In a lively and wide-ranging debate that aired earlier this month on Al Jazeera English, Brookings Executive Vice President Martin Indyk sparred with Head to Head presenter Mehdi Hasan about American efforts to resolve the Israeli-Palestinian conflict and the United States’ relationship with Israel.

Indyk began by stressing that American support for Israel is what gives the United States an influential role in the peace process and the leverage to encourage Israel to move towards peace. Indyk added that this does not mean that the United States should act as “Israel’s attorney” in the negotiations, and cited a promise he made to Palestinian leaders during the 2013-2014 peace talks led by Secretary of State John Kerry that Washington would not coordinate positions with Israel in advance. 

Brookings Executive Vice President Martin Indyk in a Head to Head interview with Al Jazeera English's Mehdi Hassan.

He pointed out that the United States has traditionally relied on its close relationship with Israel to encourage its leaders to take steps for peace and make offers to the Palestinians, and that no other potential mediator has been able to produce serious offers from Israel. “[The United States is] not neutral, we don't claim to be neutral. We have an alliance with Israel,” Indyk said. “But in order to achieve another interest that we have, which is peace in the region…and a settlement that provides for the legitimate national rights of the Palestinians, we need to be able to influence Israel.”

In responding to questions from Hasan and the audience, Indyk explained that he believes that both Israelis and Palestinians had made important concessions for peace, citing Israel’s acceptance of the Clinton Parameters in 2000, and the Palestinian Liberation Organization’s historic recognition of Israel as part of the Oslo Accords. Indyk also described the dramatic shifts in the way the United States has addressed the Palestinian issue over the past few decades, “from treating it only as a refugee issue and insisting that it be dealt with through Jordan to recognizing Palestinian national rights.” 

When asked about U.S. support for Israel at the United Nations, Indyk responded that this support is definitely warranted given the history of hostility towards Israel at the UN. However, he added that he personally wouldn’t oppose a carefully-worded resolution condemning Israeli settlements “so that the settlers in Israel understand that [settlement expansion] isn’t cost free.” Indyk rejected the notion that Israel has turned from a U.S. strategic asset in the Middle East into a burden, but explained that “making progress on the Palestinian issue enhances America’s credibility in the region and failing to make progress…hurts America’s credibility in the region.” 

Indyk concluded the discussion by reiterating his commitment to achieving Israeli-Palestinian peace and emphasizing that he would “never give up on trying to resolve this conflict in a way that meets Palestinian legitimate national aspirations to an independent and viable contiguous state living alongside Israel, a Jewish state, in peace.” 

       

Introduction

The post-World War II era has witnessed the nearly exclusive building of low density suburbia, here termed “drivable sub-urban” development, as the American metropolitan built environment. However, over the past 15 years, there has been a gradual shift in how Americans have created their built environment (defined as the real estate, which is generally privately owned, and the infrastructure that supports real estate, majority publicly owned), as demonstrated by the success of the many downtown revitalizations, new urbanism, and transit-oriented development. This has been the result of the re-introduction and expansion of higher density “walkable urban” places. This new trend is the focus of the recently published book, The Option of Urbanism: Investing in a New American Dream (Island Press, November 2007).

This field survey attempts to identify the number and location of “regional-serving” walkable urban places in the 30 largest metropolitan areas in the U.S., where 138 million, or 46 percent, of the U.S. population lives. This field survey determines where these walkable urban places are most prevalent on a per capita basis, where they are generally located within the metro area, and the extent to which rail transit service is associated with walkable urban development.

The first section defines the key concepts used in the survey, providing relevant background information for those who have not read The Option of Urbanism. The second section outlines the methodology. The third section, which is the heart of the report, outlines the findings and conclusions of the survey.

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Chris Leinberger discusses his book about the most walkable urban and metro areas in the United States with Nicole Lapin from CNN.

NICOLE LAPIN: Walkable Urbanism.  Well, it's spreading beyond the boundaries of inner cities and into suburbs as Gen-Xers and empty nesters are searching for communities offering a walkable lifestyle. Well, all of this is according to a brand new book The Option of Urbanism Investing in a New American Dream.  The book was written in conjunction with the survey by the Brookings Institution. Brookings basically compiled a list of the best places for a car-less walkable urban lifestyle. Where you can basically: work, go home, go shopping, go to school, see entertainment all within a walking distance. So joining me now to talk more about this whole idea, the new 'American Dream,' is the author of that book Chris Leinberger. He joins us live from the Brookings Institution. Chris, thank you so much.

CHRIS LEINBERGER: Why thank you Nicole.

NICOLE LAPIN: Okay, first of all, let’s talk about this list because I got in my car this morning in Atlanta. I'm assuming Atlanta is not on the list?

CHRIS LEINBERGER: It's sort of in the middle of the list – it's not towards the top.

NICOLE LAPIN: Okay, so the top ten, can we start out, what’s number one?

CHRIS LEINBERGER: Number one is Washington, D.C. – and again we are talking about the metropolitan area.

NICOLE LAPIN: So, basically the west end, west of downtown, that has changed so much lately.

CHRIS LEINBERGER: Yes it has, but downtown itself has probably been the most remarkable downtown turnaround in the country. But, then all of the downtown adjacent places like the west end – which was an old industrial section – that's almost now built out. Dupont Circle which was dangerous twenty years ago is now a very elegant place and three or four other places around downtown, so it's not just downtown. 

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Ever since World War II, the American dream has encompassed the four-bedroom house with a white picket fence, tucked away in the suburbs. But this dream has gradually turned into a nightmare, with the increase of traffic, congestion and the general inconvenience of being detached from the city. Whereas people once rejoiced in camping trips to escape metropolitan living, we are now, as a culture, magnetized towards it as the appeal for walking more and driving less steadily increases.

KOJO NNAMDI:Chris you've dubbed this new style of living- "Walkable Urbanism." What is the evidence of a rising demand for it?

CHRIS LEINBERGER: There's demographic evidence; there's consumer research evidence; but probably the most compelling evidence is the price premium people are willing to pay to live in a walkable urban place, that the survey's show anywhere from a 40% to 200% price premium on a price per square foot basis for a walkable urban place as oppose to a competitive near by drivable suburban place.

KOJO NNAMDI: So it used to be that a condo or a townhouse was entry level product for people who couldn’t afford a real house, its beginning to be the other way around?

CHRIS LEINBERGER: In fact in 2003 for the first time in the country's history, condos on a price per square foot basis cost more than single family housing, and that includes all those old condo's that were built to be a alternative to a quote "real house" which was a single family house.  Its fundamentally changed and we've only seen the beginning of this train.

KOJO NNAMDI: I am intrigued about why people's preferences are indeed changing. In your book you give some of the credit to popular culture. Talk about the difference between the baby boomers- who grew up on 'Leave it Beaver,' the 'Brady Bunch' versus Generation Xer's who watch 'Seinfeld, and 'Sex in the City.'

CHRIS LEINBERGER: That’s just a reflection of the market reality. Hollywood does more consumer research than any business in the entire economy, and there out there doing focus groups constantly. So there reflecting what’s going on. Baby Boomers when they would see somebody- an image on the screen of some young woman flimsily dressed, walking down a dark street in a city, they would think- 'Oh my God, Hill street blues, and Blade Runner.' And the Gen-Xer's think, 'oh she is going to go to a new art gallery opening right down the street with all her friends.' Whole different perception of what a city life is like.

KOJO NNAMDI: A generational difference...

  
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Walk Score®, a new Web site popular with urbanists and environmental advocates (www.walkscore.com), rates neighborhoods by their walkability--basically the ease of meeting daily needs on foot. The higher the Walk Score®, the more walkable a place is.

Beyond its utility, however, the rise of Walk Score® is another indicator that how the American Dream lays out on the ground has been fundamentally changing over the past 10 to 15 years. Dallas in general and downtown Dallas in particular is well on its way to accommodating this new version of the American Dream, but more needs to be done.

The Ozzie and Harriet drivable suburban vision of the American Dream is being supplemented by the Seinfeld vision of "walkable urbanism." Led by late-marrying young adults and empty-nester baby boomers, many households are looking for the excitement and options that living and working in a walkable urban place can bring. Current demographic trends promise continued demand.

A recent Brookings Institution survey of the largest 30 metro areas in the country identifies the 157 walkable urban places that play a regionally significant role, such as concentrations of employment, education, professional sports, entertainment and housing. It ranked these metros on their per capita number of walkable urban places. Washington, D.C., was first, followed by Boston, San Francisco, Denver and Portland.

The top 15 metro areas had the vast majority, 85%, of these walkable urban places, though only two-thirds of the surveyed population. This showed that the top 30 metros are dividing between haves and have nots: metropolitan areas that have many walkable urban options and those that are lagging. Additionally, two-thirds of these 157 places had rail transit, demonstrating the importance of rail transit to the emergence of walkable urbanism.

A surprising finding of the survey is that while downtowns are a major location of walkable urbanism, downtown adjacent places are exploding in number and size. Places like Lincoln Park in Chicago, Dupont Circle in Washington, D.C., and the Pearl District in Portland, Ore., are booming alongside their resurgent downtowns.

A major benefit of walkable urban development is that its keeps and attracts young adults to the metro area, many of whom willingly trade crushing car commutes for walkable places to live and work. Walkable urban places seem to attract the well educated, the so called "creative class." Even the nascent revival in downtown Detroit has seen 83% of new residents arriving with a college education, compared to 26% of the national population.

While the Dallas metro ranked only 25th of 30 in the Brookings' survey, there are reasons to believe your destiny is to become a major concentration of walkable urban places. That reasoning starts with your investment in Dallas Area Rapid Transit light rail and the Trinity Railway Express commuter rail. This is being followed by aggressively encouraging high-density zoning around rail stations and in downtown adjacent locations. The combination of rail transit and high density zoning is essential to allow the private real estate community to respond to the pent-up market and economic demand of walkable urban development.

Finally, it is crucial to manage the various walkable urban places that either exist or are evolving. The role model in the Dallas area is the DowntownDallas organization, which provides security, signage and strategic direction for downtown.

The future of the Dallas metro area is linked to your ability to provide both more walkability options and expanded offerings of existing walkable urban places. There should be 15-20 more places like downtown Dallas, downtown Fort Worth, Uptown, Plano Town Center and Addison Circle for the region to meet the pent-up demand for walkable urbanism.

Building those additional walkable urban places will continue the economic development miracle that has been Dallas metro for so many years and it will increase your Walk Scores® as well.

       

WALK SCORE, a new Web site popular with urbanists and environmentalists (walkscore.com), rates places for their walkability—the ease of meeting daily needs on foot.

The popularity of the site is an indicator that how the American Dream plays out on the ground has been fundamentally changing over the last 10 to 15 years.

The Ozzie and Harriet drivable suburban version of the American Dream is being supplemented by the Seinfeld vision of "walkable urbanism." Led by late-marrying young adults and empty-nester baby-boomers, many households are looking for the excitement and options living and working in a walkable urban place can bring. With almost nine of 10 new households over the next 20 years being singles or couples without children, this trend promises to continue.

A recent Brookings Institution survey of the largest 30 metro areas in the country identifies the 157 walkable urban places that play a regionally significant role. It also ranks the Top 30 metros in per capita number of walkable urban places. The Philadelphia metropolitan area ranks as the 13th highest on the number of walkable urban places per capita.

Certainly the many already revived downtowns like those in Denver, Washington, Portland, Seattle and San Diego are the most visible signs of the walkable urban trend. But there are many other places you might not suspect.

This includes the emergence of "downtown-adjacent" places like Chelsea and Union Square in New York, suburban town centers like Pasadena and Long Beach in the L.A. area and even built-from-scratch spots like Reston Town Center near Dulles Airport, 30 miles outside Washington.

A major benefit of walkable urban development is that it keeps and attracts young adults to the metro area, many of whom willingly trade crushing car commutes and high gas prices for lively walkable places to live and work.

Walkable urban places seem to attract the well-educated, the so-called "creative class."

Approximately 26 percent of Americans over 25 have college degree - but 99 percent of the new residents moving to Center City this decade have a college degree.

Walkable urbanism increases the economic development potential of the metro area in the knowledge economy. If many of the Gen X-ers and the Millennial generations do not get this lifestyle, they'll move to New York or Washington, depriving Philadelphia of the entrepreneurs it needs to grow.

Walkable urbanism is also essential to create sustainable places to live and work, reducing greenhouse-gas emissions. It is probable that walkable urban households emit less than half the greenhouse gas as driving suburban households - they walk more and unavoidably share heat with upstairs neighbors.

Center City and Society Hill are the most obvious, though not the only, locations of this trend in the Philadelphia region. The recent emergence of University City around Penn and Drexel, Manayunk and New Hope are other significant walkable urban places in the Delaware Valley.

Missing are additional places in the suburbs, particularly around commuter and subway stations.

Rail transit is crucial for walkable urbanism places to emerge.

The investment has already been made for this comprehensive, if underfunded, rail system. Building high-density, mixed-use places around these stations will fulfill pent-up market demand, promote economic growth, lower greenhouse emissions and even give their suburban neighbors a great place for a restaurant within walking distance.

Over the next few years, Philadelphia metro will no doubt see its ranking in the Brookings survey rise while more households will see their Walk Score numbers soar. Seinfeld is coming to Philadelphia. *

Leinberger is a visiting fellow at the Brookings Institution, professor at the University of Michigan and a limited partner in Arcadia Land Co., which has projects in the Philadelphia and Kansas City areas. His most recent book is "The Option of Urbanism: Investing in a new American dream" (Island Press, 2007).

       

An economic analysis of a sample of neighborhoods in the Washington, D.C. metropolitan area using walkability measures finds that:

• More walkable places perform better economically. For neighborhoods within metropolitan Washington, as the number of environmental features that facilitate walkability and attract pedestrians increase, so do office, residential, and retail rents, retail revenues, and for-sale residential values.

• Walkable places benefit from being near other walkable places. On average, walkable neighborhoods in metropolitan Washington that cluster and form walkable districts exhibit higher rents and home values than stand-alone walkable places.

• Residents of more walkable places have lower transportation costs and higher transit access, but also higher housing costs. Residents of more walkable neighborhoods in metropolitan Washington generally spend around 12 percent of their income on transportation and 30 percent on housing. In comparison, residents of places with fewer environmental features that encourage walkability spend around 15 percent on transportation and 18 percent on housing.

• Residents of places with poor walkability are generally less affluent and have lower educational attainment than places with good walkability. Places with more walkability features have also become more gentrified over the past decade. However, there is no significant difference in terms of transit access to jobs between poor and good walkable places.

The findings of this study offer useful insights for a diverse set of interests. Lenders, for example, should find cause to integrate walkability into their underwriting standards. Developers and investors should consider walkability when assessing prospects for the region and acquiring property. Local and regional planning agencies should incorporate assessments of walkability into their strategic economic development plans and eliminate barriers to walkable development. Finally, private foundations and government agencies that provide funding to further sustainability practices should consider walkability (especially as it relates to social equity) when allocating funds and incorporate such measures into their accountability standards.

The Great Recession highlighted the need to change the prevailing real estate development paradigm, particularly in housing. High-risk financial products and practices, “teaser” underwriting terms, steadily low-interest rates, and speculation in housing were some of the most significant contributors to the housing bubble and burst that catalyzed the recession. But an oversupply of residential housing also fueled the economic crisis.

However, a closer look at the post-recession housing numbers paints a more nuanced picture. While U.S. home values dropped steadily between 2008 and 2011, distant suburbs experienced the starkest price decreases while more close-in neighborhoods either held steady or in some cases saw price increases. This distinction in housing proximity is particularly important since it appears that the United States may be at the beginning of a structural real estate market shift. Emerging evidence points to a preference for mixed-use, compact, amenity-rich, transit-accessible neighborhoods or walkable places.

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When the Volkswagen emissions control scandal broke into the headlines in September, I wrote here how I felt like my lifelong love affair with VW had been violated. As an environmentalist, owning a Jetta that zipped along for 42 miles on a gallon of diesel was the best of both worlds. And it was a lie. My wife, Holly Flood, said she felt like she’d been “duped,” and since then she’s vowed never to buy another VW.

I’m not so sure. But I was pleased this week to see the agreed terms for the nearly half million of us who own the smaller diesel engine cars in the U.S. This was the largest car settlement in U.S. history.

What I like is the combination of individual and collective compensation for this crime.

Making it right with the customers

On the individual side, if this deal is approved by the judge in early October, my family will get our 2009 Jetta TDI sedan fixed for free (if the Environmental Protection Agency approves the fix), and we’ll get a check for $5,100. Holly says that’s perfect timing for a down payment on a new car (which will not be a VW).

I’m pushing for a plug-in electric hybrid, which we can charge with renewable energy we get off the grid from our local provider, People’s Power & Light. In our case, for every electron we use, they pay to have one electron put in from wind power somewhere right here in New England. Hopefully we’ll have variable pricing of electricity by then, allowing us to charge the car when the juice is cheapest, like when the wind blows at night but few people are using much electricity.

The unknown for us is whether the VW fix will noticeably harm the performance of the car. I’m guessing it will, perhaps in its remarkable torque, in its gas mileage, or both. But at this point the car has tons of my wife’s commuting miles on it, so we’re hanging on to it as the in-town backup car. Under the settlement we could get an extra $7k and give up the car entirely. That may be tempting, as it’s at that point where it’s getting substantially more expensive to maintain, and the Kelley Blue Book value is around $6k. They apparently aren’t lowballing us.

Making it right with the public

The collective part of this agreement is actually more interesting.

VW agreed to pay $4.7 billion  into environmental programs, which in my estimation will eliminate more harm than they created. One estimate guessed that scores of premature deaths occurred in the U.S. from VW’s “defeat devices” that shut off emissions controls when they were not being tested. Most of the deaths were probably in California, where there were many more sales of diesels than elsewhere in the country. (Of course in Europe the concentration of diesels is much greater and the Guardian put the number of deaths at thousands in the U.K. alone.) 

One part of this fund will go to replace diesel buses with electric ones. This will measurably improve air quality in inner cities, the precise places where extra sooty VWs were causing ill health and premature deaths with their NOx emissions. Another part will go to install electric vehicle charging stations in California. This helps overcome the “chicken and egg” problem of people not being willing to switch to electric vehicles for fear of running out of juice. The settlement says that “Volkswagen must spend $2 billion to promote non-polluting cars (“zero emissions vehicles” or “ZEV”), over and above any amount Volkswagen previously planned to spend on such technology.” That counterfactual will probably be impossible to prove, but the idea here is fairness.

A case of how America deals with environmentally criminal corporations

Sociologically, this is a fascinating case, because it reveals how our society resolves scandals that killed people through knowing contamination of the environment. As Deputy U.S. Attorney General Sally Yates harshly put it, "By duping regulators, Volkswagen turned nearly half a million American drivers into unwitting accomplices in an unprecedented assault on our environment." There are individuals inside this company who deserve criminal prosecution, but apparently most of the thousands of other employees did not know what was going on.

The corporate response has been interesting, and seems to vary sharply from how most U.S. auto firms have dealt with similar lawsuits and scandals in the past. VW did not drag out the battle, but set aside $16 billion immediately as a loss, and then settled rather generously with us. (This spring they had already given us a $500 gift card and $500 in repairs in what was essentially hush money.)

VW’s response to this crisis was creative, forward-looking, and ultimately pro-social. Just a week or so ago they announced that their new business model was to be in electrics: They announced they’d be rolling out 31 electric vehicles in the coming years. This is a remarkable turn for a company that pushed diesels for decades as the solution to climate change. This is what it looks like when a massive corporation whose reputation was built on trust and belief in the integrity of a brand seeks to battle its way back into a changing market.

Spending billions on charging stations and replacing diesel buses may make immediate sense—can we say if this is helping avoid premature deaths or it is merely crass self-interest? Does it matter? 

Of course it does. But my first impression of what VW did this week was of a fair deal that was not just lining my pocket. It was helping us get off fossil fuels as a society and benefiting human health and the environment in a substantial way. And by rebuilding a major employer in Germany, the U.S., and around the world into one that might be a part of the solution to climate change, this is a significant and fairly brilliant business move to position the company for the next half century.

Or am I merely a sucker for my old flame?

       

       

Editor's Note: The current U.S. presidential race demonstrates the deep political divisions that exist in our country. But what does it mean to be "liberal" or "conservative," "Republican" or "Democratic"? According to Shadi Hamid, certain values transcend political chasms. This post originally appeared on PBS NewsHour.

What does it mean to say that the Republican Party is on the “right”? The GOP, long defined (at least in theory) by its faith in an unbridled free market, the politics of personal responsibility, and a sort of Christian traditionalism, is no longer easily plotted on the traditional left-right spectrum of American politics. Under the stewardship of presidential nominee Donald Trump, the Republican Party appears to be morphing into a European-style ethnonationalist party. With Trump’s open disrespect for minority rights and the Bill of Rights, the GOP can no longer be considered classically “liberal” (not to be confused with capital-L American Liberalism). This is a new kind of party, an explicitly illiberal party.

These developments, of course, further constrain Republicans’ appeal to minority voters (I haven’t yet met an American Muslim willing to admit they’re voting for Trump, but they apparently exist). This makes it all the more important to distinguish between conservative values and those of this latest iteration of the Republican Party.

There are some aspects of Burkean conservative thought – including aspects of what might be called civic communitarianism – that could plausibly strike a chord in the current cultural landscape across “left” and “right,” categories which, in any case, are no longer as clearly distinguishable as they once were. (Take, for example, British Labour leader Jeremy Corbyn’s Euroskepticism and that of his opponents on the right, or the populist anti-elitism and trade protectionism that are now the province of both Republicans and Democrats).

Everyone seems angry or distrustful of government institutions, which, even when they provide much needed redistributive fiscal stimulus and services, are still blamed for being incompetent, inefficient, or otherwise encouraging a kind of undignified dependency. After the Brexit debacle, it seemed odd that some of the most Europhobic parts of Britain were the very ones that benefited most from EU subsidies. But this assumes that people are fundamentally motivated by material considerations and that they vote – or should vote – according to their economic interests.

If there’s one thing that the rise of Trump and Brexit – and the apparent scrambling of left-right divides – demonstrates, it’s that other things may matter more, and that it’s not a matter of people being too stupid to realize what’s good for them. As Will Davies put it in one of the more astute post-Brexit essays, what many Brexiteers craved was “the dignity of being self-sufficient, not necessarily in a neoliberal sense, but certainly in a communal, familial and fraternal sense.”

The communitarian instinct – the recognition that meaning ultimately comes from local communities rather than happiness-maximizing individuals or bloated nanny-states – transcends the Republican-Democratic or the Labour-Conservative chasm. In other words, an avowedly redistributive state is fine, at least from the standpoint of the left, but that shouldn’t mean neglecting the importance of local control and autonomy, and finding ways, perhaps through federal incentives, to encourage things like “local investment trusts.”

Setting up local investment trusts, expanding the child tax credit, or introducing a progressive consumption tax aren’t exactly a call-to-arms, and various traditionalist and communitarian-minded philosophers have, as might be expected from philosophers, tended to stay at the level of abstraction (authors armed with more policy proposals are more likely to be young conservative reformers like Ross Douthat, Reihan Salam, and Yuval Levin). Douthat and Salam want to use wide-ranging tax reform to alter incentives in the hope of strengthening families and communities. This is a worthy goal, but realizing such policies requires leadership on the federal level from the very legislators who we should presumably become less dependent on.

This is the reformer’s dilemma, regardless of whether you’re on the left or right. If your objective is to weaken a centralized, overbearing state and encourage mediating or “middle” institutions, then you first need recourse to that same overbearing state, otherwise the proposed changes are unlikely to have any significant impact on the aggregate, national level.

The fact that few people seem interested in talking about any of this in our national debate (we instead seem endlessly intrigued by Melania Trump’s copy-and-paste speechwriting) suggests that we’re likely to be stuck for some time to come. Incidentally, however, the Hillary Clinton campaign slogan of “Stronger Together” has an interesting communitarian tinge to it. I doubt that was the intent, and it’s only in writing this column that I even took a minute to think about what the slogan might actually mean. I, as it happens, have been much more interested in talking about – and worrying about – an unusually fascinating and frightening man named Donald Trump.

       

A recent blog suggested that CMS’ efforts to standardize assessment data was based on a goal of “….creating a functional measurement tool that could be used throughout the industry.” In fact, CMS has been working since 2005 to meet the Congressional directive to standardize assessment information at hospital discharge, and post-acute care (PAC) admission and discharge for payment and quality reporting purposes (Deficit Reduction Act of 2005). The CARE tool was developed as part of the national Post-Acute Care Payment Reform Demonstration (PAC PRD). The conceptual domains and items were selected with the input of the wide range of stakeholder communities working with PAC populations. Clinicians from acute hospitals and each of the four PAC settings, including long term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs) identified items to test in four areas: medical status, functional status, cognitive status, and some social support factors. Input was given by physicians, nurses, physical therapists, occupational therapists, speech and language pathologists, social workers and case managers working in each of the different levels of care. Initial item selection was based on a review of existing assessment items, including those in the three Federally-mandated instruments, (the IRF-PAI, MDS 2.0, and OASIS-B which were in effect at this time) and the input of each of the scientific communities working in these areas.

Developers of proprietary systems such as the UDS-MR©, Inter-RAI ©, and AM-PAC ©, as well as public domain items tested in clinical trials such as the PROMIS items, were all reviewed as part of this process. The selected items needed to be in the public domain so the measures could be modified as science advanced practice.

Over 200 providers participated nationwide to submit over 53,000 CARE assessments over the course of the PAC PRD. Participating clinicians also provided feedback during training and exit interviews. In general, positive feedback was provided on most items. Feedback showed that almost all items were commonly collected on existing instruments in hospitals and PAC providers, although some of the information may have been informally noted in charts rather than provided in the structured form of the CARE items.

The items were tested for reliability so they could be applied consistently across populations and settings. Most of the items were previously tested and found reliable in at least one of the five levels of care. Two types of reliability tests were conducted on the final CARE tool item set used in the PAC PRD. The results showed that most items when applied to the other four settings were at least as reliable as the existing Federal assessment items (Kappa scores of 0.6 or better) ensuring their reliable use in future quality measures or payment models would reach consistent results. Complete reports on item reliability and PAC PRD results can be found here.

Data standardization is critical to allow providers to exchange information as they follow the patient. The Deficit Reduction Act of 2005 directed CMS to use standardized assessment items at acute hospital discharge and PAC admission and discharge to allow for empirical comparisons of key questions arising out of changing incentives in the Medicare payment policies. The standardized CARE items are consensus-based versions of the items already collected by clinicians. These and additional items being incorporated into CMS’ assessment item library represent the “best in class.” The team developing the CARE item set represented the leading experts in each of the areas – Dr. Margaret Stineman of the University of Pennsylvania, developer of the function-related groups associated with the proprietary FIM©, Dr. Deborah Saliba, UCLA, lead developer of the MDS 3.0, and Dr. Chris Murtaugh of the Visiting Nurse Service of New York. Team members included Drs. Anne Deutsch and Trudy Mallinson of the Rehabilitation Institute of Chicago. Input was also given by Dr. David Hittle, of the University of Colorado who has worked closely with the OASIS tool, Dr. Samuel Markello, formerly of the UDS-MR©, and Dr. Patrick Murray of Case Western University.

The blog suggested that, “the early reviews of the CARE tool have been poor.” While this clearly is not true, it is worth pointing out that the author owns one of the key proprietary assessment instruments. The CARE items have been evaluated for reliability and they meet the national standards; they allow providers and others the opportunity to download the e-specification of the items without charge and to have the clinicians trained for free under CMS’ regular assessment training initiatives. CMS is currently developing quality measures using the “best in class” assessment items which all meet scientific standards. The quality measure development process already requires CMS to submit measures for endorsement by the National Quality Forum. The “loophole” identified by the UDS-MR© author is non-existent. The Measures Application Partnership is part of the existing NQF process included in the IMPACT legislation. Further, use of uniform data elements across settings, such as those used in the currently collected pressure ulcer measure, allows for exchangeability and improves communication across the system, finally creating a “data follows the person” system.

      

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Many clinicians have terrific ideas for improving the quality and cost of health care, but often don’t know how to navigate the often baffling landscape of payment and delivery reform options. To address this need in clear, practical terms, we are pleased to announce the second MEDTalk event in the “Merkin Series on Innovations in Care Delivery.” The series is designed to support clinicians and policymakers who’ve always wondered how delivery reform occurs, but didn’t know where to begin. 

Our second case focused on the work of leaders from the New Mexico Cancer Center (NMCC), and their efforts to "Reinvent Patient-Centered Cancer Care." The event featured several brief “TED-style” talks that considered the challenges of delivering oncology care, while enhancing patient experience, improving coordination of care, and reducing costs. The agenda included firsthand experiences from patients, payers, policymakers, and NMCC's clinical leadership who explores sustainable improvement strategies, and the financial mechanisms available to encourage innovations in oncology.

Video

• A Day in the Life: The Patient Experience
• The Future of Oncology: Drugs, Genetic Testing and Personalized Medicine
• The Challenge of Delivering Cancer Care in a Triple Aim World
• What We're Learning from New Oncology Payment Models
• Supporting Care While Reducing Costs: What is Possible?
• The New Mexico Experience: Aligning Clinical Redesign and Payment Reform
• Sustaining Improvements in Patient-Centered Care
• Lessons Learned and the Path Forward
• MEDTalk: Reinventing Patient-Centered Cancer Care

Event Materials

• Oncology Case Study August 2014 FINAL WEB

      

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Many clinicians have terrific ideas for improving the quality and cost of health care, but often don’t know how to navigate the frequently baffling landscape of payment and delivery reform options. To address this need in clear, practical terms, we are pleased to announce the third MEDTalk event in the “Merkin Series on Innovations in Care Delivery.” The series is designed to support clinicians and policymakers who’ve always wondered how delivery reform occurs, but didn’t know where to begin.

Our third case drew on the experiences of the Community Asthma Initiative, an enhanced pediatric asthma intervention, and their efforts in sustainability. The event featured seven brief “TED-style” talks that consider the challenges of delivering pediatric care, while tackling non-medical factors that drive suboptimal care, improving patient and family quality of life, and reducing costs. The agenda included firsthand experiences from patients, payers, policymakers, and clinical leadership from Massachusetts and Arkansas. Sustainable improvement strategies and the financial mechanisms available to encourage innovations in asthma were explored.

Video

• MEDTalk: Pediatric Asthma and Transforming Care for the Most Vulnerable
• A Day in the Life: The Patient Experience
• Challenge Accepted: Delivery of Asthma Care in a Triple Aim World
• The Community Asthma Initiative: A Case Study in Clinical Innovation
• Paying for Asthma Care: Options for Tackling Challenges
• State Medicaid Innovation: Opportunities and Barriers
• A Tale of Success: How to Get the Payer on Board
• Lessons Learned and the Path Forward
• Question and Answer Session

       

        

       

       

Federal departments and agencies received just above $133 billion in R&D funds in 2013. To put that figure in perspective, World Bank data for 2013 shows that, 130 countries had a GDP below that level; U.S. R&D is larger than the entire economy of 60 percent of all countries in the world.

The chart below shows how those funds are allocated among the most important federal departments and agencies in terms of R&D.

Those looking at these figures for the first time may be surprised to see that the Department of Defense takes about half of the pie. It should be noted however that not all federal R&D is destined to preserve U.S. military preeminence in the world. From non-defense research, 42 percent is destined to the much-needed research conducted by the National Institutes of Health, 17 percent to the research of the Department of Energy—owner of 17 celebrated national laboratories—16 percent for space exploration, and 8 percent for understanding the natural and social worlds at a fundamental level. The balance category is only lumped together for visual display not for its importance; it includes for instance the significant work of the National Oceanic and Atmospheric Administration and the National Institute of Standards and Technology.

Despite the impressive size of defense R&D, we hear little about it. While much of defense research and development is classified, in time, civilian applications find their way into mainstream commercial uses—the Internet and GPS emerged from research done at DARPA. Far more visible than defense R&D is biomedical research, clean energy research, or news about truly impressive discoveries either in distant galaxies or in the depths of our oceans.

What produces this asymmetry of visibility of federal R&D work?

In a recent Brookings paper, a colleague and I suggest that the answer lies in the prominence of R&D in the agencies’ accounting books. In short: How visible is R&D and how much the agency seeks to discuss it in public fora depends not on the relative importance, but on how large a portion of the agency’s budget is dedicated to R&D.

From a budget perspective, we identified two types of agencies performing R&D: those agencies whose main mission is to perform research and development, and those agencies that perform many functions in addition to R&D. For the former, the share of R&D in the discretionary budget is consistently high, while for the latter group, R&D is only a small part of their total budget (see the chart below). This distinction influences how agencies will argue for their R&D money, because they will make their case on the most important uses of their budget. If agencies have a low R&D share, they will keep it mixed with other functions and programs; for instance, research efforts will be justified only as supporting the main agency mission. In turn, agencies with a high R&D share must argue for their budgets highlighting the social outcomes of their work. These include three agencies whose primary mission is research (NASA, NSF, NIH), and a fourth (DoE) where research is a significant element of its mission.

There is little question that the four agencies with high R&D share produce greatly beneficial research for society. Their strategy of promoting their work publicly is not only smart budget politics but also civic and pedagogical in the sense of helping taxpayers understand that their tax dollars are well-spent. However, it is interesting to observe that other agencies may be producing research of equal social impact that flies under the public radar, mainly because those agencies prefer as a matter of good budget policy to keep a low profile for their R&D work.

One interesting conclusion for institutional design from this analysis is that promoting a research agency to the level of departments of government or its director to a cabinet rank position may bring prominence to its research, not because more and better research will necessarily get done but simply because that agency will seek public recognition for their work in order to justify its budget. Likewise, placing a research agency within a larger department may help conceal and protect their R&D funding; the politics of the department will focus on its main goals and R&D would recede to a concern of secondary interest in political battles.

In the Politics of Federal R&D we discuss in more detail the changing politics of budget and how R&D agencies can respond. The general strategies of concealment and self-promotion are likely to become more important for agencies to protect a steady growth of their research and development budgets.

Data sources: R&D data from the American Association for the Advancement of Sciences historical trends in Federal R&D. Total non-discretionary spending by federal agency from the Office of Management and Budget.

       

       

       

The Supreme Court today decided that Congress meant what it said when it enacted the Affordable Care Act (ACA). The ACA requires people in all 50 states to carry health insurance and provided tax credits to help them afford it. To have offered such credits only in the dozen states that set up their own exchanges would have been cruel and unsustainable because premiums for many people would have been unaffordable.

But the law said that such credits could be paid in exchanges ‘established by a state,’ which led some to claim that the credits could not be paid to people enrolled by the federally operated exchange. In his opinion, Chief Justice Roberts euphemistically calls that wording ‘inartful.’ Six Supreme Court justices decided that, read in its entirety, the law provides tax credits in every state, whether the state manages the exchange itself or lets the federal government do it for them.

That decision is unsurprising. More surprising is that the Court agreed to hear the case. When it did so, cases on the same issue were making their ways through four federal circuits. In only one of the four circuits was there a standing decision, and it found that tax credits were available everywhere. It is customary for the Supreme Court to wait to take a case until action in lower courts is complete or two circuits have disagreed. In this situation, the justices, eyeing the electoral calendar, may have preferred to hear the case sooner rather than later to avoid confronting it in the middle of a presidential election.

Whatever the Court’s motives for taking the case, their willingness to hear the case caused supporters of the Affordable Care Act enormous unease. Were the more conservative members of the Court poised to accept an interpretation of the law that ACA supporters found ridiculous but that inartful legislative drafting gave the gloss of plausibility? Judicial demeanor at oral argument was not comforting. A 5-4 decision disallowing payment of tax credits seemed ominously plausible.

Future Challenges for the ACA

The Court’s 6-3 decision ended those fears. The existential threat to health reform from litigation is over. But efforts to undo the Affordable Care Act are not at an end. They will continue in the political sphere. And that is where they should be. ACA opponents know that there is little chance for them to roll back the Affordable Care Act in any fundamental way as long as a Democrat is in the White House. To dismantle the law, they must win the presidency in 2016.

But winning the presidency will not be enough. It would be mid 2017 before ACA opponents could draft and enact legislation to curb the Affordable Care Act and months more before it could take effect. To borrow a metaphor from the military, even if those opposed to the ACA win the presidency, they will have to deal with ‘facts on the ground.’

Well over 30 million Americans will be receiving health insurance under the Affordable Care Act. That will include people who can afford health insurance because of the tax credits the Supreme Court affirmed today. It will include millions more insured through Medicaid in the steadily growing number of states that have agreed to extend Medicaid coverage. It will include the young adult children covered under parental plans because the ACA requires this option.

      

       

       

       

       

       

       

Israel apologized to Turkey today for the May 2010 incident on board the Mavi Marmara naval vessel, part of a flotilla to Gaza, in which nine Turks were killed from Israel Defense Forces fire. The apology came during a 30-minute telephone conversation between Israeli Prime Minister Benjamin Netanyahu and Turkish Prime Minister Recep Tayyip Erdogan, orchestrated by President Barack Obama, who was ending his 3 day visit to Israel and the Palestinian Authority. Erdogan accepted the Israeli apology, and the leaders agreed to begin a normalization process between Israel and Turkey, following the past three years, when relations were practically at a standstill. (Last December, I wrote about the beginnings of a Turkey-Israeli rapprochement, and discussed more of the policy implications here.)

This development allows the two countries to begin a new phase in their relationship, which has known crisis and tension, but also cooperation and a strong strategic partnership.

The U.S. administration played a key role behind the scenes in creating the conditions that paved the way for an Israeli apology and Turkish acceptance. Undoubtedly, a close relationship between Turkey and Israel-- two of America’s greatest allies in the region-- serves United States’ strategic interests globally and regionally. At a time when the Middle East political landscape is changing rapidly, it was imperative to end the long impasse between Ankara and Jerusalem.

Over the past year, Turkey and Israel have also come to realize that repairing their relationship and re-establishing a dialogue is at their best interest, as they face great challenges in their immediate vicinity (first and foremost, the Syrian civil war).

United States officials emphasized that this is the first step in a long process. Nevertheless, the parties will have to make a great effort to overcome years of distrust and suspicion if they want the relationship to work. No one is under the allusion that relations will go back to what they were in the “honeymoon” period of the 1990s but modest improvement can be made. It will not be an easy task, and for that to happen it is essential that the parties not only talk to each other, but also listen to one another and begin to respect each other’s sensitivities. In order for this rapprochement to be successful, United States will have to continue to oversee discussions between Turkey and Israel, and remain heavily engaged in this process.