Executive Summary

Government information technology is subject to a variety of rules, regulations, and procurement policies.  Computing is treated differently depending on whether the platform is based on desktops, laptops, mobile devices, or remote file servers known as cloud computing.  There are differences between the executive, legislative, and judicial branches of government, as well as in the level of privacy and security expected for various applications.  

Some people perceive higher security on desktop or laptop computers and lower security with the cloud because the latter’s information is stored remotely through third-party commercial providers.  In reality, though, there are serious security threats to all electronic information regardless of platform, and cloud server providers often take security more seriously than mass consumers or government officials employing weak passwords on their local computers. 

In this paper, I review current federal IT policy and discuss rules, practices, and procedures that limit innovation.  There are a variety of obstacles that make it difficult for policymakers to take full advantage of the technological revolution that has unfolded in recent years.  After outlining these issues, I make recommendations on policy changes required to improve the efficiency and effectiveness of federal computing. 

My specific recommendations include:

1. Public officials should develop more consistent rules on computing across desktop, laptop, mobile, and cloud platforms.  
2. The use of video, collaboration, and social networking should be authorized for congressional offices.  This would make legislative branch policy consistent with that of the executive branch.
3. Judicial branch computing should be modernized, with greater emphasis on cloud computing. 
4. There should be a more uniform certification process for federal agencies.  Right now, each agency is responsible for certifying its own applications.  It makes sense to have a “joint authorization board” with the power to review management services and certify particular products for use across the government. 
5. Congress should update the Electronic Communications Privacy Act to change the process by which law enforcement agents obtain electronic information.  Instead of using a prosecutor’s subpoena, legislation should require a “probable cause” search warrant that is approved by a judge.  This would provide greater safeguards in terms of online content, pictures, geolocation data, and e-mails.
6. Privacy rights should be placed on the same footing regardless of whether a person is using desktop or cloud computing.  It makes little sense to have weaker standards on one platform than another.  Consumers and government decision-makers expect the same level of protection whether they are accessing information on a desktop, laptop, mobile, or cloud storage system. 
7. Congress should amend the Computer Fraud and Abuse Act to strengthen penalties for unwanted intrusion into computing systems.  The law has inconsistent penalties and prosecutors have found that it is hard to prosecute cyber-crimes. 
8. Apps.gov represents a big step forward and government use should be expanded because it makes procurement easier and speeds public sector innovation.  It is a model of how the government can reinvent itself through digital technology in ways that improve efficiency and effectiveness.
9. Countries need to harmonize their laws on cloud computing so as to reduce current inconsistencies in regard to privacy, data storage, security processes, and personnel training,  
10. There should be mechanisms for data exchange that encourage portability across platforms.  We should avoid vendor lock-in that precludes data exchange.
11. Data on uptime, downtime, recover time, archiving, and maintenance schedules would help build public trust by providing information on computing performance.

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The appointment of new federal chief information officer Steven VanRoekel comes at a challenging time for President Barack Obama. The national economy continues to be weak. Congress plans to cut trillions from the federal budget. And in the time leading up to the 2012 election, American voters remain cynical about the ability of the government to address important policy problems in an effective manner.

In an era of deficit reduction and public cynicism, the tasks facing federal officials are to determine how to do more with less and persuade voters the government can become smarter and more effective. There are going to be fewer dollars for virtually every federal program so it is important to figure how ways to innovate and perform more efficiently.

Former CIO Vivek Kundra sought to do this through encouraging agencies to move software applications to the cloud, consolidating federal data centers, improving transparency, and improving the information technology procurement process. It is important to continue this progress even as agencies are forced to downsize their operations.

As shown in the private sector, government administrators should use technology to cut costs, improve worker productivity, and streamline operations. This is not just a matter of using technology in more innovative ways, but changing the operations and culture of the public sector. Public officials must improve its data mining activities to identify fraud and abuse in Medicare, Medicaid, the Defense Department, and other domestic programs.

New software gives managers better tools to evaluate how money is being spent and whether it is fulfilling intended goals. If it is not, programs need to be modified or eliminated. The most important weapon in Mr. VanRoekel’s arsenal may be the scalpel as he goes through the federal government’s $80 billion IT budget.

       

Much public focus is being given to a broader role for hospitals in improving the health of their communities. This focus parallels a growing interest in addressing the social determinants of health as well as health care policy reforms designed to increase the efficiency and quality of care while improving health outcomes.

This interest in the community role of hospitals has drawn attention to the federal legal standards and requirements for nonprofit hospitals seeking federal tax exemption. Tax-exempt hospitals are required to provide community benefits. And while financial assistance to patients unable to pay for care is a basic requirement of tax-exemption, IRS guidelines define the concept of community benefit to include a range of community health improvement efforts.

At the same time, the IRS draws a distinction between community health improvement spending–which it automatically considers a community benefit–and certain “community-building” activities where additional information is required in order to be compliant with IRS rules. In addition, community benefit obligations are included in the Affordable Care Act (ACA).

Specifically, the ACA requires nonprofit hospitals periodically to complete a community health needs assessment (CHNA), which means the hospital must conduct a review of health conditions in its community and develop a plan to address concerns. While these requirements are causing hospitals to look more closely at their role in the community, challenges remain. For instance, complex language in the rules can mean hospitals are unclear what activities and expenditures count as a “community benefit.” Hospitals must take additional steps in order to report community building as community health improvement.

These policies can discourage creative approaches. Moreover, transparency rules and competing hospital priorities can also weaken hospital-community partnerships. To encourage more effective partnerships in community investments by nonprofit hospitals:

• The IRS needs to clarify the relationship between community spending and the requirements of the CHNA. 
• There needs to be greater transparency in the implementation strategy phase of the CHNA. 
• The IRS needs to broaden the definition of community health improvement to encourage innovation and upstream investment by hospitals.

Download "Hospitals as Community Hubs: Integrating Community Benefit Spending, Community Health Needs Assessment, and Community Health Improvement" »

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As we explore the social determinants of health, we are discovering some very important things. One is that compared with other developed countries, the United States spends a much higher proportion of resources on medical services to treat people than on social services that improve the prospects for good health. Research shows that countries placing a greater emphasis on social services rather than medical care have better health outcomes. Recent research comparing spending on health and social services among US states also found that spending relatively more on social services is significantly related to better health outcomes.

But getting the health system to “prescribe” social services is hard. Hospitals, in particular, do not easily cooperate with social service organizations in trying to improve community health. There are many reasons for this. Institutional culture can get in the way; the health care sector’s business model is not exactly based on reducing the volume of medical services. Shifting substantial resources from medical services to social services threatens the financial interests of a major industry.

In addition, data systems of medical, educational, and social service organizations often are not compatible, and privacy concerns add to that barrier. Budget and payment systems generally don’t encourage multisector cooperation either, and community organizations often feel their independence is threatened by partnering with a large local hospital.

These problems are not unique to the health care and social services worlds. When 2 sectors seek to cooperate, the ideal is to harmonize all systems so that they can interact seamlessly. But that is an enormous task, usually requiring daunting changes for organizations in each sector.

A Role for Intermediaries

One way to enable collaboration between large institutions and sectors that find it hard to cooperate directly is to introduce intermediaries to serve as bridges. By intermediaries we mean organizations that operate in the space between institutions or people and help link them together. Successful intermediaries have the trust of each institution, and so they fulfill a “diplomatic” function. They provide skills and capacities that are lacking in the organizations they connect together. In addition to helping us achieve a better combination of medical care and social services to produce improved health, they can help health care and other sectors to work together more seamlessly.

As health care institutions seek to work with other sectors to address social determinants of health, we are beginning to see certain types of intermediaries that will be particularly helpful.

Data Intermediaries

Sharing data on patients and households is necessary to coordinate multisector services, but it also raises technical, governance, and privacy concerns. Some intermediary organizations are addressing these issues by making it easier for institutions to share data and cooperate. For instance, to make service data more available to institutions trying to work together, an initiative called Actionable Intelligence for Social Policy (AISP) works with counties and other jurisdictions to address technical and governance concerns. With the assistance of the nonprofit and nonpartisan advocacy organization Data Quality Campaign as a technical intermediary, many states and counties are tackling the privacy and other issues needed to create integrated data systems—or “data warehouses”—that can enable health systems, schools, and other sectors to coordinate services for each student. Meanwhile the National Neighborhood Indicators Partnership (NNIP) helps develop neighborhood-level data to help organizations design policy plans for addressing social and health needs.

Embedded “Extenders”

Another interesting approach is for institutions, particularly some hospitals, to bring intermediary institutions onto their premises to address social service needs for discharged patients. For instance, the nonprofit organization Health Leads trains and funds individuals to be embedded in hospitals and link patients to an array of social services and community organizations, thereby bringing skills the hospital typically does not possess in-house. Washington Adventist Hospital contracts with Seedco, a national nonprofit focused on work and family supports, to coordinate such services for its patients.

In reverse, some other institutions have an embedded staff that can link them more effectively with the health care system. School-based nurses are an example. In some states, a nonprofit organization called Communities in Schools embeds teams in schools to link students with health care services and with social service agencies that can improve their students’ health and help them succeed academically.

Budget Blenders

Restrictions on who can receive federal and state program money create funding silos that make it hard for health systems to partner with community social service organizations. A 3-track Accountable Health Communities model, which the Obama Administration will be implementing and testing over a 5-year period, may be a step towards resolving that issue. But meanwhile, some intermediaries are helping to address the problem.

One interesting example is made possible by the state of Maryland’s use of Local Management Boards (LMBs). These county-level public or nonprofit entities have the legal ability to deploy certain federal grants and programs administered by the state, as well as state resources, to local organizations with the aim of improving the health and educational success of children. In some cases the boards are governmental institutions, but in other cases, such as the Family League of Baltimore, they are intermediary organizations that coordinate and oversee funds and grantees. In this way, intermediaries that are close to the community and have trusted links with a range of health and social service organizations can help social service and health care institutions concentrate on social determinants of health.

Connectors

Some intermediaries function almost as entrepreneurs, developing creative ways to facilitate relationships between health care institutions and other sectors. The National Collaborative on Education and Health, for instance, brings together multiple organizations focused on steps to create a culture of health within schools. City Health Works, in New York’s Harlem, uses personal coaches to connect households with hospital partners and social service providers to improve health in the community.

This rich tapestry of intermediaries can help the health system collaborate more effectively and seamlessly with social services and community institutions as we focus on social determinants of health. So we can take steps to foster the use of intermediaries. For instance, states can emulate Maryland’s LMB’s, by creating county or city bodies to coordinate funding streams and steer support to innovative community organizations.

Governments and foundations can also provide the modest seed capital needed for intermediaries to develop data systems, so that they can play a more sophisticated role. The federal government can tweak the community benefit requirements for nonprofit hospitals to encourage them to invest in nonmedical services that promote health. Most important and starting at the local level, health plan administrators, health care professionals and facilities, government, school districts, and social service agencies need to sit down together to identify how to improve community health by changing patterns of spending.

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Editor's note: This piece originally appeared in JAMA Forum.

       

       

      

       

       

       

       

It is estimated that there are 95 mobile phone subscriptions per 100 inhabitants worldwide, and this boom has not been lost on the developing world, where the number of mobile users has also grown at rocket speed. In fact, in recent years the information communication technology (ICT) revolution has provided opportunities leading to “death of distance,” allowing many obstacles to better livelihoods, especially for those in remote regions, to disappear. Remarkably, though, the huge proportion of poverty-stricken populations in so many of those same regions persists.

How might, then, we think differently on the relationship between these two ideas? Can and how might ICTs act as an engine for eradicating poverty and improving the quality of life in terms of better livelihoods, strong education outcomes, and quality health? Do today's communication technologies hold such potential?

In particular, the mobile phone’s accessibility and use creates and provides us with an unprecedented volume of data on social interactions, mobility, and more. So, we ask: Can this data help us better understand, characterize, and alleviate poverty?

Mapping call data records, mobility, and economic activity

The first step towards alleviating poverty is to generate poverty maps. Currently, poverty maps are created using nationally representative household surveys, which require manpower and time. Such maps are generated at a coarse regional resolution and continue to lag for countries in sub-Saharan Africa compared to the rest of the world.

As call data records (CDRs) allow a view of the communication and mobility patterns of people at an unprecedented scale, we show how this data can be used to create much more detailed poverty maps efficiently and at a finer spatial resolution. Such maps will facilitate improved diagnosis of poverty and will assist public policy planners in initiating appropriate interventions, specifically at the decentralized level, to eradicate human poverty and ensure a higher quality of life.

How can we get such high resolution poverty maps from CDR data?

In order to create these detailed poverty maps, we first define the virtual network of a country as a “who-calls-whom” network. This signifies the macro-level view of connections or social ties between people, dissemination of information or knowledge, or dispersal of services. As calls are placed for a variety of reasons, including request for resources, information dissemination, personal etc., CDRs provide an interesting way to construct a virtual network for Senegal.

We start by quantifying the accessibility of mobile connectivity in Senegal, both spatially and across the population, using the CDR data. This quantification measures the amount of communication across various regions in Senegal. The result is a virtual network for Senegal, which is depicted in Figure 1. The circles in the map correspond to regional capitals, and the edges correspond to volume of mobile communication between them. Thicker edges mean higher volume of communication. Bigger circles mean heavier incoming and outgoing communication for that region.

Figure 1: Virtual network for Senegal with MPI as an overlay

Source: Author’s rendering of the virtual network of Senegal based on the dataset of CDRs provided as a part of D4D Senegal Challenge 2015

Figure 1 also shows the regional poverty index[1] as an overlay. A high poverty index corresponds to very poor regions, which are shown lighter green on the map. It is evident that regions with plenty of strong edges have lower poverty, while most poor regions appear isolated. 

Now, how can we give a more detailed look at the distribution of poverty? Using the virtual network, we extract quantitative metrics indicating the centrality of each region in Senegal. We then calculate centrality measures of all the arrondissements[2] within a region. We then correlate these regional centrality measures with the poverty index to build a regression model. Using the regression model, we predict the poverty index for each arrondissement.

Figure 2 shows the poverty map generated by our model for Senegal at an arrondissement level. It is interesting to see finer disaggregation of poverty to identify pockets of arrondissement, which are most in need of sustained growth. The poorer arrondissements are shown lighter green in color with high values for the poverty index.

Figure 2: Predicted poverty map at the arrondissement level for Senegal with MPI as an overlay

Source: Author’s rendering of the virtual network of Senegal based on the dataset of CDRs provided as a part of D4D Senegal Challenge 2015.

What is next for call data records and other Big Data in relation to eradicating poverty and improving the human development?

This investigation is only the beginning. Since poverty is a complex phenomenon, poverty maps showcasing multiple perspectives, such as ours, provide policymakers with better insights for effective responses for poverty eradication. As noted above, these maps can be used for decomposing information on deprivation of health, education, and living standards—the main indicators of human development index.

Even more particularly, we believe that this Big Data and our models can generate disaggregated poverty maps for Senegal based on gender, the urban/rural gap, or ethnic/social divisions. Such poverty maps will assist in policy planning for inclusive and sustained growth of all sections of society. Our methodology is generic and can be used to study other socio-economic indicators of the society.

Like many uses of Big Data, our model is in its nascent stages. Currently, we are working towards testing our methodology at the ground level in Senegal, so that it can be further updated based on the needs of the people and developmental interventions can be planned. The pilot project will help to "replicate" our methodology in other underdeveloped countries.

In the forthcoming post-2015 development agenda intergovernmental negotiations, the United Nations would like to ensure the “measurability, achievability of the targets” along with identification of 'technically rigorous indicators' for development. It is in this context that Big Data can be extremely helpful in tackling extreme poverty.

Note: This examination was part of the "Data for Development Senegal" Challenge, which focused on how to use Big Data for grass-root development. We took part in the Data Challenge, which was held in conjunction with NetMob 2015 at MIT from April 7-10, 2015. Our team received the National Statistics prize for our project titled, "Virtual Network and Poverty Analysis in Senegal.” This blog reflects the views of the authors only and does not reflect the views of the Africa Growth Initiative.

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[1] As a measure of poverty, we have used the Multidimensional Poverty Index (MPI), which is a composite of 10 indicators across the three areas: education (years of schooling, school enrollment), health (malnutrition, child mortality), and living conditions.

[2] Senegal is divided into 14 administrative regions, which are further divided into 123 arrondissements.

      

Education is at a critical juncture in many nations around the world. It is vital for student learning, workforce development, and economic prosperity. For example, research in Turkey has found that raising the compulsory education requirement from five to eight years increased the percentage of women having eight years of school by 11 percentage points, and had a variety of positive social consequences.

Yet despite the emergence of digital learning, most countries still design their educational systems for agrarian and industrial eras, not the 21st century. This creates major problems for young people who enter the labor force as well as teachers and parents who want children to compete effectively in the global economy.

In this paper, Darrell West examines how mobile devices with cellular connectivity improve learning and engage students and teachers. Wireless technology and mobile devices:

• Provide new content and facilitate information access wherever a student is located
• Enable, empower, and engage learning in ways that transform the environment for students inside and outside school
• Allow students to connect, communicate, collaborate, and create using rich digital resources, preparing them to adapt to quickly evolving new technologies
• Incorporate real-time assessment of student performance
• Catalyze student development in areas of critical-thinking and collaborative learning, giving students a competitive edge

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Policy Brief #180

	EXECUTIVE SUMMARY
	The year 2010 in Afghanistan had some encouraging signs but on balance it was less positive than had been hoped. In 2011, therefore, it is important to do two things: first, look for further improvements in our strategy; and second, develop a backup plan, should the current approach not yield the kind of progress that is necessary and expected. This policy brief addresses the first challenge, improving the U.S./NATO counterinsurgency campaign. The basic logic of current strategy is accepted, but several new initiatives or ideas are explored to make it more promising and more effective. Three main ideas are developed: Promoting Afghan political organizations built around ideas and platforms, not individuals and ethnicities, in a change from longstanding American policy that could improve the quality of governance in the country. Taking pressure off the bilateral U.S.-Afghan relationship on the issue of anticorruption, largely by creation of an international advisory board consisting of prominent individuals from key developing countries like Indonesia and Tanzania that have had considerable success improving their own nations' governance in recent times. Offering a civilian nuclear energy deal to Pakistan, conditional on clear action by Islamabad to shut down insurgent sanctuaries that are currently using its territory to attack the Afghan government as well as NATO forces.

The past year was not without good news in Afghanistan. It saw a successful deployment of nearly another 40,000 NATO troops to Afghanistan; twice as much growth in Afghan security forces together with a much more robust approach to their training; increases in American civilian capacity in Kabul and in the field; and highly effective targeting of Afghan (and Pakistani) insurgents within Afghanistan and just over the border with Pakistan. I would also count the September parliamentary elections as more good than bad, since it was Afghans who held other Afghans accountable for infractions, and since the Karzai government appears on balance to be tolerating an outcome that will reduce the strength of its cronies in the elected assembly (though this issue remains a work in progress). Finally, NATO's decision at the November Lisbon Summit to emphasize the year 2014 as the time when Afghanistan would assume full control of security operations-rather than President Obama's earlier preference to emphasize July 2011 as the point when the U.S. departure would begin-clarified the American and international commitments to get the job done right before going home. Among other benefits, this change should help convince more Afghan and Pakistani fence-sitters that they can count on us, rather than encouraging hedging behavior out of fear of a premature, hurried NATO exit.

However, 2010 also witnessed a roughly 50 percent increase in the overall level of violence that can only partially be explained by our increased presence and tempo of operations. That increase reflects a very resilient insurgency. Problematic relations between the Obama administration and the Karzai government have also continued, the corruption problem has remained intractable (largely fueled by the western presence with all of its trappings), and the Pakistani government still tolerates sanctuaries for the Haqqani network and the "Quetta Shura Taliban" (that is, the Afghan Taliban) on its territory.

For the most part, the strategy of the International Security Assistance Force (ISAF) under General David Petraeus, and the efforts of the international community more broadly, seem sound. The paramount goal in Afghanistan is to put the country's government in a position to control its own territory. That is the way to ensure that no large terrorist sanctuaries re-emerge there that could threaten the United States, nuclear-armed Pakistan, or other core western interests. But to achieve that goal, a comprehensive counterinsurgency approach that helps build up the Afghan state is needed, because establishing control of territory requires that the government possess a certain legitimacy among its people-which in turn requires some measure of economic and political progress. Hence, to achieve a fairly simple goal, we have properly undertaken a fairly ambitious strategy, after having tried the opposite, minimalist approach for the first half dozen years of the war only to see the Taliban make a comeback. Yet the strategy still needs improvement to address its two main vulnerabilities: the weakness and corruption of the Afghan government, and the schizophrenic approach to the war on the part the Pakistani government. This policy brief proposes ideas to address each of these problems. The proposals would also improve the prospects of any sound backup plan that might have to be considered this year, such as the concept that Brookings Senior Fellow Bruce Riedel and I have recently developed that we call a "Plan A-" for the country.

Afghan Governance and Anti-Corruption Efforts

Working with the Karzai government is an inherently complex matter. On the one hand, we have no choice but to partner with Afghanistan's elected leader, who in fact remains reasonably popular among his own people with a 62 percent favorability rating according to the latest polls. On the other hand, the government is widely seen as ineffective by many of its own citizens, helping generate motivation and recruits for the insurgency. So do we work with Karzai, or work around him? In fact, we must do both. We need a better way to help the Afghan government improve its performance without inciting periodic public spats along the way that set back our efforts to cooperate. And we also need a way to help build for Afghanistan's post-Karzai future, the sooner the better.

Improving Afghan Governance and Fighting Corruption

General Stanley McChrystal's 2009 assessment of the situation in Afghanistan famously and dramatically concluded that corruption in the Afghan government was comparable to the insurgency itself in posing a serious threat to the country. As such, General Petraeus has been right to focus intently on corruption since assuming command, including assigning the formidable Brigadier General HR McMaster to the task, and some positive things are happening as a result. More intelligence assets are being devoted to the problem. Field commanders and development specialists are more aware of the need to understand the power of money, and to be cognizant of whom they are empowering or embittering through their contracting processes and economic development efforts.

Yet problems remain. Corruption remains very serious. And disputes about corruption with President Karzai still go public too often. The United States and the international community more generally should reframe the issue of fighting corruption, as Marine Colonel Greg Douquet and I have previously argued. The challenge should be seen and described primarily as one of improving governance in Afghanistan rather than tackling a culture of criminality.

Blantant, extreme corruption must be prosecuted. But by criminalizing routine corruption, we not only encourage unrealistic expectations in the U.S. Congress and elsewhere about the progress that is achievable over the next few years, we may miss opportunities to work with Afghan "reconciliables"-individuals who may have had some corrupt tendencies yet also try to provide a certain level of effective governance. We also fail to recognize our own past role in the dynamic. Pumping billions of dollars a year into a poor economy, and inadvertently favoring certain power brokers and tribes over others in the process, feeds the very corruption that we so abhor.

Research on fighting corruption and improving governance points to a better way of thinking about this problem. One key insight from renowned development expert Paul Collier and others is that young democracies with weak checks on presidential powers and an easy source of cash tend to have major problems with corruption-so Afghanistan's challenges, rather than being viewed primarily as criminal, should be expected in some ways. Taking this tone with the Karzai government can improve atmospherics and bolster our odds of eliciting cooperative behavior from Kabul.

Another key finding from MIT's Benjamin Olken and other researchers is that trained, independent auditors deployed from the central government to various parts of the country can improve the quality of government performance. Government auditors could also counter the "inverse pyramid" patronage network that is common in the Karzai administration, a network in which corrupt officials "invest" in purchasing government positions and their "dividends" are paid to them in the form of bribes and extortion. Reforming Afghanistan's government will require reversing this trend, or at least mitigating it, through such auditors and other governmental improvements.

And perhaps most important of all, the development literature shows that a number of countries around the world have made headway in combating corruption and improving governance over the years. Brookings and World Bank scholars Daniel Kaufmann, Aart Kraay and Pablo Zoido-Lobaton document progress in places including Indonesia, Hong Kong, Georgia, Albania, Tanzania and Rwanda. We should try to involve more experts from such countries in the effort. President Karzai and others might react more positively to hearing suggestions about how to reduce bribes, check nepotism, and improve governance from Indonesians or Tanzanians rather than Americans.

With U.S. assistance, Afghanistan's government has improved. We are now seeing points of light in the anticorruption effort, such as President Karzai's new specialized anticorruption agency-the High Office of Oversight. Several key ministers in the Karzai cabinet are also exemplary on this front, including for example Minister of Interior Mohammadi. We should emphasize their sound efforts more often. But there is clearly a long way to go, and an international contact group may help.

Strengthening Afghan Political Parties and Institutions

Afghanistan's corruption problem is largely rooted in the fact that the young political system is still too driven by personalities-and to a lesser extent ethnicity-and not enough by ideas.

Part of the challenge is to make sure that Mr. Karzai relinquishes power in 2014, when he reaches the constitutional limit of two full presidential terms. Prudence requires that we assume Mr. Karzai will seek to change the constitution or otherwise manipulate the electoral and legal process to stay in office-not out of any megalomania, but as much as anything out of fear for himself and his friends and relatives given the uncertainty of who might follow him in office. As such, it is possible that Karzai could declare martial law and suspend future elections. He could seek a peace deal with insurgents that makes him the compromise candidate under a future modified constitution. He could even consider a military coup.

It is important to deflate this possibility before it gains momentum. U.S. policymakers should, for example, mention publicly that Mr. Karzai will no longer be president after 2014. This is unobjectionable as a point of legal fact-at least right now-so there is no reason to shy away from saying so. Talking about it enough will help clarify the international community's intentions and expectations. And given Afghanistan's long-term need for international security and economic assistance, Afghan leaders would have to take notice.

The second imperative is to strengthen Afghan political organizations. That means helping Afghanistan's reformers and patriots, of whom there are many, to form strong political movements. Mr. Karzai has chosen some good cabinet officials and governors, but these are just a few individuals. Afghanistan's organized political parties are very weak. There are some fledgling new movements-like the one spearheaded by former foreign minister and presidential candidate Abdullah Abdullah. But they are loosely organized and have relatively vague policy platforms.

Afghanistan needs political movements tied to ideas and governing principles rather than ethnicity or individuals. Mr. Karzai has so far discouraged their formation. He has argued that Afghans dislike political parties because of the legacy of Communist Party abuses in the late 1970s and 1980s. But the 1980s are increasingly ancient history. Those who oppose parties today seem motivated mostly by their own desire to divide and conquer a weak, inchoate opposition.

It is time for the U.S. government and the many other governmental and nongovernmental organizations present in Afghanistan to strongly support the activities of new political movements. They should encourage and fund Afghans as they hold policy conferences, create research institutes, do grass-roots political organizing, and talk policy and politics in print, on television and on the radio. This approach need not be anti-Karzai; the president himself could form a party.

Such dynamics could affect even the shorter-term calculations of Afghan politicians. If Afghan voters in 2014 and thereafter are empowered to make real policy choices, candidates will take notice and start developing ideas they can run on. That may be as good an antidote to weak governance and rampant corruption as we can find-not only for the future but for today as well.

Getting Pakistan Off the Fence

Pakistan arguably remains the most complex ally the United States has ever had in wartime. Nine years into the campaign, we still cannot clearly answer the question of whether Pakistan is with us or against us. America needs bold new policy measures to help Islamabad-in all its many dimensions and factions-make up its mind.

Despite allowing massive NATO logistics operations through its territory and helping the United States pursue al Qaeda operatives, Pakistan tolerates sanctuaries on its soil for the major insurgencies fighting in Afghanistan. These include the Afghan Taliban (known as the Quetta Shura Taliban because its principle base remains in Quetta in the Pakistani province of Baluchistan) as well as the Haqqani and Hezb-i-Islami Gulbuddin (HiG) networks. The Haqqanis straddle the border between the Afghan provinces of Khost, Paktia, and Paktika as well as North Waziristan and other tribal areas within Pakistan; HiG is further north, operating in and around the Khyber Pass connecting Kabul and Jalalabad in Afghanistan with Peshawar and points east in Pakistan. Thus, all three major Afghan insurgent groups have home bases in Pakistan, and despite the occasional drone strike are generally beyond NATO's reach as a result.

Pakistan has taken some worthy actions against extremists in its remote northern and western areas in recent years. Specifically, it has recognized the so-called Pakistani Taliban (the Tehrik-i-Taliban Pakistan, or TTP) as a mortal threat to the Pakistani state and responded accordingly in some tribal areas. Pakistanis argue, however, that limited numbers of ground troops combined with the past year's devastating floods prevent them from doing more. Quetta, North Waziristan, and other key places remain dens of iniquity, havens for extremists who continue to attack NATO and Afghan troops across the border and then return home for rest, regrouping, and fresh recruiting. Major command-and-control hubs are permanently located within Pakistan as well, and key insurgent leaders like Mullah Omar (to say nothing of Osama bin Laden) probably remain safely ensconced on Pakistani territory where U.S. forces cannot get at them. But it is perhaps not just a matter of available troops. Pakistan would rather have the Taliban and the Haqqanis back in power, especially in the country's south and east, than any group like the former Northern Alliance, which it views as too close to India. Since Islamabad cannot be sure that the current Afghan political system will survive, therefore, it keeps a backup plan based largely on the Taliban and its associates.

Under these circumstances, part of the right policy is to keep doing more of what the Obama administration has been doing with Pakistan-building trust, as with last fall's strategic dialogue in Washington; increasing aid incrementally, as with the new five-year, $2 billion aid package announced during that dialogue; encouraging Pakistan-India dialogue (which would help persuade Islamabad it could safely move more military forces from its eastern border to its western regions) and coordinating militarily across the Afghanistan-Pakistan border region. But President Barack Obama needs to think bigger. The clarification that the U.S.-led ISAF mission will continue until 2014, and indeed beyond, at the November Lisbon summit was a step in the right direction but more is needed.

Obama should offer Islamabad a much more expansive U.S.-Pakistani relationship if it helps win this war. Two major incentives would have particular appeal to Pakistan. One is a civilian nuclear energy deal like that being provided to India, with full safeguards on associated reactors. Pakistan's progress on export controls in the wake of the A.Q. Khan debacle has been good enough so far to allow a provisional approval of such a deal if other things fall into place as well, including Islamabad’s compliance with any future fissile production cutoff treaty. Second is a free trade accord. Struggling economically, Pakistan needs such a shot in the arm, and a trade deal could arguably do even more than aid at this point.

But the key point is this: Pakistan should be told that these deals will only be possible if the United States and its allies prevail in Afghanistan. Small gestures of greater helpfulness are not adequate; bottom-line results are what count and what are needed. If Afghanistan turns around in a year or two, the deals can be set in motion and implemented over a longer period that will allow the United States to continually monitor subsequent Pakistani cooperation in the war. These terms are really just common sense, and they are based on political realism about America's domestic politics as well as its strategic interests, since there is no way the Congress would support such a nuclear deal if Pakistani policy ultimately contributed to our losing the war in Afghanistan.

Conclusion

Current strategy in Afghanistan is built on reasonably sound counterinsurgency principles and is fairly promising in its prospects for the year ahead. But every such operation is different. That is a basic corollary of counterinsurgency theory, with its emphasis on local politics, conditions, and personalities-meaning that there is no reason to believe that current strategy is good enough just because its fundamentals are time-tested.

A number of other policy reforms, beyond those discussed here, may be worth considering in the coming months as well. The numerical goal for the Afghan security forces is probably still too low, and should approach 400,000 uniformed personnel rather than the current 305,000 target (this debate is well underway as of this writing). The legal system remains weak, with glaring problems such as a major dearth of judges and severely inadequate pay for prosecutors, as well as no clear strategy for linking the formal justice system to the local, traditional justice systems that remain important in Afghanistan today. Finally, in the aftermath of the September 2010 parliamentary elections, some patchwork solution to the disenfranchisement of Pashtuns in provinces like Ghazni where many of them could not vote (or had their votes thrown out) is probably needed. Perhaps some additional modest number of Pashtuns could be given non-voting adjunct status in the parliament, allowing their voices to be heard even if they were ultimately not able to win seats.

But the three changes to our current approach discussed in this policy brief are central, and have not received their due attention. On the anticorruption front, adoption of a less bilateral approach that includes a high-level international advisory body on good governance for the Karzai government could improve the tone and substance of the effort. On the Afghan politics front, the international community should be unapologetic about supporting Afghan political parties built on ideas and agendas more than personalities and ethnicities. And finally, in regard to Pakistan, an informal but public U.S. offer to pursue a bilateral civilian nuclear energy deal should Pakistan help us win the war by clamping down on insurgent sanctuaries, might motivate greater efforts by our on-again off-again allies across the border. Adoption of these recommendations would improve our prospects for at least moderate success in Afghanistan and help make 2011 the belated turnaround year that we so badly need.

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Nigeria is facing a confluence of troubles: dramatically reduced oil prices have pummeled a country that depends on oil exports for two-thirds of its national revenues; the Boko Haram insurgency continues to wreak havoc particularly in the north of the country, where suicide bombings (many of which are now carried out by kidnapped girls) have killed hundreds; and corruption remains a drain on the country, which ranked 136th out of 168 countries on Transparency International’s 2015 Corruptions Perceptions Index.

But amidst this, Nigeria completed its first peaceful transition of power nine months ago—to Muhammadu Buhari, who has since made some progress in reforming the military, sacking corrupt leaders, and injecting energy into the counter-Boko Haram campaign. 

On February 29, the Africa Security Initiative at Brookings hosted a discussion on the current state of Nigeria, featuring EJ Hogendoorn of the International Crisis Group, Madeline Rose of Mercy Corps, Mausi Segun of Human Rights Watch, and Amadou Sy from Brookings. Brookings’s Mike O’Hanlon moderated the conversation.

As O’Hanlon argued at the start, Nigeria is one of the most important countries in the world, but appears little in policy debates. Nigeria is sub-Saharan Africa’s largest economy, and security risks emanating in the country can have spillover effects. All of the participants stressed that Nigeria should factor more centrally in conversations about international security, economic development, and humanitarian issues.

Nigeria’s ups and downs

O’Hanlon started by framing three overlapping challenges in Nigeria:

• The struggle against Boko Haram, which is more complicated than a pure terror group, but has also pledged loyalty to ISIS.
• The question of reform, to include the army, the police, and the entire government.
• The state of the economy, since Nigerian livelihoods need to be improved if there is any hope to handle the first two situations. 

Hogendoorn praised the peaceful transition of power to President Buhari, calling it a “stunning achievement” for the country and those who helped from the outside. However, the problems facing Nigeria—namely the insurgency in the Niger Delta, declining oil prices, and corruption and government mismanagement (at state and federal levels)—are large, he said. He argued that declining oil prices and income are impacting the government’s ability to fulfill promises, and that state governments are powerful and difficult to reform. He praised some anti-corruption institutions in Nigeria, as well as a number of effective governors who have changed corruption situation dramatically over a short period of time. But in the end, he said, it comes down to good leadership. The Nigerian people must demand accountability. 

Rose detailed how things have changed in Nigeria since Mercy Corps became heavily involved in the area in 2012. Mercy Corps’ main missions there include violence reduction, education, and creating opportunity for young girls, as well as humanitarian response. While there has been progress on chronic violence in Nigeria, particularly in the northeast of the country, Rose stressed that there is much to be done. She concluded that there is not enough attention to the human element of the crisis. For example, Rose noted that displacement is common across the Northeast. The displaced are mainly women and children. In the displaced groups, the eldest becomes de facto head of household—sometimes forcing leading adolescent girls to turn to selling sex for food or money for food. Rose called on the government to address this. 

Segun agreed that the focus needs to change regarding crisis response in Nigeria. In the past, the focus has been almost entirely on a military response. This has not been a workable plan, she said, partly because the “military operates above the law.” The reforms in Nigeria must have a social component, Segun argued. Lack of access to opportunity, economic problems, and desertification of major water bodies have all combined to drive farmers and fisherman from the Northeast and into the heart of the conflict. 

Sy returned to the importance of economic interests in resolving the crises in Nigeria. He reminded the audience that the country is the largest economy of sub-Saharan Africa, and that is important for the entire continent. Since two-thirds of the government revenue comes from oil, the oil shock has dealt a huge blow. But there is hope for Nigeria, Sy noted. One reason is stimulus via investment outside the oil sector. There has been an increase in infrastructure spending, as well as on human development (namely in education and health). In both cases, he said the biggest issue will be implementation. Sy gave four recommendations to the Nigerian government: 1) increase infrastructure expenditure, 2) make government more lean and cost-effective, 3) increase taxation in non-oil revenue items, and 4) reduce corruption. 

Overall, the participants expressed cautious hope for Nigeria despite the problems it faces. The government there still has a long list of to-do’s, but there is reason to believe that it is on the right general track.

      

       

Legislative proposals to accelerate and improve the development of innovative drugs and medical devices generally focus on reforming the clinical development and regulatory review processes that occur before a product gets to market. Many of these proposals – such as boosting federal funding for basic science, streamlining the clinical trials process, improving incentives for development in areas of unmet medical need, or creating expedited FDA review pathways for promising treatments – are worthy pursuits and justifiably part of ongoing efforts to strengthen biomedical innovation in the United States, such as the 21^st Century Cures initiative in the House and a parallel effort taking shape in the Senate.

What has largely been missing from these recent policy discussions, however, is an equal and concerted focus on the role that postmarket evidence can play in creating a more robust and efficient innovation process. Data on medical product safety, efficacy, and associated patient outcomes accrued through routine medical practice and through practical research involving a broad range of medical practices could not only bolster our understanding of how well novel treatments are achieving their intended effects, but reinforce many of the premarket reforms currently under consideration. Below and in a new paper, we highlight the importance of postmarket evidence development and present a number of immediately achievable proposals that could help lay the foundation for future cures.

Why is postmarket evidence development important?

There are a number of reasons why evidence developed after a medical product’s approval should be considered an integral part of legislative efforts to improve biomedical innovation. First and foremost, learning from clinical experiences with medical products in large patient populations can allow providers to better target and treat individuals, matching the right drug or device to the right patient based on real-world evidence. Such knowledge can in turn support changes in care that lead to better outcomes and thus higher value realized by any given medical product.

Similarly, data developed on outcomes, disease progression, and associated genetic and other characteristics that suggest differences in disease course or response to treatment can form the foundation of future breakthrough medical products. As we continue to move toward an era of increasingly-targeted treatments, this important of this type of real-world data cannot be discounted.

Finally, organized efforts to improve postmarket evidence development can further establish infrastructure and robust data sources for ensuring the safety and effectiveness of FDA-approved products, protecting patient lives. This is especially important as Congress, the Administration, and others continue to seek novel policies for further expediting the pre-market regulatory review process for high-priority treatments. Without a reliable postmarket evidence development infrastructure in place, attempts to further shorten the time it takes to move a product from clinical development to FDA approval may run up against the barrier of limited capabilities to gather the postmarket data needed to refine a product’s safety and effectiveness profile. While this is particularly important for medical devices – the “life cycle” of a medical device often involves many important revisions in the device itself and in how and by whom it is used after approval – it is also important for breakthrough drugs, which may increasingly be approved based on biomarkers that predict clinical response and in particular subpopulations of patients.

What can be done now?

The last decade has seen progress in the availability of postmarket data and the production of postmarket evidence. Biomedical researchers, product developers, health care plans, and providers are doing more to collect and analyze clinical and outcomes data. Multiple independent efforts – including the U.S. Food and Drug Administration’s Sentinel Initiative for active postmarket drug safety surveillance, the Patient-Centered Outcomes Research Institute’s PCORnet for clinical effectiveness studies, the Medical Device Epidemiology Network (MDEpiNet) for developing better methods and medical device registries for medical device surveillance and a number of dedicated, product-specific outcomes registries – have demonstrated the powerful effects that rigorous, systematic postmarket data collection can have on our understanding of how medical products perform in the real-world and of the course of underlying diseases that they are designed to treat.

These and other postmarket data systems now hold the potential to contribute to data analysis and improved population-based evidence development on a wider scale. Federal support for strengthening the processes and tools through which data on important health outcomes can be leveraged to improve evidence on the safety, effectiveness, and value of care; for creating transparent and timely access to such data; and for building on current evidence development activities will help to make the use of postmarket data more robust, routine, and reliable.

Toward that end, we put forward a number of targeted proposals that current legislative efforts should consider as the 2015 policy agenda continues to take shape:

Evaluate the potential use of postmarket evidence in regulatory decision-making. The initial Cures discussion draft mandated FDA to establish a process by which pharmaceutical manufacturers could submit real-world evidence to support Agency regulatory decisions. While this is an important part of further establishing methods and mechanisms for harnessing data developed in the postmarket space, the proposed timelines (roughly 12 months to first Guidance for Industry) and wide scope of the program do not allow for a thoughtfully-, collaboratively-considered approach to utilizing real-world evidence. Future proposals should allow FDA to take a longer, multi-stakeholder approach to identify the current sources of real-world data, gaps in such collection activities, standards and methodologies for collection, and priority areas where more work is needed to understand how real-world data could be used.

Expand the Sentinel System’s data collection activities to include data on effectiveness. Established by Congress in 2007, Sentinel is a robust surveillance system geared toward monitoring the safety of drugs and biologics. In parallel to the program for evaluating the use of RWE outlined above, FDA could work with stakeholders to identify and pursue targeted extensions of the Sentinel system that begin to pilot collection of such data. Demonstration projects could enable faster and more effective RWE development to characterize treatment utilization patterns, further refine a product’s efficacy profile, or address pressing public health concerns – all by testing strategic linkages to data elements outside of Sentinel’s safety focus.

Establish an active postmarket safety surveillance system for medical devices. Congress has already acted once to establish device surveillance, mandating in 2012 that Sentinel be expanded to include safety data on medical devices. To date, however, there has been no additional support for such surveillance or even the capability of individually tracking medical devices in-use. With the recently finalized Unique Device Identifier rule going effect and the ability to perform such tracking on the horizon, the time is now to adopt recent proposals from FDA’s National Medical Device Postmarket Surveillance System Planning Board. With Congressional authorization for FDA to establish an implementation plan and adequate appropriations, the true foundation for such a system could finally be put into place.

These next steps are practical, immediately achievable, and key to fully realizing the intended effect of other policy efforts aimed at both improving the biomedical innovation process and strengthening the move to value-based health care.

      

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The role of clinical pharmacology and experimental medicine

The high failure rate of investigational compounds during drug development, especially in late stages of the clinical development process, is widely seen as a key contributor to the outsize amount of time and resources necessary to develop new drugs. Advances in clinical pharmacology and experimental medicine have the potential to rebalance these trends by providing researchers with the tools to more efficiently and systematically identify promising targets and compounds, appropriate patient populations, and adequate doses for study much earlier in development. 

On July 28, the Center for Health Policy at Brookings, in collaboration with the International Consortium for Innovation & Quality in Pharmaceutical Development and the U.S. Food and Drug Administration (FDA), hosted a public meeting to tackle these issues. Through presentations and case studies, leading experts from industry, academia, and government agencies explored the evolving role of clinical pharmacology tools in pre-clinical and clinical development, existing gaps in the application of those tools, and how emerging science could be better leveraged to improve the efficiency of drug development programs and better optimize treatments. Discussion at this event will potentially be harnessed to inform downstream guidance documents, to establish best practices for the application of emerging clinical pharmacology tools, or to support academic publications. Speakers will convene privately to discuss such downstream deliverables and key takeaways from the conference.

Click here to access the full event agenda.

Video

• Introductory keynotes: Framing the issues
• Optimizing target and compound selection to enhance early stage decision-making
• The right dose for the right patient: Challenges and opportunities in dose optimization
• Precision medicine: Trial enrichment, biomarker science, and mechanistic reasoning to optimize patient selection
• Applications of clinical pharmacology to support demonstration of efficacy

Event Materials

• Event Slide Deck
• Clinical Pharmacology Public Conference
• Clinical Pharmacology Backgrounder
• Clinical Pharmacology Private Roundtable

       

EXECUTIVE SUMMARY

Parents, educators, government ministers and policymakers in all contexts and countries around the world are concerned with learning and how to improve it. There are many reasons for this, but none is more important than the fact that learning is at the heart of success at the individual, community and global levels. Learning First is the title of this report, with the strong implication that learning should be the foremost goal of education policies worldwide.

The present review seeks not only to explain why this is the case but also focuses on what we need to know—that is, what research is needed—in order to improve learning in the decades to come, particularly among those children most in need. This question is addressed in the following six sections.

1. Learning Goals and Research. The first section begins with a historical synopsis of international education goals put forward in 1990 at the World Conference on Education for All in Jomtien (Thailand), in 2000 at the Education for All conference in Dakar, and later in 2000 as a part of the UN Millennium Development Goals for 2015. In 2011, the Center for Universal Education at the Brookings Institution published A Global Compact on Learning: Taking Action on Education in Developing Countries, which stated that there is a “global learning crisis—which affects children and youth who are out of school with limited learning opportunities and those who are in school but not learning the skills they need for their futures.” The present review of learning research in low-income countries follows from that report. The overall purpose is to explore the most pressing learning issues today that require further research attention in the years to come.
    
2. Learning Definitions and Contexts. This section reviews how the field of education has defined learning over the years. Here, learning is defined as a modification of behavior due to experience—such as in knowledge, skills, attitudes and values. Three main principles of effective learning are suggested: individual active involvement, social participation, and meaningful engagement. As a way to emphasize the importance of learning contexts, three individual stories—Illa, a four-year-old Quechua-speaking girl in Peru; Pawan, an eight-year-old primary school student in urban India; and Rachida, a young illiterate woman in rural Morocco—are provided in order to better explain the importance of learning as a culturally specific phenomenon. These stories help to illustrate a more general learning framework, encompassing the relationship between two dimensions of learning—its processes and contexts. A discussion follows concerning the need to disaggregate learners and their learning contexts—between countries and within countries—as a way to overcome frequent and simplistic generalizations about how the “average” child learns.
    
3. Global Change and the Contexts of Learning. This section considers the issue of global change on how learning and learning contexts are being transformed around the world. For example, researchers need to pay more attention to the impact of migration on children’s learning and on educational systems more broadly. In each instance of translocation, children confront the challenges of adapting to a new environment that may include different languages, dialects or cultures within the nonformal learning contexts of daily life. Similarly, in formal education contexts, student migrants have to cope with contrasts in culture, lifestyle and language of schooling, and demonstrate skills and achievement that may vary dramatically with their culture of origin. Other changes due to globalization include increased multilingualism in schools, growing overcrowding in classrooms, inability to keep up with teacher training, changes in intergenerational learning, and the growing importance of 21st-century skills. Based on these observations, it is suggested that learning contexts and needs should be understood as a shifting target.

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Youth summer jobs programs have experienced a resurgence of interest and investment since the Great Recession, driven by concerns about high unemployment rates among young people, particularly those who are low-income, black, or Hispanic. Recent research points to summer jobs programs as a positive lever for change by reducing violence, incarceration, and mortality and improving academic outcomes.They are often a jurisdiction’s most high-profile youth employment initiative.

But good intentions do not always lead to results. Research has not yet linked summer jobs programs to improved employment outcomes, evaluations to date are silent on effective program design, and in the absence of agreed-upon standards and best practices, there is no guarantee of quality.They are complicated and labor-intensive to operate, and many jurisdictions had to re-build their programs after a long hiatus following the end of dedicated federal funding in the late 1990s.

On Thursday, July 14, the Brookings Metropolitan Policy Program hosted an event that explored core elements associated with high-performing programs and made recommendations to strengthen summer jobs programs. The event featured a presentation on the finding of a new paper by Brookings fellow Martha Ross and co-author Richard Kazis, titled, “Youth Summer Jobs Programs: Aligning Ends and Means,” followed by a response panel, comprised of leaders from metro areas across the country.  

Join the conversation on Twitter at #SummerJobs

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Presentation by Martha Ross

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Photo

From left to right: Richard Kazis, Nonresident Fellow, The Brookings Institution; Kerry Sullivan, President, Bank of America Charitable Foundation; Honorable Michael A. Nutter, Former Mayor, City of Philadelphia;  Ana Galeas, Summer Camp Counselor, DC Scores, and Participant, Mayor Marion S. Barry Summer Youth Employment Program; Michael Gritton, Executive Directlor, KentuckianaWorks

Video

• Welcome and presentation
• Panel discussion
• Closing remarks

Audio

• Improving youth summer jobs programs

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160714_youth_jobs_transcript

       

William Galston and E.J. Dionne, Jr. make the case for universal voting – a new electoral system in which voting would be regarded as a required, civic duty. Why not treat showing up at the polls in the same way we treat a jury summons, which compels us to present ourselves at the court? Galston and Dionne argue that universal voting would enhance the legitimacy of our governing institutions, greatly increasing turnout and the diversity of the American voter base, and ease the intense partisan polarization that weakens our governing capacity.

Citing the implementation of universal voting in Australia in 1924, the authors conclude that universal voting increases citizen participation in the political process. In the United States, they write, universal voting would promote participation among citizens who are not likely to vote—those with lower levels of income and education, young adults, and recent immigrants. By evening out disparities in the electorate, universal voting would put the state on the side of promoting broad civic participation.

In addition to expanding voter participation, universal voting would improve electoral competition and curb hyperpolarization. Galston and Dionne assert that the addition of less partisan voters in the electorate, would force candidates to shift their focus from mobilizing partisan bases to persuading moderates and less committed voters. Reducing partisan rhetoric would help ease polarization and increase prospects for compromise.. Rather than focusing on symbolic, political gestures, Washington might have an incentive to tackle serious issues and solve problems.

Galston and Dionne believe that American democracy cannot be strong if citizenship is weak. And right now, they contend citizenship is strong on rights but weak on responsibilities. Making voting universal would begin to right this balance and send an important message: we all have the duty to help shape the country that has given us so much.

Galston and Dionne recognize that the majority of Americans are far from ready to endorse universal voting. By advancing a proposal that stands outside the perimeter of what the majority of Americans are likely to support, Galston and Dionne aim to enrich public debate—in the short term, by advancing the cause of more modest reforms that would increase participation; in the long term, by expanding public understanding of institutional remedies to political dysfunction. 

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• Dionne and Galston discuss their paper on universal voting

      

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

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

Customer-Facing Changes:

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

Service Provider Changes:

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

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

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

Pathway One: Through Big Data

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

Pathway Two: Through local Businesses

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

Pathway Three: Through Socio-Financial Networks

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

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

      

       

       

“If the Americans and their regional allies want to pass through the Strait of Hormuz and threaten us, we will not allow any entry,” said deputy commander of Iran’s Revolutionary Guards, Hossein Salami, last Wednesday. Iran has a long history of making threats against this critical waterway, through which some 17 million barrels of oil exports pass daily, though it has not carried them out. But multiple regional security threats highlight threats to energy transit from and through the Middle East and North Africa (MENA)—and demand new thinking about solutions.

Weak spots

Hormuz attracts attention because of its evident vulnerability. But recent years have seen severe disruptions to energy flows across the region: port blockades in Libya; pipeline sabotage in Egypt’s Sinai, Yemen, Baluchistan in Pakistan, and Turkey’s southeast; attacks on oil and gas installations across Syria and Iraq; piracy off Somalia. Energy security is threatened at all scales, from local community disturbances and strikes, up to major regional military confrontations.

Of course, it would be best to mitigate these energy security vulnerabilities by tackling the root causes of conflict across the region. But while disruption and violence persist, energy exporters and consumers alike should guard against complacency.

A glut of oil and gas supplies globally—with low prices, growing U.S. self-sufficiency, and the conclusion of the Iranian nuclear deal—may seem to have reduced the urgency: markets have hardly responded to recent flare-ups. But major economies – even the United States – still remain dependent, directly or indirectly, on energy supplies from the MENA region. Spare oil production capacity is at unusually low levels, leaving the balance vulnerable to even a moderate interruption.

Most concern has focused on oil exports, given their importance to the world economy. But the security of liquefied natural gas (LNG) shipments is an under-appreciated risk, particularly for countries such as Japan and South Korea which are heavily dependent on LNG. A disruption would also have severe consequences for countries in the Middle East and North Africa, depriving them not only of revenues but potentially of critical imports.

Doing better 

There are three broad groups of approaches to mitigating the risk of energy transit disruptions: infrastructure, institutions, and market. 

1. Infrastructure includes the construction of bypass pipelines avoiding key choke-points and strategic storage.
   
   Existing bypass pipelines include SUMED (which avoids the Suez Canal); the Habshan-Fujairah pipeline in the UAE (bypassing Hormuz); and the Saudi Petroline, which runs to the Red Sea, hence offering an alternative to the Gulf and Hormuz. Proposed projects include a link from other Gulf Cooperation Council (GCC) countries to Oman’s planned oil terminal at Duqm on the Indian Ocean; new or rehabilitated pipelines from Iraq across Jordan and Turkey; an expansion of Petroline; and a new terminal in southern Iran at Jask.
   
   Strategic storage can be held by oil exporters, by importers, or a combination (in which exporters hold oil close to their customers’ territory, as with arrangements between Saudi Arabia and Japan, and between Abu Dhabi and Japan and India).


2. Institutional approaches include mechanisms to deal with disruptions, such as cooperative sharing arrangements.
   
   More analysis has focused on infrastructure than on institutional and market mitigation. Yet these approaches have to work together. Physical infrastructure is not enough: it has to be embedded in a suitable framework of regulation, legislation, and diplomacy. Cross-border or multilateral pipelines require agreements on international cooperation; strategic storage is most effective when rules for its use are clear, and when holders of storage agree not to hoard scarce supplies. 
   
   The effective combination of infrastructure and institutions has a strategic benefit even if it is never used. By making oil exporters and consumers less vulnerable to threats, it makes it less likely that such threats will be carried out.
   
   Alliances can be useful for mutual security and coordination. However, they raise the difficult question of whom they are directed against. Mutually-hostile alliances would be a threat to regional energy security rather than a guarantor. Organizations such as the International Energy Agency (IEA), the International Energy Forum (IEF), Organization of Petroleum Exporting Countries (OPEC), Gulf Cooperation Council, and the Association of Southeast Asian Nations (ASEAN) could all have roles, but none is ideally placed. Rather than creating another organization, reaching an understanding between existing bodies may be more effective.


3. In general, markets cope well with the task of allocating scarce supplies. Better and timelier data, such as that gathered by the IEF, can greatly improve the functioning of markets. Governments do have a role in protecting the most vulnerable consumers and ensuring sufficient energy for critical services, but price controls, rationing, and export bans have usually been counterproductive, and many of the worst consequences of so-called energy crises have come from well-meaning government interference with the normal market process of adjustment.
   
   However, it is generally difficult or impossible for a single company or country to capture all the benefits of building strategic infrastructure—which, as with a bypass pipeline, may only be required for a few months over a period of decades. International financing, perhaps backed by a major energy importer—mostly likely China—can help support such projects, particularly at a time of fiscal austerity in the Middle East.

Energy exporters within the MENA region may often find their interests divergent. But the field of energy security is one area for more fruitful cooperation—at least between groups of states, and some external players, particularly their increasingly important Asian customers. If regional tensions and conflicts cannot be easily solved, such action at least alleviates one of the serious risks of the region’s turmoil.

For more on this topic, read Robin Mills’ new analysis paper “Risky routes: Energy transit in the Middle East.”

      

       

       

There are now more than 335 Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) in 47 states, DC, and Puerto Rico. Early results show that most Medicare ACOs are succeeding at meeting their quality benchmarks, but only about a quarter of MSSP participants have been able to reduce their spending enough below projected financial targets to qualify for shared savings. While these results are encouraging, especially given the financial and practice transformation necessary to succeed as an ACO, they also suggest that more work is needed from both CMS and the providers to ensure continued sustainability of the MSSP ACOs.

Given that the first three year cycle of MSSP ends in 2015 and more providers will likely be entering the MSSP in the coming years , the Centers for Medicare and Medicaid Services (CMS) has indicated that they intend to release a Notice of Proposed Rulemaking (NPRM) that will establish the rule for participation in the Medicare ACO program. In anticipation of these coming changes, the Engelberg Center for Health Care Reform released an issue brief that identifies the "Top Eight ACO Challenges" to encourage further discussion and considerations for ensuring the continued success of ACOs. These potential policy alternatives build on discussions with ACO Learning Network members and other related stakeholders implementing accountable care across the country and include the following issues.

These issues, and many others, will be a focus of the discussions at the upcoming Fifth National ACO Summit later this week.

Top Eight Medicare ACO Challenges

1. Make Technical Adjustments to Benchmarks and Payments
In order for ACOs to qualify for shared savings, they must be able to hold spending below a financial benchmark set using historical spending patterns and meet a certain threshold of person and population-level quality metrics. A number of issues should be considered that affect the ACO’s chances of being able to attain shared savings and have more predictability about their performance: benchmark calculation methodology, how to adjust for regional variation in performance, and risk adjustment.

2. Transition to More Person-Based Payments
The ultimate goal of an ACO is to improve quality at the patient and population level and control the growth of health care costs. In order to successfully achieve this mission, ACOs must over time make a transition to payments that involve the assumption of more risk by the provider organization with a reward for better health outcomes for groups of patients. ACOs must have a clear transition path for increasing accountability and assumption of more risk for patient health outcomes.

3. Increase Beneficiary Engagement
Patients can play a critical role in helping to achieve the goals of an ACO. Health outcomes are determined by whether patients follow prescribed therapies. Increasing beneficiary engagement holds the potential to make patients more activated members of the ACO who can contribute to its success. A number of issues should be considered to improve beneficiary engagement, including adjusting attribution methods, creating more incentives for patients to seek care within the ACO, and finding opportunities to activate patients as part of the care team.

4. Enhance and Improve Alignment of Performance Measures
A central tenet of Medicare ACOs is delivering high quality health care as determined by performance on 33 measures established by CMS. ACOs must meet performance benchmarks in order to be eligible for shared savings, ensuring that these organizations are delivering high value, rather than simply cheaper, care. A number of barriers exist to achieving better performance measurement, including administrative burdens, lack of measure alignment among payers, lack of rewards for quality improvement, and concerns about measure selection.

5. Enable Better and More Consistent Supporting Data
In order to succeed as an ACO, organizations must be able to effectively collect, interpret, and use clinical and claims data to transform care of their patients. ACOs need to adopt new health IT systems and other technologies in order to collect and use the growing amount of data. ACOs currently struggle with reconciling data between different sources, dealing with patients who opt out of data sharing, lack of timeliness for receiving data, difficulty of tracking patients through the health system, and delays in performance feedback.

6. Link to Additional Value-Based Payment Reforms
ACOs are just one of many payment reforms that health care organizations across the country are implementing to improve quality and reduce costs. Aligning the vision and components of these other initiatives with ACO reforms has the potential to reinforce the shared goals and fundamentally change the health system. However, there are barriers to achieving this alignment such as lacks of linkages to bundled payments and other new payment models, multi-payer ACOs with different payment systems, and inability for organizations to participate in multiple CMS payment innovations.

7. Develop Bonus Payments and Other Incentives to Participate
In order to effectively transform clinical practice, ACOs must create or procure significant financial and human capital, as well as transform their information technology and delivery infrastructure. A recent survey estimates the average start-up cost for creating an ACO to be $2 million, with some ACOs investing significantly more in their first few years. Many ACOs, especially smaller ones, struggle to find sufficient start-up capital, are uncertain if they can assume the level of risk required for an ACO, and need significant staff and clinical change to effectively transform care.

8. Support Clinical Transformation
Becoming and succeeding as an ACO is a vast undertaking that requires immediately beginning to transform practice, finance, and operations. However, many providers, particularly those that are less experienced at systemic practice transformation, need more support in undertaking clinical transformation.

Downloads

• Issue Brief: Improving the Medicare ACO Program

      

Contributors: Alice M. Rivlin and Christine Dang-Vu

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

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

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

Top Eight ACO Challenges

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

Downloads

• Issue Brief: Improving the Medicare ACO Program

      

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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• Changes to Medicare ACO Program

       

Editor's Note: this article originally appeared in the 2012 Print Version of AARP: The Journal.

Using one platform to offer a variety of services

Known in the UK under the term “corporate platform” to indicate that it expands options available on the employer’s benefit platform, the development allows employees to use the employer’s retirement savings mechanism to save and invest for additional nonretirement purposes. When the corporate platform is fully implemented, employees will be able to man­age almost all of their investments and savings plans from one location, thus giving them a con­solidated view of their entire financial status. If carried to its full potential, the expanded saving platform will allow employees to shop for sav­ings products, among options that are available on the platform, instead of having to seek them out from individual suppliers—a search that often takes up work hours. Of even greater value, it gives employees one source to go to for indi­vidualized advice or financial literacy training.

The enhancement has special significance in the UK, where by fall 2012, the larger employers that don’t offer any other type of pension or retirement savings plan, must begin to automatically enroll their employees into basic retirement savings accounts. This requirement is causing a great deal of discussion about the future role of employer-provided benefits, as well as recon­sideration of the fees and services included in a traditional package. The platform enhancements allow an employer to differentiate its employee benefit package from the required basic account structure. It also gives younger employees a benefit of more immediate value, than they would have from a retirement savings account that they won’t access for a good 40 years.

Presentations from a variety of service providers at an October 2011 summit hosted by Pensions Insight, a UK trade journal, showed that the platform can be easily customized to meet the special needs of a specific workforce. Using a single computer interface, employees can select from a wide variety of savings and investment options that are appropriate for their income level and stage of life. Thus, an upper income manager who manages his or her own finances could see more sophisticated products, while an entry-level worker sees more basic sav­ings products. Live presentations by financial professionals who explain what is available on the computer platform add to the system’s value and increase its use.

A place to provide choice and to build financial literacy

The platform will have special value for moderate- and lower-income employees. While higher salaried employees may appreciate the opportunity to build their investments, the real value of the platform will be to enable moder­ate- and lower-income workers to find savings opportunities that they might otherwise miss because they don’t know where to go, are uncertain about what is a fair price, or for a variety of other reasons. Because employees tend to believe that services included on the corporate platform are implicitly endorsed by the employer, they usually have greater faith that the services are from legitimate providers at a fair price.

Employees at all levels can also use the site to receive guidance on individual products or basic financial literacy training. Individuals can choose from a range of options, from short videos on a specific topic by experts or fellow employees, to longer connected courses designed to meet the needs of specific age or income groups. Use is increased when employ­ees receive emails or text messages geared to birthdays or other life events, or generated after the employee visits a specific part of the website.

Understanding the value of peer evaluations to motivate others, some providers include a place where employees can post feedback about spe­cific products or savings choices. These postings help to guide other employees’ decisions and build the reputation of the platform as a source of unbiased information. The site can also include links to outside advisors who can answer specific questions, guide employees to another site for more information, or perform other services either online or over the telephone.

Differing age groups can be contacted and guided through different technologies. At the UK platform summit, David Harris, of Tor Financial Consulting, showed that younger employees preferred different communication methods than either older workers or the usual way employers provide information. However, the platform is able to use a wide variety of methods and is equally effective no matter which is used.

The platform’s value to international policy makers

Although the UK’s platform is intended as an enhancement to employer-provided benefits, it can also be used for a wide variety of policy goals, as the basic structure can be easily adapted to meet almost any nation’s specific tax and savings system. In the United States alone, policy experts have proposed dedicated savings accounts for nonretirement purposes ranging from unemployment benefits and retraining, home purchases, health care, and long-term health care coverage, to repaying student loans or building college balances for children or grandchildren. However, if all of these various accounts were established and funded, it is doubtful the employee would have any money left for food, clothing, and shelter.

Rather than having a host of specific savings programs, employees may be better served by more flexible accounts usable for a variety of purposes, as outside developments or chang­ing needs dictate. The platform concept would allow individuals to choose which purposes they need to save for and how much to save for each. Combined with targeted guidance or education, this structure could expose individuals to pos­sibilities they might not have considered before.

The structure is ideally suited to employment situations, but it could also be used by the self-employed or by consultants at sites aimed specifically at them and sponsored by trade associations, unions, or even government agen­cies. While their circumstances may preclude payroll deductions, the same products could be offered through direct debits to bank accounts.

The added value of nudge

The flexibility of the platform allows it to be used by employees with all levels of financial sophistication, but new participants would benefit from a variation on automatic enroll­ment that places certain amounts, in addition to the retirement savings amount, into a general savings account or similar vehicle. The automatic savings amounts deducted need not be large, and where the law allows, could vary according to employee age, with a larger proportion of the overall deduction going to nonretirement purpose for younger employees and to retirement for older ones.

As with automatic retirement enrollment, the employee would have the ability to vary amounts, divide the total among various accounts, and even stop all future contributions. However, automatic enrollment would offer workers direct experience with the nonretire­ment side of the platform. By varying enrollment in various accounts according to employees’ age, automatic enrollment could encourage them to consider saving for various purposes, such as a first home, college tuition for children, or additional health services.

Improving retirement security

Although the platform is applicable to a wide variety of other uses, its primary purpose is to build retirement security. Before retirement, the platform helps employees understand how to save, what they have, and how much more they need for a comfortable lifestyle. The other savings provide funds that can be used in the event of an emergency, thus helping to reduce leakage from retirement accounts in countries that allow early access to that money. At retire­ment, the platform helps individuals to see what other assets are available, and what loans or other liabilities must be factored in. In the UK, it is also being used to encourage individuals to use annuities and add them to their invest­ments. The UK experience can help to guide US policymakers in their efforts to increase the use of similar products.

The enhanced information and flexibility of the corporate platform should help individuals to better understand their finances and how to meet their goals. It moves retirement savings plans from a minor part of employees’ financial lives, to a central feature that has many more uses than just an event many years in the future. This promotes regular use of the platform, and a fuller understanding of what is necessary for a comfortable retirement.

      

Increasingly, many Marylanders are unprepared for retirement.

The US has the broadest range of retirement savings options in the world. There are thousands of retirement products offered. But most Marylanders don’t use them.

The need is growing. The Baby Boomers are the largest generation in history. They will live longer in retirement than any generation in history.

But – financially – many are not prepared. Many have virtually no retirement savings: more than a third those within ten years of retirement age have saved less than $10,000. $10,000 invested and spent over the average person’s retirement works out to about $1,000 of income per year. Even with Social Security, that’s not much to live on.

Fears about retirement are the #1 economic concern. Many Marylanders know they’re unprepared – and they’re worried about it. Concerns about retirement security are now more broadly based than the cost of health care, fear of job loss or other economic concerns – and have been for over a decade.3 Those concerns have grown since the financial crisis, even though the stock market has recovered. Many know they’ll have to defer retirement—and many fear they will never be able to afford to retire at all.

The key to retirement saving is having a retirement plan and contributing to it every paycheck. But many businesses, including most smaller businesses, don’t offer retirement plans. As a result 1,000,000 Marylanders working in private businesses across the State don’t have a retirement plan. There are, of course, individual retirement accounts (IRAs) -- but almost no one uses them who didn’t get access through an employer-based plan via payroll deduction.

Having a plan is essential, but not a panacea. Even when plans are available, many employees don’t join. Many who do contribute and save less than they need to meet their own goals. Even with plans, many will need to save more.

The challenge continues at retirement, because most of these plans are paid out in a single lump sum payment—few plans offer reliable retirement income for life that traditional pensions do. Since most retirees do not consult financial advisors and are not financial experts themselves, some who live longer than average or are unlucky in their investments will find that they haven’t saved enough and will exhaust their savings.

They will, of course, have Social Security. That’s why it’s so important that Social Security be both preserved and strengthened. But the average monthly benefit in Maryland is about $1,300 and for most people Social Security covers only a fraction of their basic needs in retirement. Most Marylanders will need additional income from retirement savings – and the State of Maryland can help them get it.

Other states and other governments are making it easier for people to save and for private employers to help them do it. Maryland should, too. Acting now will save Maryland taxpayers millions in the future.

California, Massachusetts, and Illinois have already enacted legislation. Illinois created a new program that requires employers who have no retirement plan to automatically enroll their employees in a state-created program. Massachusetts authorized a program for uncovered employees of non-profits. California created a board to plan and propose program similar to that in Illinois. Similar legislation is being or has been introduced in some fifteen other states – states all across the country with varying political orientations, populations, and economic bases.

Although there are many variations under consideration, these programs generally provide for an automatic payroll deduction of a set amount unless the employee opts out. Funds are to be invested professionally and may be pooled to achieve higher returns and lower costs. Those who cannot or do not want to make complex financial decisions are not required to do so – their contributions are placed automatically into a reliable fund or set of funds.

In order to ensure that employers – many of whom are small businesses – can participate in a program, it must be designed to help them avoid significant disruption, expense or administrative burden. This can be accomplished by enabling employers to use current payroll processes to help their employees to build retirement security, without requiring employers to make contributions themselves.

If Maryland doesn’t act now, Maryland taxpayers will face higher costs for decades to come.

These plans are designed to be self-sustaining: their operating costs are paid for by plan contributions and the State would not assume any obligations. In practice, however, these plans will end up saving taxpayer funds: If Maryland doesn’t act now, Maryland taxpayers will face higher costs for decades to come, as retirees are forced to turn to State assistance instead of living on their own savings.

There are many ways to improve retirement security. The key is for businesses to help their employees save, without becoming overburdened themselves.

Task Force is not recommending any one approach, but strongly recommends that Maryland join other states, by developing and implementing a plan that helps Marylanders have more secure retirements.We recommend development of a specific state-based program that meets Maryland’s needs from the options discussed in our report.

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• Download the full report

       

When a new drug is approved in the United States, it is virtually impossible to know all of the risks that a population may encounter when using that product. Even though the U.S. Food and Drug Administration (FDA) requires drug manufacturers to meet rigorous standards demonstrating the drug’s safety and effectiveness for its intended use, once approved, drugs can be used by many more patients than were studied in clinical trials. This may include patients with unique clinical conditions, differing health status, ethnicity, age, or other characteristics which were not well-represented before the drug’s approval. Further, the drugs themselves can be used in different ways and in different settings than were studied. Until recently, FDA did not have the necessary tools and data access to rapidly and consistently track the risks of serious side effects of regulated drugs after approval. Recognizing this challenge, FDA has developed a pilot system to make the best use of available electronic health data using a new data and research network capable of evaluating the safety of medical products in the U.S. 

Authorized by the Food and Drug Administration Amendments Act (FDAAA) of 2007, this pilot is known as Mini-Sentinel, and is part of FDA’s larger Sentinel Initiative. Sentinel was envisioned as a national electronic system to track the safety of regulated medical products, through the use of existing health insurance claims and electronic clinical data that are generated as part of routine care. In the four years since its inception, Mini-Sentinel has made tremendous progress toward developing this system. Mini-Sentinel is comprised of insurance claims and clinical data from 18 participating data-partners, including some of the largest private health plans in the United States. In order to best protect patient privacy, the data from each partner is maintained behind each individual health plan fire-wall. This “distributed data” approach allows a single coordinating center to distribute FDA safety questions in the form of “queries,” to each of the participating data partners to be run against their own data. Aggregated summary results are then sent back to the coordinating center for final analysis. This process allows FDA to access data that can help in addressing safety questions in near real-time.  

Through Mini-Sentinel, FDA has the capability to better understand the safety outcomes using electronic health care data of approximately 169 million covered lives. This accumulation of data represents the capture of 382 million person-years of observation time and billions of prescription dispensings.[1] Examples of the types of safety questions that have already been addressed by Mini-Sentinel include the following:

• Safety concerns with drugs used to treat high blood pressure and the incidence of angioedema;
• Safety concerns with a new diabetes treatment and the incidence of heart attacks; and
• Impact of FDA regulatory actions (i.e. drug label changes) intended to mitigate serious risks of drugs.

The Mini-Sentinel pilot has demonstrated substantial progress and has proven to be a very useful tool for FDA, largely due to the strong partnerships developed between FDA, collaborating academic institutions, and private health plans. However, in order to ensure continued progress and long-term sustainability, it will be critical for progress to continue in several key areas. 

First, continued methods development and data understanding will be necessary to ensure FDA has access to the most innovative tools. The field of pharmacoepidemiology and drug safety surveillance is still young and the continued development of better study designs and analytic tools to quantify risks of serious adverse events, while accounting for many confounding factors that are inherent on observational data, will be critical. Further, as health reforms impact that way health care is delivered and financed (e.g., development of accountable care organizations and increased use of bundled payments), the electronic health data will change. It will be important to focus efforts on understanding how these changes will impact data used for safety evaluations. 

Second, it is clear that Sentinel’s contributions may extend well beyond FDA’s medical product assessments. The tools and infrastructure that have been developed by FDA over the last four years could be used as a platform to establish a national resource for a more evidence-based learning health care system. This system will enable a better understanding of not only the risks, but also benefits and best uses, of drugs in the post-market settings. 

FDA has initiated steps to ensure the long-term sustainability and impact of Sentinel infrastructure and tools. Within the next few years, FDA has proposed that Sentinel be transitioned into three main components: the Sentinel Operations Center, the Nation Resource Data Infrastructure, and the Methodological Resource for Medical Product Surveillance using Electronic Healthcare Databases. FDA has indicated that while the Sentinel Operations Center will continue to serve as FDA’s portal to the distributed database, the Nation Resource Data Infrastructure could potentially be used by other groups to support broader evidence generation. Potential groups with interest in improving our understanding of the impact of medical products and who could benefit from this framework include the National Institutes of Health, the Regan-Udall Foundation, the Patient Centered Outcomes Research Institute, and other possible stakeholder groups, such as the private industry. 

Collectively, these components will ensure that FDA continues to have the tools to engage in medical product surveillance, while ensuring the long-term sustainability of the system. In just four years, the Sentinel Initiative has laid the groundwork to transform how FDA, and the nation, benefits from electronic health care data. This network continues to foster a community of stakeholders committed the evidence generation, which will ultimately contribute to a learning health care system.

For more information on these issues, including discussion by leaders from Sentinel stakeholders, please visit the Sentinel Initiative Public Workshop event page. There you will find archived video, presentations, and further reading.

Video

• New Advances in Medical Records Reflects the Realities of the U.S. Healthcare System

       

       

November's U.S. Bureau of Labor Statistics (BLS) employment report showed continued improvement in the job market, with employers adding 211,000 workers to their payrolls and hourly pay edging up compared with its level a year ago. The pace of job growth was similar to that over the past year and somewhat slower than the pace in 2014. For the 69^th consecutive month, private-sector payrolls increased. Since the economic recovery began in the third quarter of 2009, all the nation’s employment gains have occurred as a result of expansion in private-sector payrolls. Government employment has shrunk by more than half a million workers, or about 2.5 percent. In the past twelve months, however, public payrolls edged up by 93,000.

The good news on employment gains in November was sweetened by revised estimates of job gains in the previous two months. Revisions added 8,000 to estimated job growth in September and 27,000 to job gains in October. The BLS now estimates that payrolls increased 298,000 in October, a big rebound compared with the more modest gains in August and September, when payrolls grew an average of about 150,000 a month.

Average hourly pay in November was 2.3 percent higher than its level 12 months earlier. This is a slightly faster rate of improvement compared with the gains we saw between 2010 and 2014. A tighter job market may mean that employers are now facing modestly higher pressure to boost employee compensation. The exceptionally low level of consumer price inflation means that the slow rate of nominal wage growth translates into a healthy rate of real wage improvement. The latest BLS numbers show that real weekly and hourly earnings in October were 2.4 percent above their levels one year earlier. Not only have employers added more than 2.6 million workers to their payrolls over the past year, the purchasing power of workers' earnings have been boosted by the slightly faster pace of wage gain and falling prices for oil and other commodities.

The BLS household survey also shows robust job gains last month. Employment rose 244,000 in November, following a jump of 320,000 in October. More than 270,000 adults entered the labor force in November, so the number of unemployed increased slightly, leaving the unemployment rate unchanged at 5.0 percent. In view of the low level of the jobless rate, the median duration of unemployment spells remains surprisingly long, 10.8 weeks. Between 1967 and the onset of the Great Recession, the median duration of unemployment was 10.8 weeks or higher in just seven months. Since the middle of the Great Recession, the median duration of unemployment has been 10.8 weeks or longer for 82 consecutive months. The reason, of course, is that many of the unemployed have been looking for work for a long time. More than one-quarter of the unemployed—slightly more than two million job seekers—have been jobless for at least 6 months.  That number has been dropping for more than five years, but remains high relative to our experience before the Great Recession.

If there is bad news in the latest employment report, it's the sluggish response of labor force participation to a brighter job picture. The participation rate of Americans 16 and older edged up 0.1 point in November but still remains 3.5 percentage points below its level before the Great Recession. About half the decline can be explained by an aging adult population, but a sizeable part of the decline remains unexplained. The participation rate of men and women between 25 and 54 years old is now 80.8 percent, exactly the same level it was a year ago but 2.2 points lower than it was before the Great Recession. Despite the fact that real wages are higher and job finding is now easier than was the case earlier in the recovery, the prime-age labor force participation rate remains stuck well below its level before the recession. How strong must the recovery be before prime-age adults are induced to come back into the work force? Even though the recovery is now 6 and a half years old, we still do not know.