As the biological basis of more diseases are fully revealed, and the drugs targeting medical problems become more focused and effective, more patients are finding themselves on costlier specialty medicines. At the same time, consumers find themselves paying a growing portion of their drug bills out of pocket as the structure of insurance changes. These two developments have combined to result in significant consumer hardship.

In response to these trends, there has been political pressure to enact policies giving federal and state governments authority to set drug prices or limit price increases. However, these policies could have the unintended consequence of reducing the incentive to develop more effective drugs.

In Europe, government price-setting authorities systematically overpay for some older, less innovative drugs while reducing the prices of and access to newer, more significant breakthroughs. Many worry that enacting a similar policy in the United States would reduce the profitability of new, innovative research endeavors.

We believe that certain regulatory reforms can address these concerns and encourage more robust competition within the drug market. These policies would allow prices to more easily adjust to reflect how medicines are prescribed and the outcomes they deliver, and thus would help control rising spending and reduce the burden of drug costs for consumers. One way to make drug pricing more competitive is to implement selling models that tie the price of drugs more closely to the usefulness of the clinical setting in which they are being prescribed. However, existing regulations obstruct this type of market-oriented approach.

Pricing Based On Indication And Outcomes

The Centers for Medicare and Medicaid Services (CMS) recently announced that as early as 2017, it plans to pursue changes in the way Medicare pays for injectable drugs under its Part B program to give drug makers more flexibility to price products based on indications and outcomes. Yet the Medicare program left open how the relative value of different indications would be determined. Would drug makers be free to vary prices based on clinical demand and the benefits being offered in different clinical settings? Or as the rule suggests, will CMS try to influence these conclusions with an assessment of clinical value?

CMS’ proposed rule also does not address several challenges associated with a value-based pricing framework. For example, the proposal did not address the small molecule drugs that are the focus of much of the price scrutiny, only injectable drugs paid for as part of the medical benefit. Moreover, enabling such a framework for value-based pricing would require simultaneous regulatory reforms at the Food and Drug Administration (FDA), as well as the Office of the Inspector General. Because the impediments to this sort of policy effort cut across multiple agencies, it will likely require a legislative remedy to fully enable.

Inside CMS, enabling drug makers to adjust prices based on the purpose for which medicines are being prescribed will require changes to the existing rules that govern drug pricing. For example, federal regulators will need to relax the way that they implement current price-setting constructs like the calculation for Medicaid best price, the ceiling price for the 340B program, and the reporting rules for Medicare’s Part B average sales price. These rules complicate the ability of companies to price the same drug differently, based on how it’s being prescribed, or to enter into “value-based’ contracts that tie drug prices and discounts to measures of how a population of patients benefit from a given treatment.

Take, for example, the Medicaid Best Price rules. Best price is the lowest manufacturer price paid for a drug by any purchaser. It’s defined by the Medicaid statute as “any wholesaler, retailer, provider, health maintenance organization, or nonprofit or government entity” with some exceptions (Note 1). In short, it’s the cheapest price at which a drug is sold. A drug’s reported best price is required to reflect all discounts, rebates, and other pricing adjustments. It’s the benchmark that the government uses to make sure that state Medicaid programs are receiving the lowest price for which a drug is being offered to any purchaser.

Under these rules, if a drug maker enters into a contract with a private health plan to discount a drug based on how it’s being used (or the clinical results that it achieves) then the discount that’s offered when the drug is used in settings that are judged to yield less value would become the new benchmark for calculating the Medicaid best price. The rebates offered to a private insurer under the terms of just one value-based contract would establish the new price offered to all Medicaid programs, regardless of whether or not the Medicaid plans were also entering into similar contracting arrangements. So Medicaid plans that did not contract to pay higher prices when drugs were used in certain higher value settings, and lower prices when they were prescribed for lower value indications, would nonetheless pay a price for all of their prescriptions that reflected the lowest price offered under a value-based arrangement. This new Medicaid price could, in turn, influence other price schedules.

Consider a drug maker that offered a 90 percent discount on a drug when it didn’t produce any of its expected benefit. Under current rules, that deeply discounted price would become the new Medicaid best price, but not necessarily the blended price that reflects the average price being paid under a contract where the price fluctuated based on how a drug was being prescribed. This could create a significant disincentive for manufacturers to offering indication and outcome-based prices. For these reasons, enabling drug makers to adjust prices based on these parameters will require changes to rules on how drug makers must track and report prices to the government under Medicaid and to the 340B drug program.

Similar challenges to value-based pricing are posed by Medicare’s calculation of average sales price (ASP) as part of its framework for reimbursing injectable drugs paid under Part B. The ASP is defined as a manufacturer’s sales of a drug to all U.S. purchasers in a calendar quarter divided by the total number of units of the drug sold by the manufacturer in that same quarter (Note 2). The ASP is net of any price concessions, such as volume discounts, prompt pay discounts, cash discounts, free goods contingent on purchase requirements, chargebacks, and rebates other than those obtained through the Medicaid drug rebate program.

Manufacturers that offer discounts under commercial, value-based contracts would probably face reductions in their calculated ASP as a result of the concessions. In turn, they would see their reimbursement under Medicare Part B also decline, regardless of whether Medicare entered into the same outcome or indication-based contracts. Since the private market pegs its own pricing off of the ASP, a single value-based contract that served to lower the ASP could have the effect of reducing a drug maker’s reimbursement across every other contract. For drug manufacturers, this is another disincentive to entering into these arrangements.

Moreover, without significant regulatory changes, it is unlikely that Medicare would participate in a value-based system due to both legal and practical limitations. In the past, CMS has avoided these contracting arrangements when sponsors have approached the agency with such proposals. Even if CMS asserts the legal authority to enter into such arrangements, it is unclear whether the agency has the informational capacity to implement them. Managing a value-based system would require careful tracking of how and when drugs are prescribed, and collecting information to measure outcomes. Currently, CMS probably lacks the capacity to carry out this level of measurement and analysis. So for now, it will mostly be left to private payers to pursue value-based arrangements.

Reducing Regulatory Barriers

To reduce obstacles to value-based pricing, new regulations would need to be issued to clarify how drug makers, insurance plans, and health systems can rationalize value-based and indication-based contracts with their price reporting calculations. Medicare probably has the requisite authority to do so under constructs created by the Affordable Care Act. Additionally, Congress could provide clear authority and direction through legislation addressing these policy opportunities.

The Medicare and Medicaid programs could exempt value-based contracts that meet certain criteria from the requirement that the resulting prices, and the discounts, be used toward calculating Medicaid best price. CMS recently signaled that it had the existing authority to address some of these issues through a pilot program designed under the Center for Medicare and Medicaid Innovation (CMMI). Such a program could enable commercial health plans to adapt their reporting obligations to test how value-based and indication-based contracts would impact overall spending and outcomes. While the proposed regulation lays out Medicare’s general intent to pursue these strategies, it does not outline the parameters needed in order to go forward.

Some of the regulatory discretion that is required to change drug-pricing systems may be outside of the Medicare agency’s direct control. For example, the Office of the Inspector General (OIG) would have to change its interpretation of anti-kickback rules to enable drug makers to provide discounts based on the clinical indications for which drugs are prescribed, as well as the outcomes they deliver. Otherwise, under the OIG’s existing interpretation of its authority, these arrangements could be perceived as inducements to prescribing.

Fostering outcomes-based and indication-based pricing will also require FDA to adapt some of its existing rules and practices. Currently, drug makers are largely prevented from offering price concessions based on how a drug is used unless all of the prescribing options are listed precisely and completely on the drug’s label. When a drug maker secures approval for a new medicine, what appears on its drug label forms the basis for any outcomes-based contracts with health plans or Pharmacy Benefit Managers (PBMs), even if it would make more sense to contract for drugs based on measuring outcomes for which the drug is not explicitly approved. So far, FDA’s sometimes-purposeful ambiguity over the scope of its authority in these areas of commercial speech creates enough legal risk to discourage these sorts of business interactions.

In order to enable these arrangements, FDA would have to concede that commercial, contract-related communications constitute protected speech under the First Amendment and thus are not subject to the agency’s active regulation. At the least, FDA could stipulate that it does not forfeit its authority to regulate these and similar forms of commercial communication, but as a matter of policy will exercise enforcement discretion when it comes to value-based contracts and their negotiation. Better still, Congress can more firmly establish the same safe harbors in legislation, rather than leaving it up to FDA to stipulate these important legal principles in non-binding guidance or regulation.

Another impediment to contracting based on outcomes measurement is uncertainty over the FDA’s regulation of pre-approval communication. FDA prohibits pre-approval communication, but has not specified whether these restrictions extend to discussions between drug makers and drug purchasers that are conducted as part of contracting discussions prior to a drug’s launch. Pre-market commercial discussions are an important part of the ability to negotiate these complex, value-based contracts, as the contracts would need to be put into place at the time of approval. Because targeted pre-approval conversations between manufacturers and health plans are not inherently promotional, FDA as a matter of policy should not seek to regulate them.

Absent these collective regulatory impediments, drug makers and those who pay for medicines could have more ability and incentive to engage in price negotiations based on the indication for which a medicine is being prescribed by providers and the variable outcomes that it delivers to patients. In the absence of reforms to make drug pricing more competitive, the political alternative may well be regulated pricing. This approach would end up skewing investment because it would inevitably allocate capital based on political priorities rather than scientific priorities and clinical goals.

The discussion over drug prices is driven by a fair degree of politics, but the debate arose because of secular changes in the political economy of health care, and increasing costs to consumers. These challenges need to be addressed with constructive measures that foster access to and competitive pricing of medicines, while preserving market-based rewards for innovation, and the efficient allocation of capital to these efforts.

Note 1: Exceptions to the best price include prices that are charged to certain federal purchasers (sales made through federal supply schedule, single award contract prices of any federal agency, federal depot prices, and prices charged to the Department of Defense, Department of Veterans Affairs, Indian Health Service, and the Public Health Service), eligible state pharmaceutical assistance programs, and state-run nursing homes.

Note 2: Section 1847A(c) of the Social Security Act (the Act), as added by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), P.L. No. 108-173, defines an ASP as a manufacturer’s sales of a drug to all purchasers in the United States in a calendar quarter divided by the total number of units of the drug sold by the manufacturer in that same quarter.

Editor's Note: Both authors consult with and invest in life science and healthcare services companies.

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

As the nation still struggles with high healthcare costs that consume larger and larger portions of patient budgets as well as government coffers, the search for ways to get costs under control continues. Total healthcare spending in the U.S. now represents almost 18 percent of our entire economy. One promising cost-savings approach is called “reference pricing,” where the insurer establishes a price ceiling on selected services (joint replacement, colonoscopy, lab tests, etc.). Often, this price cap is based on the average of the negotiated prices for providers in its network, and anything above the reference price has to be covered by the insured consumer.

A study published in JAMA Internal Medicine by James Robinson and colleagues analyzed grocery store Safeway’s experience with reference pricing for laboratory services such as such as a lipid panel, comprehensive metabolic panel or prostate-specific antigen test. Safeway’s non-union employees were given information on prices at all laboratories through a mobile digital platform and told what Safeway would cover. Patients who chose a lab charging above the payment limit were required to pay the full difference themselves.

Employers see this type of program as a way to incentivize employees to think through the price of services when making healthcare decisions. Employees enjoy savings when they switch to a provider whose negotiated price is below the reference price, whereas if they choose services above it, they are responsible for the additional cost.

Robinson’s results show substantial savings to both Safeway and to its covered employees from reference pricing. Compared to trends in prices paid by insurance enrollees not subject to the caps of reference pricing, costs paid per test went down almost 32 percent, with a total savings over three years of $2.57 million – patients saved $1.05 million in out-of-pocket costs and Safeway saved $1.7 million.

I wrote an accompanying editorial in JAMA Internal Medicine focusing on different types of consumer-driven approaches to obtain lower prices; I argue that approaches that make the job simpler for consumers are likely to be even more successful. There is some work involved for patients to make reference pricing work, and many may have little awareness of price differences across laboratories, especially differences between those in some physicians’ offices, which tend to be more expensive but also more convenient, and in large commercial laboratories. Safeway helped steer their employees with accessible information: they provided employees with a smartphone app to compare lab prices.

But high-deductible plans like Safeway’s that provide extensive price information to consumers often have only limited impact because of the complexity of shopping for each service involved in a course of treatment -- something close to impossible for inpatient care. In addition, high deductibles are typically met for most hospitalizations (which tend to be the very expensive), so those consumers are less incentivized to comparison shop.

Plans that have limited provider networks relieve the consumer of much complexity and steer them towards providers with lower costs. Rather than review extensive price information, the consumer can focus on whether the provider is in the network. Reference pricing is another approach that simplifies—is the price less than the reference price? What was striking about Robinson’s results is that reference pricing for laboratories was employed in a high-deductible plan, showing that the savings achieved—in excess of 30 percent compared to a control—were beyond what the high deductible had accomplished.

While promising, reference pricing cannot be applied to all medical services: it works best for standardized services and where variation in quality is less of a concern. It also can be applied only to services that are “shoppable,” which is only about one-third of privately-insured spending. Even if reference pricing expanded to a number of other medical services, other cost containment approaches, including other network strategies, are needed to successfully contain health spending and lower costs for non-shoppable medical services.

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

Gasoline purchases are an essential part of the American way of life. There were about 250 million motor vehicles in the United States in 2008 – just under a vehicle per person. Americans drive an average of more than 11,000 miles per year and gasoline purchases are an essential part of most households’ budgets. Between 1995 and 2003, gasoline prices in the U.S. averaged about $1.49 a gallon, with average prices rising above $2.00 in 2004. By the summer of 2008, gasoline prices had reached a national average of $4.11 per gallon. At that time, Americans earning less than $15,000 a year were spending as much as 15 percent of their household income on gasoline – double the proportion from seven years earlier. In addition, unpredictable fuel costs make planning monthly household expenditures difficult, which can be detrimental to individual welfare and even to the overall economy.

Gasoline prices fell in the aftermath of the 2009 economic crisis. Prior and during the financial crisis, rising gasoline prices were seen as a symptom of an uncertain economic situation, as well as evidence of the questionable sustainability of our future oil supply. Gasoline prices abated along with the decrease of economic activity that accompanied the onset of the recession, reaching their minimum in late December 2008. A few months later, as the economy entered a gradual recovery phase, gasoline prices also trended upward. In contrast to the previous period of great uncertainty about future oil supplies, however, these price trends were considered more positively as signs of the U.S. economic recovery.

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ABSTRACT

Of the many regulatory responses to climate change, cap-and-trade is the only one currently endorsed by large segments of the scientific, economic and political establishments. Under this type of system, regulators set the overall path of carbon dioxide (CO2) reductions, allocate or auction the appropriate number of emissions allowances to regulated entities and – through trading – allow the market to converge upon the least expensive set of abatement opportunities. As a result, the trading price of allowances is not set by the regulator as it would be under a tax system, but instead evolves over time to reflect the underlying supply and demand for allowances. In this paper, I develop a simple theory that relates the initial clearing price of CO2 allowances to the marginal cost premium of carbon-free technology, the maximum rate of energy capital replacement and the market interest rate. This theory suggests that the initial clearing price may be lower than the canonical range of CO2 prices found in static technology assessments. Consequently, these results have broad implications for the design of a comprehensive regulatory solution to the climate problem, providing, for example, some intuition about the proper value of a possible CO2 price trigger in a future cap-and-trade system.

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It is no secret that American elections are getting wildly expensive. If you are unlucky enough to live in a swing state or a state with a competitive race for US House, US Senate or Governor, you know that every even numbered year means frequent phone calls, a barrage of campaign mail, and endless television ads. Candidates want your vote, and sometimes it seems their strategy is to annoy the average voter into turning out to the polls.

However, beyond direct candidate appeals, outside groups are now spending heavily on competitive races of all types. Many statewide campaigns now cost tens of millions of dollars, and interest groups, PACs, and other organizations are ponying up with substantial sums to try to reach voters and do one of two things. They either try to convince you one candidate deserves your vote or dissuade you from voting for the other candidate.

How much money is flowing into races beyond what candidates themselves spend? The answer is staggering. Below we profile the 20 most expensive Senate races since 2010 in terms of independent expenditures. The chart shows not only how expensive races are, but the extent to which outside groups seek to influence electoral outcomes.  

This chart shows that races are getting more expensive. Among these races, only two (Colorado and Pennsylvania) are from 2010. Half (10) of the races are being waged this cycle, and even though data are updated through Sunday, the totals are certain to rise. Those ten races alone have totaled over $435 million in spending in those states.

The totals provide a small picture into the magnitude of money in American politics. The totals exclude direct candidate spending and spending by other, outside groups not subject to as rigorous FEC disclosure requirements.

As campaigns continue to become more expensive and outside groups see participation in elections as a path toward influencing outcomes of both races and policy, there is one political certainty: over the next two to four years, many of the campaigns on this list will be displaced by future, more expensive campaigns for the Senate.

The recent fall in world oil prices undoubtedly has an impact on the politics of the Middle East, where many states rely heavily on oil to fund their governments and to float their economies more generally. One can cite serious domestic and regional disruptions that have followed severe oil price declines in the recent past. Will the current period of dropping prices result in domestic upheaval and regional war? Is the price drop part of a Saudi power play against its regional rivals?

Read Sultans of Swing? The Geopolitics of Falling Oil Prices

In this Policy Briefing, F. Gregory Gause, III answers the above questions by analyzing the regional impact of previous declines in the price of oil. He argues that Saudi Arabia is merely continuing its policy of only considering production cuts to arrest falling prices if other producers join them. Gause also finds that, despite memorable exceptions, oil-dependent regimes are actually more stable than their non-oil counterparts, including during periods of lower prices.

In considering the Middle East, Gause identifies a pattern of the region’s oil producers negotiating agreements on production cuts, rather than coming to blows, when faced with low prices. He stresses that if Iran, and perhaps Russia, approach Saudi Arabia about negotiating an oil deal, the United States should encourage such talks, and be ready to expand them to include the largest strategic picture of the Middle East.

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Editors' Note: U.S.-Israeli relations have taken a hit in recent years as the United States has become increasingly frustrated with the Netanyahu government's lack of initiative on advancing a peace process with the Palestinians. Tamara Wittes examines the domestic Israeli and American trends poised to further strain relations if the countries' leaders do not address these challenges head on. This article originally appeared in Haaretz on December 3, 2015—before the annual Saban Forum.

The past year brought unprecedented tensions in the U.S.-Israeli relationship, with many arguments and counterarguments about who is to blame. Beyond the tactical debates—about personality clashes, or the propriety of Israel parachuting into arguments between Congress and the U.S. president—are deeper challenges facing these two close allies. Last weekend, the Center for Middle East Policy at Brookings convened the Saban Forum in Washington to address these issues and to understand the future trajectory of the U.S.-Israeli relationship.

The first question that needs to be asked is why a bilateral relationship that for so long was kept above politics has now become a subject of bitter partisanship—in Israel, as well as in the United States. How did distasteful personal rhetoric become politically acceptable in a relationship that used to be carefully protected? Why did politicians lose their self-restraint about using the U.S.-Israel relationship as a wedge issue against their opponents? Why were opponents of the Iran nuclear deal, in Israel and in the United States, prepared to drag the American Jewish community and Democratic friends of Israel into the fray and force them to choose between supporting Israel and supporting their president?

Some argue that these trends result from differing levels of public support for Israel among Democratic and Republican voters. Polls show that Democratic voters are less supportive of the current Israeli government’s policies than Republican voters. If voters in the United States are splitting on partisan lines, the theory goes, then their elected representatives should follow. But polls that ask simplistic questions produce crude results.

A more detailed survey by my colleague Shibley Telhami shows us something deeper: the lenses Americans use to evaluate Israel’s conflict with the Palestinians have changed over time. Today, Americans increasingly look at the Israeli-Palestinian conflict through the lens of human rights—and this is especially true for younger Americans, African Americans and Hispanic Americans. This makes them sensitive to the suffering of Palestinian civilians, and to heavy handed Israeli counter-terrorism policies. These groups form a larger proportion of the voting public than they have in past, and a growing proportion of the Democratic Party’s core constituency. Likewise, American Evangelical Christians look at Israel through a lens of prophetic fulfillment, which combined with their conservative political preferences puts them squarely on the side of more hawkish Israeli policies. And Evangelicals are a core constituency for the Republican Party. These underlying changes in attitudes have shifted the calculus for American politicians. But that doesn’t mean a partisan split on “support for Israel” is inevitable. It does point to specific aspects of Israeli policy that affect how Israel is viewed. As American society becomes “majority-minority,” where no group, including Americans of European origin, constitutes a majority of the population, Israelis should keep these underlying lenses in mind.

[T]he lenses Americans use to evaluate Israel’s conflict with the Palestinians have changed over time.

A second issue to examine is Israelis’ combination of vulnerability and national pride. Even in a post-9/11 era, Americans have a hard time appreciating the sense of vulnerability and fear that Israelis face from ongoing terrorism and rocket fire. The Gaza War last year brought this vulnerability into sharp focus—the war went on longer than any in Israel’s history other than War of Independence, and the rocket threat affected most of the country’s civilian population. The large numbers of Palestinians killed and wounded led some in America to question Israeli tactics.  U.S.-Israeli cooperation on Iron Dome produced impressive results and was trumpeted in the American media—but when you are walking outside and an air raid siren goes off, your faith in Iron Dome does not erase your sharp sense of fear.

Israelis’ sense of vulnerability is compounded by the asymmetric nature of the threats Israel is facing, and by the sense among many Israelis that their effort to reach a resolution of their conflict with the Palestinians has reached a dead end. The fear of another war and a sense that the neighborhood has turned deeply hostile, weigh heavily, in a way Americans have trouble understanding. Israelis become all the more anxious when they sense that their most important international ally might not see their security threats the same way they do.

Paradoxically, though, this sense of vulnerability coexists for Israelis with a sense of greater self-confidence about Israel’s military strength, its economic dynamism, and its wider relationships with the world. Particularly on the Israeli political right, there is today a stronger strain of nationalism and national pride (as evidenced in the “No Apologies” slogan of the Jewish Home Party in the last elections). In many countries around the world, including U.S. allies, the rise of right-wing nationalism is marked in part by politicians thumbing their nose at the global superpower: the United States. Israel, it appears, is no longer an exception to that rule.

Israelis become all the more anxious when they sense that their most important international ally might not see their security threats the same way they do.

These issues—Americans’ perceptions of Israeli policy toward the Palestinians, and Israelis’ combination of fear and self-confidence—go beyond the personalities of leaders or the choices of politicians. To bridge these gaps, the U.S.-Israel dialogue must reach beyond government meetings and Israel-Diaspora engagement— instead, Israelis and Americans must commit to understanding one another’s societies better than we do today.

Finally, and unavoidably, there is a policy problem driving U.S.-Israeli tensions—but it’s not what you might think. The Israeli and American governments are both struggling to deal with the disintegration of a twenty-year-old framework for settling the Israeli-Palestinian conflict. After the Oslo Declaration was signed in September, 1993, Americans, Israelis and Palestinians shared an approach to settling the conflict: direct bilateral negotiations mediated by the United States. But after the failure of the Kerry talks last spring, the two leaders in Jerusalem and Ramallah have no inclination to return to direct bilateral talks, and each of them in their own way emerged from the latest effort with questions about the role of the United States.

In the international community and the region, meanwhile, the loss of faith in the U.S.-led bilateral process has led to experiments with other modes of shaping the conflict, from economic pressure on Israel to new proposals for action by the UN Security Council. Netanyahu’s controversial words before Election Day last spring— that there would be no Palestinian state under his watch—were less of a unilateral declaration than a recognition of reality. The White House now more-or-less agrees, with Obama aides telling reporters that they did not expect peace on Obama’s watch. The longstanding, bilateral negotiating process was Washington’s main leverage in pushing back against other international efforts—and now that the negotiating process has ended, these efforts will inevitably escalate. Without U.S.-Israeli agreement on a way forward, further policy gaps are likely.

The Israeli and American governments are both struggling to deal with the disintegration of a twenty-year-old framework for settling the Israeli-Palestinian conflict.

This begs a question many American officials and analysts are asking: If there is no prospect for renewed bilateral talks toward a two-state solution, what is Israel’s Plan B? Does the Israeli government have a clear vision for its future relationship with the Palestinians? Israel expects American understanding as it takes steps it deems necessary to protect its citizens and ensure their future security. But American patience with Israel’s control over the West Bank is predicated on that control being temporary. There is impatience in Washington that Israel’s leadership has not tried to articulate a path forward beyond the immediate crisis—indeed, my colleague Natan Sachs argues that the current Israeli leadership has embraced “anti-solutionism” as a strategy. That's a very difficult position for any American administration to support.

If their modern history is any guide, Israelis will not remain passive before the forces now reshaping the Middle East; instead, they will insist on charting their own path into the future. When Israelis finally do develop a clear view of their chosen road, their first stop to explain it and seek support will inevitably be Washington. But Washington may not wait forever—especially as the stalemate is generating sustained violence. The time is now to lay the foundations for that crucial policy discussion, by updating American and Israeli understandings of one another’s dynamic societies, and by building on the Saban Forum and similar platforms to enrich our bilateral dialogue.