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" »

Downloads

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

INTRODUCTION

Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts.

National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being.

There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike.

The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts). Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts. However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits.

Downloads

• malaria africa caprara

This keynote presentation by Bruce Katz at City Hall in Seattle describes how a vibrant center city stimulates a region's economy. The presentation also assesses how Seattle is faring on this front and what steps the city should take as it looks to the future.

The metro program hosts and participates in a variety of public forums. To view a complete list of these events, please visit the metro program's Speeches and Events page which provides copies of major speeches, powerpoint presentations, event transcripts, and event summaries.

Downloads

• Download

INTRODUCTION

Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts.

National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being.

There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike.

The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts). Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts. However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits.

Downloads

• malaria africa caprara

One in five tax filers in the United States claims the Earned Income Tax Credit—a refundable federal tax credit targeted to low-income working Americans that has proven to be one of the nation’s most effective anti-poverty policies. Last year, at tax time the average EITC filer claimed just over $2,400 through the credit.

However, the share of filers claiming the EITC and the level of benefits they receive vary widely within and across communities, as shown by the local-level IRS data we post each year on our EITC Interactive data tool. For instance, almost one in three filers in the Memphis metro area claimed the credit (32 percent) in tax year 2013 compared to just 12 percent of filers in metro Boston. Local labor market conditions can affect these numbers, like the incidence and concentration of low-wage jobs or regional differences in cost of living and average wage levels. But the credit itself is also designed to vary across different kinds of filers and families. Maximum credit levels for workers without children are quite small, but they increase considerably for workers with one, two, or three children—boosting the credit’s work incentive and anti-poverty impacts.

For the first time, our EITC Interactive tool now includes data on how EITC receipt varies by the number of children claimed.

According to that data, last tax year workers without qualifying children received an average credit of $281 (Figure 1). Although they made up almost one in four EITC filers, childless workers accounted for just 3 percent of EITC dollars claimed, due to the small size of their credit (Figure 2). In contrast, workers with one child—the largest share of EITC filers (37 percent)—claimed an average credit of $2,316. Workers with two kids accounted for 27 percent of EITC filers, but with an average credit of $3,682 they took home 40 percent of all EITC dollars. Working families with three or more children made up the smallest share of EITC filers last tax year, but claimed the largest credit on average at $4,036.

These data, which are available down to the ZIP code level, offer insights into the ways in which the makeup of the EITC population (and the low-wage workforce more generally) varies across places. Returning to the Memphis and Boston regions, each metro area received more than half a billion dollars through the EITC last year ($517 and $512 million, respectively). However, the number of filers claiming the EITC was much larger in metro Boston (256,456) than in the Memphis metro area (178,241). In part, these numbers reflect the fact that 30 percent of metro Boston’s EITC filers were childless workers. In the Memphis metro area, just 15 percent of EITC filers did not have qualifying children, while 41 percent had one child, 31 percent had two children, and 12 percent had three or more children—higher than Boston’s share of EITC filers with children across the board (37 percent had one child, 24 percent had two children, and 9 percent had three or more children).

For EITC outreach campaigns working to ensure eligible filers claim the EITC at tax time, and for practitioners looking to use tax time to connect low-income workers to financial services and benefits, these numbers give a sense of who lives in their community and how to target their services. For advocates and policymakers, these numbers help shed light on how potential changes to the credit might affect different places.

For instance, the Obama administration, several legislators, and at least one presidential candidate have proposed expanding the EITC for workers without qualifying children to make it a more effective poverty alleviation and work support tool. Every congressional district in the country has childless workers or noncustodial parents who would stand to benefit from that expansion. But that expansion would be particularly important for the more than 240 districts—largely clustered on the coasts and roughly split between Republican and Democratic representatives—with above average shares of childless EITC filers (Map 1).

In contrast, if Congress does not act to make recent expansions to the credit permanent, every district will see a cut in EITC benefits in 2017, when the credit for workers with three or more children is set to disappear. In particular, more than 200 districts with above average shares of EITC filers with three or more kids—this time predominantly Republican districts clustered in the Intermountain West, parts of the Great Plains, and along the Texas border—would be most affected (Map 2). 

In the coming weeks, we will be delving deeper into the impact of proposed and potential changes to the EITC and releasing new resources on the EITC-eligible population and the credit’s anti-poverty impact. In the meantime, these new EITC Interactive data offer an important resource that can help practitioners, policymakers, advocates, and researchers better understand how the EITC affects low-income workers and families and their communities across the country.

Event Information

Under the Food and Drug Administration Amendments Act (FDAAA) of 2007, the FDA has the authority to require pharmaceutical manufacturers to develop Risk Evaluation and Mitigation Strategies (REMS) for drugs or biologics that carry serious potential or known risks. Since that time, the REMS program has become an important tool in ensuring that riskier drugs are used safely, and it has allowed FDA to facilitate access to a host of drugs that may not otherwise have been approved. However, concerns have arisen regarding the effects of REMS programs on patient access to products, as well as the undue burden that the requirements place on the health care system. In response to these concerns, FDA has initiated reform efforts aimed at improving the standardization, assessment, and integration of REMS within the health care system. As part of this broader initiative, the agency is pursuing four priority projects, one of which focuses on improving provider-patient benefit-risk counseling for drugs that have a REMS attached.

Under a cooperative agreement with FDA, the Center for Health Policy at Brookings held an expert workshop on July 24 titled, “Risk Evaluation and Mitigation Strategies (REMS): Building a Framework for Effective Patient Counseling on Medication Risks and Benefits”. This workshop was the first in a series of convening activities that will seek input from stakeholders across academia, industry, health systems, and patient advocacy groups, among others. Through these activities, Brookings and FDA will further develop and refine an evidence-based framework of best practices and principles that can be used to inform the development and effective use of REMS tools and processes.

Event Materials

• REMS_PBRC_Meeting_Agenda
• REMS BR Speaker Bios
• REMS BenefitRisk Meeting Summary
• REMS BenefitRisk communication white paper

Editor’s Note: The following is a transcript of the House of Representatives’ Special Select Committee hearing on the Benghazi scandal, taking place in a parallel universe not very far away. It is satire, obviously, but perhaps only because of an almost random quirk of fate.

Representative Trey Gowdy: I would like to call this hearing to order. We are gathered today to get to the bottom of the horrific events of March 18 to 25, 2011, when over 100,000 inhabitants of Benghazi were cruelly killed in the worst act of genocide since Rwanda. Libya has since descended into a catastrophic civil war on a par with Syria, and yet Colonel Gadhafi is still in power. Worse, the situation has exacerbated extremism and threatens to spur Islamic terrorism throughout the region. The recent intervention of Russian forces in the Libyan civil war ensures that any chance the United States had of ending Gadhafi’s cruel tyranny has been missed. 

This was the greatest moral and strategic failure of U.S. foreign policy in 20 years. And yet there has been little or no accountability. Former U.N. Ambassador Susan Rice was even promoted to Secretary of State, while former National Security Council staffer Samantha Power stepped down, apparently in quiet protest at the president and Secretary Hillary Clinton’s weak and morally vacuous policy. Ms. Power's new sequel "A Problem From Hell" has now been made into the Oscar-winning movie "Hotel Benghazi." This scandal, this moral failing is now seared into the conscience of our nation.

This Special Select Committee was stood up 18 months ago and has been working diligently since that day to build on the work of multiple other congressional inquiries to get at the truth of this national shame. We know that the Obama administration had intelligence about the risk of genocide in Benghazi but it decided not to act. Indeed, the entire world knew. The questions we want answered are: What did the administration know about the approaching genocide? And when did it know it? 

We are joined by former Secretary of State Hillary Clinton. Madam Secretary, we appreciate you taking time off from the campaign trail. I understand you have a short statement. 

Secretary Hillary Clinton: Thank you, Representative Gowdy. This is my fourth time appearing before the U.S. Congress on this issue; 37 members of my staff and family have appeared, and my dog is currently fighting a subpoena. So I will keep this brief.

While we deeply regret the Benghazi genocide, we must remember that we had incomplete information about Colonel Gadhafi's intentions. We were faced with a difficult choice: Should we intervene to stop an uncertain atrocity, committing U.S. troops to an uncertain mission with no exit plan and no vital national interest? Or should we try to shape events without the use of U.S. forces, using the many other tools at our disposal? 

We decided that U.S. military intervention was not prudent. We were worried about a failed state and losing U.S. personnel on the ground. The administration instead sought to mobilize the international community to prevent any genocide and ultimately to bring Gadhafi and his henchmen to justice at the International Criminal Court. 

We continued throughout my tenure as secretary of state—and until this day—to work to bring the civil war to an end and to help the moderate Libyan opposition to overthrow the regime. 

We made some tough calls and we must acknowledge that we were not always right. Knowing what we know now, I wish that we had acted more forcefully. Indeed, I was personally in favor of a no-fly zone to protect Libyan civilians. But hindsight is twenty-twenty and the president decided to stay out. 

Representative Gowdy: Madam Secretary, with all due respect, Gadhafi's intention was quite clear. Just days before the slaughter he said, and I quote: “All of these germs, rats and scumbags, they are not Libyans.” He told them "It's over…We are coming tonight…We will find you in your closets, ” adding: “We will show no mercy.” U.S. NGOs on the ground provided detailed information of troop movements. What more evidence did you need of imminent war crime? Why did you not act? Isn’t the role of the secretary of state to persuade the president? 

If something went wrong, I would be the first to say war is unpredictable and involves risk. I am confident the Congress would have fully supported you.

Secretary Clinton: Congressman, with all due respect, Congress at the time steadfastly opposed our intervention. Had we acted and had the aftermath been messy—as we fully expected—I have no doubt that you would be calling me here to account for that, noting that our own assessments showed we had no capacity to bring stability to Libya. What if we had lost U.S. military personnel or diplomats? What if a U.S. overthrow of the Gadhafi regime merely led to more and different chaos and violence, as we saw in Iraq?

Representative Gowdy: Madam Secretary, the greater shame is clearly inaction in the face of a moral imperative. I can assure you, and I feel confident I speak for all of my colleagues, that had you acted, we would have had your back, come what may. If something went wrong, I would be the first to say war is unpredictable and involves risk. I am confident the Congress would have fully supported you. 

Secretary Clinton: Thank you Congressman, but you will excuse me if I still have some doubts on that score. I guess we’ll never know. 

On Thursday, when former Secretary of State Hillary Rodham Clinton appears before the Senate Benghazi Committee for a new round of hearings, reporters with vivid historical imaginations will be pining for an epic battle. Melodramatic journalists may recall the 1950-1951 Kefauver Committee investigating organized crime, which introduced politicized television dramas to millions of Americans. They may evoke the 1954 Army-McCarthy hearings, when the aristocratic Boston lawyer Joseph Welch cold-cocked the anti-communist Senator Joe McCarthy by asking: “Have you no sense of decency, sir, at long last? Have you left no sense of decency?” They will yearn for the constitutional grandeur of the 1973 Senate Watergate hearings, which exposed Richard Nixon’s corruption. Alas, most likely, we will endure yet another round of the 1990s’ tawdry Clinton follies, which diminished both parties and helped trigger our current political depression.

Although Hillary Clinton often performs well under pressure and probably has rehearsed a dramatic soundbite or two to rile her partisan base, these hearings are bad news for her campaign. The email server scandal has gotten more traction than the Clintonites would have expected. It stirs fears that both Hillary and Bill Clinton are so convinced of their own goodness, their own idealism, their own contributions to the public good, that they exempt themselves from the rules ordinary Americans must follow. The scandal also reminds many of the Clintons’ moral blindspot, their ethical sloppiness that led them into the cozy, overlapping, ambiguities, and occasional lies behind the Whitewater mess, the Travelgate coverup, the Paula Jones sexual harassment, the Monica Lewinsky obstruction of justice, and a host of lesser Clinton catastrophes.

Many Americans had Clinton fatigue by 2000, despite Clinton’s record high approval ratings. And with our Canadian neighbors just having voted in Justin Trudeau due to Stephen Harper fatigue, Hillary Clinton should remember that American voters want a fresh start after enduring a decade and a half of terrorist fears and economic woes, preceded by a scadal-plagued, hyper-partisan period of peace and prosperity in the 1990s.

Democrats also should worry that Hillary Clinton’s best defense is pretty offensive. She will play the partisan card. In the final question of the Democratic debate, Anderson Cooper asked “Which enemy are you most proud of?” Hillary Clinton answered: “Well, in addition to the NRA, the health insurance companies, the drug companies, the Iranians. Probably the Republicans.” In his presidential announcement-esque I’m-not-running speech Vice President Joe Biden pointedly said: “I don’t think we should look at Republicans as our enemies.” How does a candidate who compares Republicans to Iranians woo centrist voters in crucial swing states? And you can imagine the general campaign commercials asking: How does a president who demonizes her rivals work with them after Election Day?

Republicans should not be too cocky about these hearings either. The male senators pounding away at millions of American women’s best chance at a female president should beware the Anita Hill effect. During the 1991 fight over the sexual harassment allegations during Clarence Thomas’s Supreme Court nomination hearings, hostile senators interrogating Thomas’s female accuser looked like bullies who, in the parlance of the time, “just didn’t get it.” For the last six years, the Democrats have cleverly cast the Republicans as the party of no. In the 1990s, the Clintons cleverly cast the Republicans as a party of Ken Starrs, prosecutorial prigs abusing congressional and federal powers to subvert the political process and undermine the Constitution.

Moreover, Hillary Clinton’s defense during the last set of hearings more accurately reflects the public mood. Four brave Americans died. Their Islamist terrorist murderers are the guilty ones, not whatever mistaken spin the Obama administration may or may not have put on it subsequently.

Since the 1990s, gotcha journalism and politics have ruined politicians’ reputations and soured Americans on politics. Unlike the Watergate scandal, which produced heroes defending the Constitution like Judge John Sirica and Senator Sam Ervin, the Clinton scandals, and especially the Monica Lewinsky debacle, tarnished everyone involved. Journalists and Republicans looked like bullies, invading people’s privacy, treating personal indiscretions as high crimes not even misdemeanors. Feminists and Democrats sounded like hypocrites, excusing sexual harassment and the White House as a hostile workplace for women as long as the perpetrator was a pro-choice liberal. The people’s business suffered. In post Watergate America, the Pig-Pen-like cloud shrouding the Clintons, and their supporters’ “everybody does it” defense, had once naïve Americans now cynically grumbling, “they’re all guilty of something.”

Inevitably, after the Thursday hearings, too many Republicans and Democrats will assess the results based on quickie polls suggesting who “won” or “lost” the exchange, and whether Hillary Clinton’s popularity rises or falls. Washington should start tracking a different set of poll results. Back in the 1950s and the 1960s, the vast majority of Americans trusted their government. The most recent Gallup poll has only 19 percent of Americans surveyed agreeing that “you can trust government to do what is right.” Those metrics suggested that both Democrats and Republicans, all the presidential candidates, the president, Congress, and the Supreme Court, have disappointed the American people. A healthy democracy needs citizens with more faith in their government, we don’t need more recriminations, the criminalizing of politics, or more partisan clashes. Perhaps it is time for Senate Republicans to join Democrats in creating a bipartsan committee to investigate that problem, and begin by inviting all presidential candidates to testify about what they will do to make Americans believe in Washington again.

Rooftop solar is booming in U.S. cities.

One of the most exciting infrastructure developments within metropolitan America, the installation of over a million solar photovoltaic (PV) systems in recent years, represents nothing less than a breakthrough for urban sustainability — and the climate.

Prices for solar panels have fallen dramatically. Residential solar installations surged by 66 percent between 2014 and 2015 helping to ensure that solar accounted for 30 percent of all new U.S. electric generating capacity. And for that matter, recent analyses conclude that the cost of residential solar is often comparable to the average price of power on the utility grid, a threshold known as grid parity.

So, what’s not to like? Rooftop solar is a total winner, right?

Well, not quite: The spread of rooftop solar has raised tricky issues for utilities and the public utilities commissions (PUCs) that regulate them. 

Specifically, the proliferation of rooftop solar installations is challenging the traditional utility business model by altering the relationship of household and utility—and not just by reducing electricity sales. In this respect, the solar boom has prompted significant debates in states like New York and California about the best rates and policies to ensure that state utility rules and rates provide a way for distributed solar to flourish even as utilities are rewarded for meeting customer demands. Increasingly, this ferment is leading to thoughtful dialogues aimed at devising new forms of policy and rate design that can—as in New York—encourage distributed energy resources (DERs) while allowing for distribution utilities to adapt to the new era.

However, in some states, the ferment has prompted a cruder set of backlashes. Most pointedly, some utilities contend that the “net-metering” fees paid to homeowners with rooftop installations for excess solar power they send back to the grid unfairly transfer costs to the utilities and their non-solar customers.

And so in a number of states, utility interests have sought to persuade state regulators to roll back net-metering provisions, arguing they are a net cost to the overall electricity system.  Most glaringly, the local utility in Nevada successfully wielded the cost-shift theory last winter to get the Nevada Public Utilities Commission to drastically curtail the state’s net-metering payments, prompting Solar City, Sunrun, and Vivint Solar—the state’s three largest providers of rooftop panels—to leave the Nevada market entirely. The result: New residential solar installation permits plunged 92 percent in Nevada in the first quarter of 2016.

All of which highlights a burning question for the present and future of rooftop solar: Does net metering really represent a net cost shift from solar-owning households to others? Or does it in fact contribute net benefits to the grid, utilities, and other ratepayer groups when all costs and benefits are factored in? As to the answer, it’s getting clearer (even if it’s not unanimous). Net metering — contra the Nevada decision — frequently benefits all ratepayers when all costs and benefits are accounted for, which is a finding state public utility commissions, or PUCs, need to take seriously as the fight over net metering rages in states like Arizona, California, and Nevada.  Regulators everywhere need to put in place processes that fairly consider the full range of benefits (as well as costs) of net metering as well as other policies as they set and update the policies, regulations, and tariffs that will play a critical role in determining the extent to which the distributed solar industry continues to grow.

Fortunately, such cost-benefit analyses have become an important feature of state rate-setting processes and offer important guidance to states like Nevada.  So what does the accumulating national literature on costs and benefits of net metering say?  Increasingly it concludes— whether conducted by PUCs, national labs, or academics — that the economic benefits of net metering actually outweigh the costs and impose no significant cost increase for non-solar customers.  Far from a net cost, net metering is in most cases a net benefit—for the utility and for non-solar rate-payers.

Of course, there are legitimate cost-recovery issues associated with net metering, and they vary from market to market. Moreover, getting to a good rate design, which is essential for both utility revenues and the growth of distributed generation, is undeniably complicated.  If rates go too far in the direction of “volumetric energy charges”—charging customers based on energy use—utilities could have trouble recovering costs when distributed energy sources reach higher levels of penetration. On the other hand, if rates lean more towards fixed charges—not dependent on usage—it may reduce incentives for customers to consider solar and other distributed generation technologies.  

Moreover, cost-benefit assessments can vary due to differences in valuation approach and methodology, leading to inconsistent outcomes. For instance, a Louisiana Public Utility Commission study last year found that that state’s net-metering customers do not pay the full cost of service and are subsidized by other ratepayers. How that squares with other states’ analyses is hard to parse.

Nevertheless, by the end of 2015, regulators in at least 10 states had conducted studies to develop methodologies to value distributed generation and net metering, while other states conducted less formal inquiries, ranging from direct rate design or net-metering policy changes to general education of decisionmakers and the public. And there is a degree of consensus.  What do the commission-sponsored analyses show? A growing number show that net metering benefits all utility customers:

• In 2013 Vermont’s Public Service Department conducted a study that concluded that “net-metered systems do not impose a significant net cost to ratepayers who are not net-metering participants.” The legislatively mandated analysis deemed the policy a successful component of the state’s overall energy strategy that is cost effectively advancing Vermont’s renewable energy goals.

• In 2014 a study commissioned by the Nevada Public Utility Commission itself concluded that net metering provided $36 million in benefits to all NV Energy customers, confirming that solar energy can provide cost savings for both solar and non-solar customers alike. What’s more, solar installations will make fewer costly grid upgrades necessary, leading to additional savings. The study estimated a net benefit of $166 million over the lifetime of solar systems installed through 2016. Furthermore, due to changes to utility incentives and net-metering policies in Nevada starting in 2014, solar customers would not be significantly shifting costs to other ratepayers.

• A 2014 study commissioned by the Mississippi Public Services Commission concluded that the benefits of implementing net metering for solar PV in Mississippi outweigh the costs in all but one scenario. The study found that distributed solar can help avoid significant infrastructure investments, take pressure off the state's oil and gas generation at peak demand times, and lower rates. (However, the study also warned that increased penetrations of distributed solar could lead to lower revenues for utilities and suggested that the state investigate Value of Solar Tariffs, or VOST, and other alternative valuations to calculate the true cost of solar.)

• In 2014 Minnesota’s Public Utility Commission approved a first-ever statewide “value of solar” methodology which affirmed that distributed solar generation is worth more than its retail price and concluded that net metering undervalues rooftop solar. The “value of solar” methodology is designed to capture the societal value of PV-generated electricity. The PUC found that the value of solar was at 14.5 cents per kilowatt hour (kWh)—which was 3 to 3.5 cents more per kilowatt than Xcel's retail rates—when other metrics such as the social cost of carbon, the avoided construction of new power stations, and the displacement of more expensive power sources were factored in.

• Another study commissioned by the Maine Public Utility Commission in 2015 put a value of $0.33 per kWh on energy generated by distributed solar, compared to the average retail price of $0.13 per kWh — the rate at which electricity is sold to residential customers as well as the rate at which distributed solar is compensated. The study concludes that solar power provides a substantial public benefit because it reduces electricity prices due to the displacement of more expensive power sources, reduces air and climate pollution, reduces costs for the electric grid system, reduces the need to build more power plants to meet peak demand, stabilizes prices, and promotes energy security. These avoided costs represent a net benefit for non-solar ratepayers.

These generally positive PUC conclusions about the benefits of net metering have been supported by research done by a national lab and several think tanks. Important lab research has examined how substantially higher adoption of distributed resources might look.

In a forward-looking analysis of the financial impacts of net-metered energy on utilities and ratepayers, Lawrence Berkeley National Lab found that while high use of net-metered solar generation may decrease utility shareholders' earnings, it will have a "relatively modest" impact on ratepayers. The report examined solar penetration levels that are "substantially higher than [those that] exist today" — 10 percent compared to today's 0.2 percent — and concluded that “even at penetration levels significantly higher than today, the impacts of customer-sited PV on average retail rates may be relatively modest." The report further said that utilities and regulators "may have sufficient time to address concerns about the rate impacts of PV in a measured and deliberate manner"

Similarly, a growing number of academic and think tank studies have found that solar energy is being undervalued and that it delivers benefits far beyond what solar customers are receiving in net-metering credits:

• For instance, a review of 11 net metering studies by Environment America Research and Policy Center has found that distributed solar offers net benefits to the entire electric grid through reduced capital investment costs, avoided energy costs, and reduced environmental compliance costs. Eight of the 11 studies found the value of solar energy to be higher than the average local residential retail electricity rate: The median value of solar power across all 11 studies was nearly 17 cents per unit, compared to the nation’s average retail electricity rate of about 12 cents per unit.

• A 2015 cost-benefit study of net metering in Missouri by the Missouri Energy Initiative found that even accounting for increased utility administrative costs and the shifting of some fixed expenses, net metering is a net benefit for all customers regardless of whether they have rooftop solar. The study used values for two kinds of costs and two benefits and concluded that net metering’s “net effect” is positive. The typical solar owner pays only 20 percent less in fixed grid costs and costs the utility an estimated $187 per interconnection. Meanwhile, solar owners benefit the system through reduced emissions and energy costs.

• Likewise, a study by Acadia Center found the value of solar to exceed 22 cents per kWh of value for Massachusetts ratepayers through reduced energy and infrastructure costs, lower fuel prices, and lowering the cost of compliance with the Commonwealth's greenhouse gas requirements. This value was estimated to exceed the retail rate provided through net metering.

• In yet another study, researchers at the University at Albany, George Washington University, and Clean Power Research have found that solar installations in New York deliver between 15 and 40 cents per kWh to ratepayers. The study noted that these numbers provide economic justification for the existence of incentives that transfer value from those who benefit from solar electric generation to those who invest in solar electric generation.

In short, while the conclusions vary, a significant body of cost-benefit research conducted by PUCs, consultants, and research organizations provides substantial evidence that net metering is more often than not a net benefit to the grid and all ratepayers.

As to the takeaways, they are quite clear: Regulators and utilities need to engage in a broader and more honest conversation about how to integrate distributed-generation technologies into the grid nationwide, with an eye toward instituting a fair utility-cost recovery strategy that does not pose significant challenges to solar adoption.

From the state PUCs’ perspective, until broad changes are made to the increasingly outdated and ineffective standard utility business model, which is built largely around selling increasing amounts of electricity, net-metering policies should be viewed as an important tool for encouraging the integration of renewable energy into states’ energy portfolios as part of the transition beyond fossil fuels. To that end, progressive regulators should explore and implement reforms that arrive at more beneficial and equitable rate designs that do not prevent solar expansion in their states. The following reforms range from the simplest to the hardest:

• Adopt a rigorous and transparent methodology for identifying, assessing, and quantifying the full range of benefits and costs of distributed generation technologies. While it is not always possible to quantify or assess sources of benefits and costs comprehensively, PUCs must ensure that all cost-benefit studies explicitly decide how to account for each source of value and state which ones are included and which are not. Currently methodological differences in evaluating the full value of distributed generation technologies make comparisons challenging. States start from different sets of questions and assumptions and use different data. For instance, while there is consensus on the basic approach to energy value estimation (avoided energy and energy losses via the transmission and distribution system), differences arise in calculating other costs and benefits, especially unmonetized values such as financial risks, environmental benefits, and social values. In this regard, the Interstate Renewable Energy Council’s “A Regulator’s Guidebook: Calculating the Benefits and Costs of Distributed Solar Generation” and the National Renewable Energy Laboratory’s “Methods for Analyzing the Benefits and Costs of Distributed Photovoltaic Generation to the U.S. Electric Utility System” represent helpful resources for identifying norms in the selection of categories, definitions, and  methodologies to measure various benefits and costs.

• Undertake and implement a rigorous, transparent, and precise “value of solar” analytic and rate-setting approach that would compensate rooftop solar customers based on the benefit that they provide to the grid. Seen as an alternative to ‘traditional’ net-metering rate design, a “value of solar” approach would credit solar owners for (1) avoiding the purchase of energy from other, polluting sources; (2) avoiding the need to build additional power plant capacity to meet peak energy needs; (3) providing energy for decades at a fixed prices; and (4) reducing wear and tear on the electric grid. While calculating the “value of solar” is very complex and highly location-dependent, ultimately PUCs may want to head toward an approach that accurately reflects all benefits and costs from all energy sources. Value of solar tariffs are being used in Austin, Texas (active use) and Minnesota (under development).

• Implement a well-designed decoupling mechanism that will encourage utilities to promote energy efficiency and distributed generation technologies like solar PV, without seeing them as an automatic threat to their revenues. As of January 2016, 15 states have implemented electric decoupling and eight more are considering it. Not surprisingly, it is states that have not decoupled electricity (such as Nevada) that are fighting net metering the hardest. Typically, decoupling has been used as a mechanism to encourage regulated utilities to promote energy efficiency for their customers. However, it can also be used as a tool to incentivize net metering by breaking the link between utility profits and utility sales and encouraging maximum solar penetration. Advocates of decoupling note that it is even more effective when paired with time-of-use pricing and minimum monthly billing.

• Move towards a rate design structure that can meet the needs of a distributed resource future. A sizable disconnect is opening between the rapidly evolving new world of distributed energy technologies and an old world of electricity pricing. In this new world, bundled, block, “volumetric” pricing—the most common rate structure for both residential and small commercial customers—can no longer meet the needs of all stakeholders. The changing grid calls, instead, for new rate structures that respond better to the deployment of new grid technologies and the proliferation of myriad distributed energy resources, whether solar, geothermal, or other.  A more sophisticated rate design structure, in this regard, would take into consideration three things: (1) the unbundling of rates to specifically price energy, capacity, ancillary services,  and so on; (2) moving from volumetric bloc rates to pricing structures that recognize the  variable time-based value of electricity generation and consumption (moving beyond just peak versus off-peak pricing to  fully real-time pricing); and (3) moving from pricing that treats all customers equally to a pricing structure that more accurately compensates for unique, location-specific and technology specific values.

• Move towards a performance-based utility rate-making model for the modern era. Performance based regulation (PBR) is a different way of structuring utility regulation designed to align a utility’s financial success with its ability to deliver what customers and society want. Moving to a model that pays the utility based on whether it achieves quantitatively defined outcomes (like system resilience, affordability, or distributed generation integration) can make it profitable for them to pursue optimal grid solutions to meet those outcomes. The new business model would require the PUC and utilities to make a number of changes, including overhauling the regulatory framework, removing utility incentives for increasing capital assets and kilowatt hours sold, and replacing those incentives with a new set of performance standard metrics such as reliability, safety, and demand-side management. New York’s Reforming the Energy Vision  proceeding is the most high-profile attempt in the country to implement a PBR model.

Options also exist for utilities to address the challenges posed by net metering:

• Utilities, most notably, have the opportunity to adjust their existing business models by themselves owning and operating distributed PV assets (though not to the exclusion of other providers).  On this front, utilities could move to assemble distributed generation systems, such as for rooftop solar, and sell or lease them to homeowners. In this regard, utilities have an advantage over third-party installers currently dominating the residential rooftop solar industry due to their proprietary system knowledge, brand recognition, and an existing relationship with their customers. Utilities in several states such as Arizona, California, and New York are investigating or have already invested in the opportunity.

• Furthermore, utilities can also push the envelope on grid modernization by investing in a more digital and distributed power grid that enables interaction with thousands of distributed energy resources and devices.

Ultimately, distributed solar is here to stay at increasing scale, and so state policies to support it have entered an important new transitional phase. More and more states will now likely move to update their net-metering policies as the cost of solar continues to drop and more homeowners opt to install solar panels on their homes.

As they do that, states need to rigorously and fairly evaluate the costs and benefits posed by net metering, grid fees, and other policies to shape a smart, progressive regulatory system that works for all of the stakeholders touched by distributed solar.

Utilities should have a shot at fair revenues and adequate ratepayers. Solar customers and providers have a right to cost-effective, reliable access to the grid. And the broader public should be able to expect a continued solar power boom in U.S. regions as well as accelerated decarbonization of state economies. All of which matters intensely. As observes the North Carolina Clean Energy Technology Center and Meister Consultants Group: “How key state policies and rates are adapted will play a significant role in determining the extent to which the [solar PV] industry will continue to grow and in what markets.”

INTRODUCTION

Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts.

National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being.

There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike.

The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts). Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts. However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits.

Downloads

• malaria africa caprara