Led by presidential candidate Bernie Sanders, one-time supporters of ‘single-payer’ health reform are rekindling their romance with a health reform idea that was, is, and will remain a dream.  Single-payer health reform is a dream because, as the old joke goes, ‘you can’t get there from here.

Let’s be clear: opposing a proposal only because one believes it cannot be passed is usually a dodge.One should judge the merits. Strong leaders prove their skill by persuading people to embrace their visions. But single-payer is different. It is radical in a way that no legislation has ever been in the United States.

Not so, you may be thinking. Remember such transformative laws as the Social Security Act, Medicare, the Homestead Act, and the Interstate Highway Act. And, yes, remember the Affordable Care Act. Those and many other inspired legislative acts seemed revolutionary enough at the time. But none really was. None overturned entrenched and valued contractual and legislative arrangements. None reshuffled trillions—or in less inflated days, billions—of dollars devoted to the same general purpose as the new legislation. All either extended services previously available to only a few, or created wholly new arrangements.

To understand the difference between those past achievements and the idea of replacing current health insurance arrangements with a single-payer system, compare the Affordable Care Act with Sanders’ single-payer proposal.

Criticized by some for alleged radicalism, the ACA is actually stunningly incremental. Most of the ACA’s expanded coverage comes through extension of Medicaid, an existing public program that serves more than 60 million people. The rest comes through purchase of private insurance in “exchanges,” which embody the conservative ideal of a market that promotes competition among private venders, or through regulations that extended the ability of adult offspring to remain covered under parental plans. The ACA minimally altered insurance coverage for the 170 million people covered through employment-based health insurance. The ACA added a few small benefits to Medicare but left it otherwise untouched. It left unaltered the tax breaks that support group insurance coverage for most working age Americans and their families. It also left alone the military health programs serving 14 million people. Private nonprofit and for-profit hospitals, other vendors, and privately employed professionals continue to deliver most care.

In contrast, Senator Sanders’ plan, like the earlier proposal sponsored by Representative John Conyers (D-Michigan) which Sanders co-sponsored, would scrap all of those arrangements. Instead, people would simply go to the medical care provider of their choice and bills would be paid from a national trust fund. That sounds simple and attractive, but it raises vexatious questions.

• How much would it cost the federal government? Where would the money to cover the costs come from?
• What would happen to the $700 billion that employers now spend on health insurance?
• How would the $600 billion a year reductions in total health spending that Sanders says his plan would generate come from?
• What would happen to special facilities for veterans and families of members of the armed services?

Sanders has answers for some of these questions, but not for others. Both the answers and non-answers show why single payer is unlike past major social legislation.

The answer to the question of how much single payer would cost the federal government is simple: $4.1 trillion a year, or $1.4 trillion more than the federal government now spends on programs that the Sanders plan would replace. The money would come from new taxes. Half the added revenue would come from doubling the payroll tax that employers now pay for Social Security. This tax approximates what employers now collectively spend on health insurance for their employees...if they provide health insurance. But many don’t. Some employers would face large tax increases. Others would reap windfall gains.

The cost question is particularly knotty, as Sanders assumes a 20 percent cut in spending averaged over ten years, even as roughly 30 million currently uninsured people would gain coverage. Those savings, even if actually realized, would start slowly, which means cuts of 30 percent or more by Year 10. Where would they come from? Savings from reduced red-tape associated with individual insurance would cover a small fraction of this target. The major source would have to be fewer services or reduced prices. Who would determine which of the services physicians regard as desirable -- and patients have come to expect -- are no longer ‘needed’? How would those be achieved without massive bankruptcies among hospitals, as columnist Ezra Klein has suggested, and would follow such spending cuts? What would be the reaction to the prospect of drastic cuts in salaries of health care personnel – would we have a shortage of doctors and nurses? Would patients tolerate a reduction in services? If people thought that services under the Sanders plan were inadequate, would they be allowed to ‘top up’ with private insurance? If so, what happens to simplicity? If not, why not?

Let me be clear: we know that high quality health care can be delivered at much lower cost than is the U.S. norm. We know because other countries do it. In fact, some of them have plans not unlike the one Senator Sanders is proposing. We know that single-payer mechanisms work in some countries. But those systems evolved over decades, based on gradual and incremental change from what existed before. That is the way that public policy is made in democracies. Radical change may occur after a catastrophic economic collapse or a major war. But in normal times, democracies do not tolerate radical discontinuity. If you doubt me, consider the tumult precipitated by the really quite conservative Affordable Care Act.

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

Tomorrow, President Obama unveils his last budget, and we’re sure to see plenty of proposals for spending on education and skills. In the past, the Administration has focused on investments in early childhood education, community colleges, and infrastructure and research. From a budgetary standpoint, the problem with these investments is how to capture their benefits as well as their costs.

First step: find out what works. The Obama Administration has been emphatic about the need for solid evidence in deciding what to fund. The good news is that we now have quite a lot of it, showing that investing in human capital from early education through college can make a difference. Not all programs are successful, of course, and we are still learning what works and what doesn’t. But we know enough to conclude that investing in a variety of health, education, and mobility programs can positively affect education, employment, and earnings in adulthood.

For example:

1. Young, low-income children whose families move to better neighborhoods using housing vouchers see a 31 percent increase in earnings;

2. Quality early childhood and school reform programs can raise lifetime income per child by an average of about $200,000, for at an upfront cost of about $20,000;

3. Boosting college completion rates, for instance via the Accelerated Study in Associate Programs (ASAP) in the City University of New York, leads to higher earnings.

If such estimates are correct (and we recognize there are uncertainties), policymakers are probably underinvesting in such programs because they are looking at the short-term costs but not at longer-term benefits and budget savings.

First, the CBO’s standard practice is to use a 10-year budget window, which means long-range effects are often ignored. Second, although the CBO does try to take into account behavioral responses, such as increased take-up rates of a program, or improved productivity and earnings, it often lacks the research needed to make such estimates. Third, the usual assumption is that the rate of return on public investments in human capital is less than that for private investment. This is now questionable, especially given low interest rates.

A hot topic in budget politics right now is so-called “dynamic scoring.” This means incorporating macroeconomic effects, such as an increase in the labor force or productivity gains, into cost estimates. In 2015, the House adopted a rule requiring such scoring, when practicable, for major legislation. But appropriations bills are excluded, and quantitative analyses are restricted to the existing 10-year budget window.

The interest in dynamic scoring is currently strongest among politicians pushing major tax bills, on the grounds that tax cuts could boost growth. But the principles behind dynamic scoring apply equally to improvements in productivity that could result from proposals to subsidize college education, for example—as proposed by both Senator Sanders and Secretary Clinton. Of course, it is tough to estimate the value of these potential benefits. But it is worth asking whether current budget rules lead to myopia in our assessments of what such investments might accomplish, and thus to an over-statement of their “true” cost.

Employment among lower-income men has declined by 11 percent since 1980 and has remained flat among lower-income women. Men and women in the top and middle of the income distribution, on the other hand, have been working as much or more since 1980, creating a growing “work gap” in labor market income between haves and have-nots.   

This paper simulates the effect of five labor market interventions (higher high school graduation rate, minimum wage increases, maintaining full employment, seeing all household heads work full time, and virtual marriages between single mothers and unattached men) on the average incomes of the poorest one-third of American households. They find that the most effective way to increase average incomes of the poorest Americans would be for household heads to work full time, whereas the least effective intervention would be increasing education.

In terms of actual impact on incomes, the simulation of all household heads working full time at their expected wage increased average household earnings by 54 percent from a baseline of $12,415 to $19,163. The research also suggests that even if all household heads worked just some—at expected wages or hours—average earnings would still increase by 16 percent.

The least effective simulation was increasing the high school graduation rate to 90 percent and having half of those “newly” graduated go on to receive some form of post-secondary education. The authors note that the low impact of increasing education on mobility is likely because only one in six of bottom-third adults live in a household in which someone gains a high school degree via the intervention.

Because single parents are disproportionately represented among low-income families, Sawhill and coauthors also explored the impact of adding a second earner to single-parent families through a simulation that pairs low-income, single-mother household heads with demographically similar but unrelated men. That simulation increased the average household earnings of the bottom-third only modestly, by $508, or about 4 percent.

Efforts to increase employment among heads of the poorest households must take into consideration why those household heads aren’t working, they note. According to data from the 2015 Census, the most cited reason for women not working is “taking care of home and family” and for men it is being “ill or disabled.”  

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On April 2, 2011, Ethiopia embarked upon the construction of what is expected to be the biggest hydroelectric power plant in Africa.  Called the Grand Ethiopian Renaissance Dam (GERD), it will be located on the Blue Nile, 40 kilometers (25 miles) from the border with the Republic of Sudan and will have the capacity to produce 6,000 megawatts of electricity.  The GERD, once completed and made operational, is expected to ameliorate chronic domestic energy shortages, help the country’s households (especially those located in the rural areas) switch to cleaner forms of energy and allow the government to earn foreign exchange through the exportation of electricity to other countries in the region.  Although authorities in Addis Ababa believe that the dam will contribute  significantly to economic growth and development—not just in Ethiopia, but also in neighboring countries, such as Sudan—its construction has been very controversial.  The major controversies revolve around Ethiopia’s decision to fund the building of the dam from its own sources and the potential impacts of the dam on downstream countries, especially Egypt.  

Ethiopia opted to source funds for the construction of the GERD through selling bonds to citizens at home and abroad.  Government employees have been encouraged to devote as much as one or two months of their salaries to the purchasing of the GERD bonds.  Most public workers in Ethiopia earn relatively low wages and face a significantly high cost of living.  Hence, they are not likely to be able to sacrifice that much of their salaries to invest in this national project.  Nevertheless, many of them have been observed purchasing the GERD bonds, primarily because of pressure from the government and the belief that participation in this national project is a show of one’s patriotism.

The government of Ethiopia has also encouraged the private sector to invest in the GERD project.  Specifically, private domestic banks and other business enterprises are expected to purchase millions of Birr worth of these bonds.  The government also hopes that Ethiopians in the diaspora will contribute significantly to this massive effort to develop the country’s hydroelectric power resources.  However, many Ethiopians in the diaspora have not been willing to invest in the GERD project, citing pervasive corruption in the public sector and dictatorial government policies as reasons why they would not commit the resources necessary to move the project forward.  Additionally, Ethiopians living outside the country have argued that the present government in Addis Ababa continues to impede the country’s transition to democracy by making it virtually impossible for opposition parties to operate, using draconian laws (e.g., anti-terrorism laws) to silence legitimate protests and generally denying citizens the right to express themselves.  For these reasons, many of them have refused to invest in the GERD project.  Finally, Ethiopia’s traditional development partners, including such international organizations as the World Bank and the International Monetary Fund, appear to be unwilling to lend the country the necessary funds for the construction of the dam given the controversies surrounding the dam and their policies on the building of megadams.

Egypt has registered its opposition to the construction of the GERD.  In fact, before he was ousted, former Egyptian president Mohamed Morsi made it known to authorities in Addis Ababa that Egypt would not support the project.  The Egyptians, as they have done before, have invoked the Anglo-Egyptian Treaty of 1929, which granted Egypt veto power over all construction projects on the Nile River and its tributaries.  According to Cairo, then, Ethiopia was supposed to obtain permission from Egypt before embarking on the GERD project.

In May 2010, five upstream riparian states (Ethiopia, Kenya, Uganda, Rwanda and Tanzania) signed the Nile Basin Cooperative Framework Agreement (CFA), which, they argue, would provide the mechanism for the equitable and fair use of Nile River waters.  On June 13, 2013, the Ethiopian Parliament ratified the CFA and incorporated it into domestic law.  The other four signatories have not yet ratified the treaty but plan to do so eventually.  Egypt and Sudan, however, have refused to sign the CFA and continue to argue that the 1929 Anglo-Egyptian Treaty, as well as the 1959 bilateral agreement between Egypt and Sudan, represent the only legal mechanisms for Nile River governance.  Recently, however, the government of Sudan has indicated its support for the GERD, and South Sudan, which gained its independence from Khartoum on July 9, 2011, does not oppose the project either.

Significant increases in population in Egypt, the need for the country to expand its irrigated agricultural base, as well as other industrial needs have significantly increased the country’s demand for water.  Unfortunately for Egyptians, the only viable source of water in the country is the Nile River.  Thus, Egyptians, as made clear by their leaders, are not willing to relinquish even one drop of water.  The country’s bitter opposition to the GERD stems from the fact that it will reduce the flow of water into the Nile River and force Egyptians to live with less water than now.  Egyptian leaders are not willing to accept the assertion made by the Ethiopian government that the construction of the dam will not significantly reduce the flow of water from the Blue Nile into Egypt.  Thus, Cairo has hinted that it would employ all means available to stop the construction of the GERD.

The site of the GERD was identified during geological surveys conducted between 1956 and 1964 by the United States Bureau of Reclamation.  Although studies determining the feasibility of a dam on the Blue Nile were completed almost half a century ago, previous Ethiopian governments did not make any attempt to build such a structure on the Blue Nile.  This inaction may have been due to Egypt’s ability to lobby the international donor community and prevent it from providing Addis Ababa with the necessary financial resources to complete the project, Ethiopia’s chronic internal political instability, or Egypt’s military strength and its strong ties with neighboring Sudan (the latter shares the same interests as Egypt regarding the waters of the Nile River).  In fact, the 1929 Anglo-Egyptian Treaty and the 1959 bilateral agreement between Sudan and Egypt granted both countries complete control of all the waters of the Nile River.

Since the ouster of Hosni Mubarak, Egypt has been weakened significantly, politically, economically and militarily.  The struggle between the military and civil society for control of the government has been a major distraction to the Egyptian military, and it is unlikely that it can effectively face a relatively strong and more assertive Ethiopian military.  Hence, it appears that this might be the most opportune time for Ethiopia to initiate such a construction project.  Perhaps more important is the fact that virtually all of the upstream riparian states are no longer willing to allow both Egypt and Sudan to continue to monopolize the waters of the Nile River.  In addition, Ethiopia is relatively at peace and maintains good relations with its neighbors, particularly the Republic of Sudan, which would be critical in any successful attack on Ethiopia by Egypt.  Of course, Addis Ababa has also invoked and relied on the Cooperative Framework Agreement which, besides Ethiopia, has been signed by four other upstream riparian States—the CFA favors the equitable and fair use of the waters of the Nile River.  Authorities in Addis Ababa believe that the GERD will contribute to such fair and equitable use; after all, the Blue Nile (which is located in Ethiopia) provides 86 percent of the water that flows into the Nile River.  Up to this point, Ethiopia has made virtually no use of that water, allowing Egypt and Sudan alone to dictate its usage.

Critics of the GERD, including some Ethiopians within and outside the country, argue that Addis Ababa initiated the building of the dam just to divert public attention away from internal political tensions associated with lack of religious freedom, human rights violations, suppression of the press, and the economic and political polarization that has become pervasive throughout the country during the last several decades. 

Given the economic significance of the Blue Nile for the source country (Ethiopia) and downstream countries (Egypt and Sudan), it is critical that these countries engage in constructive dialogue to find a mutually beneficial solution for the project.  Such negotiations should take into consideration the fact that the status quo, characterized by Egyptian monopolization of the waters of the Nile River and the exclusion of Ethiopia from exploiting its own water resources for its development, cannot be maintained.  Thus, the construction of the GERD should be taken as a given and the three countries—Egypt, Sudan and Ethiopia—should find ways to maximize the benefits of the dam and minimize its negative impacts on the downstream countries.  As part of that negotiation, both Egypt and Sudan should abandon their opposition to the CFA, sign it and encourage their legislatures to ratify it.  The Nile River and its tributaries should be considered common property belonging to all Nile River Basin communities and should be managed from that perspective.

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The recent outbreak of hostilities between Israel and Hamas is a serious setback to ongoing Turkish-Israeli normalization efforts. Israel launched Operation Protective Edge, its third operation against Hamas since leaving Gaza in 2005, in response to rockets and missiles fired by Hamas from Gaza into Israel. As in Israel’s two previous Gaza campaigns, Operation Cast Lead (2008-09) and Operation Pillar of Defense (2012), Turkey quickly condemned Israel’s actions, yet offered to mediate, together with Qatar, between Israel and Hamas.

After Turkish Prime Minister Recep Tayyip Erdogan, in the midst of his presidential campaign, equated Israeli policy towards Gaza to a “systematic genocide” and accused Israel of surpassing “Hitler in barbarism,” Israel accepted an Egyptian cease-fire proposal. Israeli Foreign Minister Avigdor Lieberman accused Turkey and Qatar of “sabotaging the cease-fire proposal,” and Israeli Prime Minister Benjamin Netanyahu complained to U.S. Secretary of State John Kerry about Erdogan’s statements.

Turkish leaders’ harsh rhetoric sparked violent demonstrations in front of Israel’s embassy in Ankara and its consulate in Istanbul, lead the Israeli government to evacuate diplomats’ families, and issue a travel warning advising against travel to Turkey, which prompted numerous cancellations of tourist travel. On Sunday, Netanyahu refrained from declaring Turkish-Israeli reconciliation dead, but accused Erdogan of anti-Semitism more aligned with Tehran then the West.

These heightened Israeli-Turkish tensions come just as the two countries were negotiating a compensation deal for families of victims of the May 31, 2010 Mavi Marmara incident. The deal was intended to facilitate a long-awaited normalization between the two countries, more than a year after Israel’s official apology. The draft stipulated an estimated $21 million in Israeli compensation, the reinstatement of each country’s ambassador, and the reestablishment of a senior-level bilateral dialogue. However, a series of issues has prevented the deal’s finalization, including: Turkish domestic political considerations about the timing (related to March 2014 municipal elections and August 2014 presidential elections) and Israeli demands for Turkish commitments to block future lawsuits related to the Marmara incident.

With the ongoing Gaza conflict, prospects for normalization have again faded at least in the short term, and policymakers on both sides seem to have accepted a limited relationship. Erdogan even declared publicly that as long as he’s in power, there is no chance “to have any positive engagement with Israel”, dismissing any prospect for normalization. Israeli-Turkish animosity runs deep, not only among leaders, but at the grassroots level as well. While it may be difficult to look beyond the short term, a focus on the broader regional picture suggests four reasons why the two countries would benefit from restoring ties.

• First, they share strategic interests. Turkey and Israel see eye to eye on many issues: preventing a nuclear Iran; concerns over spillover from the Syrian civil war; and finally, the rise of the Islamic State of Iraq and the Levant (ISIS/ISIL) and security and stability in Iraq. A resumed dialogue and renewed intelligence sharing can pave the way for more concrete cooperation between Turkey and Israel on all these regional issues, with development of a joint approach toward Syria topping the agenda.
• Second, regional environment may be beyond their control, the bilateral relationship is not. Normalization can eliminate one factor of instability in an unstable region.
• Third, Washington sees greater cooperation and cohesiveness in the U.S.-Turkey-Israel triangle as essential. President Obama has sought to restore a dialogue between Ankara and Jerusalem, including efforts to “extract” an Israeli apology and Turkish acceptance. Senior U.S. officials remain active in trying to improve the Turkish-Israeli relationship.
• Fourth, normalization may convey benefits in the economic sphere, with possible cooperation on natural gas, tourism, and enhanced trade. Gas in particular is viewed as a possible game-changer. In 2013, bilateral trade first crossed the $5 billion mark, and data from the first six months of 2014 indicates a continued rise. A political thaw can help accelerate these joint business opportunities. 

Nevertheless, at this stage it is clear that serious U.S. involvement is required for Turkish-Israeli rapprochement to succeed, even in a limited fashion. At present, there are far greater challenges for U.S. foreign policy in the region. The question now is whether the relationship between two of America’s closest regional allies reflects a new “normal,” or whether the leaders of both countries – and the U.S. – can also muster the political will to reconnect the US-Turkey-Israel triangle along more productive lines.

Check back to Brookings.edu for Dan Arbell’s upcoming analysis paper: The U.S.-Turkey-Israel Triangle.