities, metrics and selection criteria, and by working with IHDA and other stakeholders to leverage greater private sector investment.

This recipe for success is now being deployed in communities beyond Chicago. Baltimore is preparing to advertise for its first round of developer applicants under the leadership of the Baltimore Metropolitan Council, with regionwide PHAs, the State Housing Finance Agency, and a regional housing counselor lined up as supportive partners. In St. Louis, the regional planning and housing finance organizations both attended the February conference where I met Stephen, signaling the potential for greater collaboration for both these entities and the PHAs.

Like many housing advocates and professionals, my colleagues and I at BRicK Partners derive a lot of satisfaction from supporting communities like Baltimore and St. Louis and individuals like Stephen and his peers with replicable best practices. Given today’s political realities, we don’t expect major changes in the federal formulas and statutes behind some of the regional inequities, but “work arounds” such as RHI can still scale up. Nationwide, just a small percentage of HCVs have been converted for such flexible supply-side solutions, but there is reason to be hopeful that this will change. The Regional Mobility Demonstration proposed in the 2017 budget as well as federal public housing voucher legislation passed by the House of Representatives earlier this year are signs that there is real momentum to advance regional strategies that increase access to opportunity for low income residents and families. 

INTRODUCTION

The Obama administration needs to focus on executing its existing financial rescue plans, keep the TARP focused on the banking sector, and create a contingency plan should the banking system destabilize again.

Crystal balls are dangerous, especially when it comes to economic predictions, which is why it is important for the administration to chart a path forward. Public policy must remain focused on the very real possibility that the apparent easing in the economy’s decline may be followed by little or no growth for several quarters and there could possibly be another negative turn. One of the risks is that the United States is very connected to the rest of the world, most of which is in severe recession. The global economy could be a significant drag on U.S. growth.

Cautious optimism should be the order of the day. We fear that the recent reactions of the financial markets and of some analysts carry too much of the optimism without recognizing enough of the uncertainty. There remains a lot of uncertainty and policymakers should not rest on their laurels or turn to other policies, even if they look more exciting. It is vital to follow through on the current financial rescue plans and to have well-conceived contingency plans in case there is another dip down.

We propose three recommendations for the financial rescue plans:

• Focus on execution of existing programs. The Administration has created programs to deal with each of the key elements necessary to solve the financial crisis. All of them have significant steps remaining and some of them have not even started yet, such as the programs to deal with toxic assets. As has been demonstrated multiple times now since October 2008, these are complex programs that require a great deal of attention. It is time to execute rather than to create still more efforts.
• Resist the temptation to allocate money from the TARP to other uses—it is essential to maintain a reserve of Congressionally-authorized funds in case they are needed for the banks. It would be difficult to overemphasize the remaining uncertainties about bank solvency as they navigate what will remain a rough year or more. The banks could easily need another $300 billion of equity capital and might need still more. It is essential that the administration have the ammunition readily available.
• Third, make sure there is a contingency plan to deal with a major setback for the banking system. The plan needs broad support within the administration and among regulators and, ideally, from key congressional leaders. We probably won’t need it, but there is too high a chance that we will require it for us to remain without one. The country cannot afford even the appearance of the ad hoc and changing nature of the responses that were evident last fall.

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The Roma people, the largest minority group in Europe and in many European countries, trail other ethnic groups in almost every characteristic that defines well-being. Perhaps of greatest importance, the Roma are less educated than other ethnic groups. But they also suffer from excess health problems, high unemployment, poverty, and political weakness. The Roma population of Bulgaria is certainly no less disadvantaged than the Roma in other countries. An especially poignant example of Bulgarian Roma disadvantage is that the death rate among children under age 1, a prime indicator of children’s health in any nation, is 25 per 1,000 for Roma children as compared with 9.9 for children of Bulgarian ethnic origin. The mathematics of death almost before life gets started is a symbolic indicator of the Roma burden in Bulgaria. Similarly, research conducted for UNICEF by the University of York shows that the poverty rate among Roma children in Bulgaria is 92 percent, perhaps the highest poverty rate for any ethnic group in Europe. By contrast, the poverty rate among children of Bulgarian heritage is less than half as high at 43 percent.

It is not surprising, then, that over at least the past decade, the European Union (EU) and most European governments, joined by the Open Society Foundation, the World Bank, and other organizations, have created important initiatives to address all these problems. It is possible to think that now is an historic moment in which European governments and dominant ethnic groups, after eight or nine centuries of the most pernicious types of discrimination against the Roma, are finally, albeit often reluctantly, admitting the problems facing their Roma populations and their own role in creating and sustaining these problems. Equally important, most of the Central and Eastern European (CEE) governments, where discrimination against the Roma has been and continues to be particularly intense, are gradually adopting policies to address the problems.

To the extent that the moment of Roma opportunity has arrived, perhaps the most important force moving Bulgaria and other CEE nations in the direction of integration and inclusion is the EU. In the period leading up to the ascension of Bulgaria and other CEE nations to membership in the EU, all the new member states were required to meet a host of conditions required by the EU as the price of admission. Among these conditions were laws outlawing discrimination and requiring equality of educational opportunity. The CEE nations complied with the EU directive to pass such laws, but implementation of the laws in Bulgaria and other nations has been something less than aggressive.

Nor is EU ascension the only force driving the CEE nations to reduce discrimination against the Roma and other minorities. The Open Society, the World Bank, and a number of other private organizations, including several Roma nongovernmental organizations (NGOs), have initiated a sweeping program to promote inclusion of the Roma in the civil society of the CEE nations. Called the “Decade of Roma Inclusion” (2005-2015) the initiative is notable for getting all the CEE nations (plus Spain) to participate, to commit themselves to activities designed to promote inclusion and nondiscrimination, and to make a financial commitment to a fund administered by the World Bank to promote the initiative. As a part of the initiative, Bulgaria and the other participating nations originated ten-year action plans. The Bulgarian action plan, the purpose of which is to create a set of goals and activities that will promote Roma integration, includes proposals for education, health care, housing, employment, discrimination and equal opportunity, and culture.

An important part of the Decade program was the establishment of the Roma Education Fund in 2005. Eight nations (Canada, Greece, Ireland, Netherlands, Slovenia, Sweden, Switzerland, and the UK), as well as several international agencies including the Open Society, pledged a total of 34 million Euros to support Fund activities during the Roma decade. The major goal of the fund is to “support policies and programs which ensure quality education for Roma, including the desegregation of education systems.”

By joining the EU, Bulgaria and the other CEE nations brought themselves into a well-developed culture of inclusion and a complex system of interlocking laws and agencies that not only outlaw exclusion and discrimination, but provide funds to implement inclusion policies and to monitor the extent to which EU nations are aggressively implementing these laws. The laws and directives include the EU Charter of Fundamental Rights, the European Commission against Racism and Intolerance, the Racial Equality Directive, and several others. It would be a mistake to conclude that every EU member, even the original 15 EU nations with relatively more advanced economies and longer histories as democracies than the CEE nations, faithfully implement every component of the various legal requirements of being an EU member. Even so, EU requirements and funds have initiated both profound legal changes and a host of programs to increase the social, economic, political, and cultural inclusion of the Roma as well as studies and evaluations that bring some light to the actual situation of the Roma and other minorities in member nations. Given the all but inevitable distance between the laws on inclusion and discrimination the CEE nations passed in order to join the EU and the actual implementation of those laws, studies commissioned by various EU agencies and NGOs illuminate the gaps between policies and implementation.

An excellent example of such illumination is a 2006 study commissioned by the Economic and Scientific Policy program of the European Parliament. The report is a hard-hitting assessment of the status of Roma throughout Europe with regard to their legal status and socio-economic conditions. The latter category includes assessments of Roma exclusion from employment, education, social services, health care, and community integration. The upshot of the report is that although there may be some progress in these important areas of integration, the Roma are still a second-class group throughout the CEE nations. Seemingly, good laws have not yet produced good results. Laws may be changed, but changing human behavior and culture takes longer.

CEE governments and their defenders are reluctant to admit the lamentable lack of progress in Roma integration. In part for this reason, the European Commission, based on extensive evidence from evaluations, surveys, and news reports of often ferocious discrimination against the Roma, felt the need to publish “An EU Framework for National Roma Integration Strategies up to 2020” in April 2011. The need for a new framework is a clear signal that the EU Commission believes the CEE governments in general and Bulgaria in particular are not achieving the results the EU hoped for when it approved these nations for EU membership and is therefore trying to push the governments of these nations into further action.

Following publication of the Framework, the Open Society released one of the most thorough and provocative reports on the situation faced by the Roma in Europe and strategies that should be adopted to attack the wide range of Roma disadvantages. Appropriately entitled “Beyond Rhetoric,” the Open Society report includes entire chapters on two issues that I will examine in more detail below.

First, the Open Society strongly recommends that nations collect ethnically disaggregated data. Logically enough, the report holds that it is impossible to document the effects of policy initiatives on the Roma and other groups unless outcome data, including measures of health, education, housing, employment, income, and death rates by age, are collected for individual ethnic groups. So important are ethnically disaggregated data that the report goes so far as to recommend that, if necessary, governments should change their statistical systems to “incorporate ethnic data components into regular statistical surveys.” A second recommendation that deserves special attention is the report’s emphasis on early childhood education and care. Virtually every report about the Roma emphasizes the vital importance of education in fighting Roma exclusion, but the Open Society report strongly recommends that nations implementing the EU Framework should “give urgent consideration” to establishing an early child development fund to “support innovative early development programs and allow for scale up of what works.”

Beyond these specific recommendations, the Open Society report emphasizes that the EU Commission stated explicitly in its Framework document that “member states do not properly use EU money for the purpose of effective social and economic integration of Roma. As if this judgment, which seems to represent the views of many EU agencies, the World Bank, the Open Society, and many Roma groups themselves, needed additional reinforcement, a United Nations expert on minority issues visited Bulgaria this summer and called upon the government to “turn its policies on Roma integration into concrete action.” She went on to give what seems to represent the views of all these groups on the flaws in the Bulgarian government’s approach to fighting Roma exclusion: “Many policies seem to remain largely only rhetorical undertakings aimed at external audiences – official commitments that are not fulfilled in practice.” The result, according to the UN expert, is that “all the evidence demonstrates that Roma remain in desperate circumstances at the very bottom of the socio-economic ladder.” In particular, she mentioned that the access of Roma children to quality education “remains overwhelmingly unfulfilled.”

If CEE nations are now entering a period in which governments will be working, often ineffectively or at a very modest pace, to improve the conditions of the Roma, judging by the efforts of other nations to reduce discrimination against minority groups and by the stately rate of progress so far in the CEE nations, it can be assumed that the fight for Roma equality in Bulgaria will be measured in decades. In the U.S., for example, the Civil Rights movement of the 1950s and 1960s was largely successful. By the mid-1960s, vital court decisions had dismantled major parts of the system of legal discrimination against blacks and the federal government had enacted programs to ensure voting rights and other fundamental rights to blacks. To enhance the legal war on poverty and discrimination, the federal government also initiated an army of social programs designed to boost the education, health, employment, housing, and political participation of the poor in general and blacks in particular. Yet today, nearly half a century after achieving legal rights and the initiation of large-scale government inclusion programs, blacks (and Hispanics) still trail whites by large margins in education, income, housing, poverty levels, and health. Although achieving significant progress against discrimination may require decades or generations, discrimination will not diminish until strong legal, economic, and social forces are mobilized against it. Expecting a long struggle cannot be a reason not to begin.

If the history of making substantial progress in overcoming ethnic discrimination in the U.S. can serve as a rough comparison to the situation of the Roma in CEE nations, several factors are going to be vital in the fight of the Roma to overcome discrimination and exclusion in Bulgaria and throughout Europe. These factors include an antidiscrimination plan, aggressive implementation of the plan by all levels of government, leadership by the Roma themselves, educational progress by Roma children and young adults, political activism by the Roma people, a media committed to accurate reporting and fairness, and a civil society that reflects underlying public opinion favoring integration and opposed to discrimination. Most of these factors appear to be present in Bulgaria, often in rudimentary and brittle form, but present and in many cases moving in the right direction nonetheless. The progress that is just now beginning can be greatly enhanced by the efforts of groups that have the resources, the will, and the vision to roll up their sleeves and help promote Roma inclusion.

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