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Drug Prices Are a Populist Campaign Issue. Here Are the Latest Proposals to Lower Costs.

Medicare -- New York Times - 4 hours 7 min ago
After years of public outrage, some bipartisan solutions are emerging. But whether they will make it through a divided Washington is still unclear.
Categories: Elder, Medicare

On the Doorstep With a Plea: Will You Support Medicare for All?

Medicare -- New York Times - Sat, 06/15/2019 - 10:06am
The nation’s largest nurses’ union is pushing Medicare for all from door to door to door in swing House districts. But the campaign for a single-payer health system is slow going.
Categories: Elder, Medicare

Sanders Presents Vision of Democratic Socialism in Speech

Medicare -- New York Times - Wed, 06/12/2019 - 5:37pm
Senator Bernie Sanders, the Vermont independent seeking the Democratic nomination for president, offered a strong defense of democratic socialism in an effort to fend off criticism about his electability.
Categories: Elder, Medicare

Advancing U.S. interests through security cooperation

Brookings Institute -- Medicare - Tue, 06/11/2019 - 12:38pm

Every day, the U.S. manages 14,000 open foreign military sales cases with 185 countries. Recent attempts by near-peer competitors to erode U.S. technological advantages has made security cooperation between the U.S. and these countries even more significant.[author-bio]

On June 4, Senior Fellow Michael O’Hanlon hosted Lieutenant General Charles Hooper, director of the Defense Security Cooperation Agency (DSCA), to discuss these dynamics and the role of the DSCA in supporting allies and promoting U.S. interests abroad.

O’Hanlon asked Hooper to discuss regional examples of DSCA’s approach to security cooperation. Hooper argued that American security cooperation with Colombia has been highly successful, as demonstrated by Colombia’s self-sustaining defense capability with U.S. assistance. More contentious regional topics include the sale of F-35 fighter jets to Turkey, weapon transfers to Saudi Arabia amidst the ongoing war in Yemen, and cooperation with the Afghan National Security Forces. With all three, Hooper acknowledged ongoing tensions. While the U.S. strives to achieve common security goals through partnerships with allies, there can be difficulty in guaranteeing that weapons are used responsibly. Despite this tension, Hooper underscored that the DSCA’s key objectives are strengthening alliances and attracting new partners, providing allies and partners with defense services and articles faster, and ensuring the consistent application of U.S. values.

At the end of the event, Lt. General Hooper took questions from the audience. You can watch the discussion here:

Research Intern Hannah Markey contributed to this post.[more-blog-posts]

Categories: Elder

How can city governments protect themselves against ransomware attacks?

Brookings Institute -- Medicare - Tue, 06/11/2019 - 9:54am

The most recent incident in a series of ransomware attacks on American cities and municipalities happened in May in Baltimore. The hackers locked multiple systems such as emails, voicemail, and the parking fines database. The debacle delayed the sales of about 1500 homes in the city. Hackers have demanded over $100,000 in bitcoins in order to release these files, which has been declined by Baltimore’s mayor.


Ransomware attacks have quickly become a preferred method of hacking with the emergence of bitcoins and other cryptocurrencies that enable hackers to receive their ransom without being tracked and identified. The popularity of cryptocurrency has soared in the recent years with fluctuations in their value. As these currencies become more mainstream, so does the incentive of hackers to make a quick buck through ransomware attacks. As I had warned before, we should expect ransomware attacks to become more frequent as cryptocurrency becomes more popular.

The bad news is that once a computer system is hacked with ransomware the options are very limited. The first option is to pay the ransom. While this is the quickest way to release the files, law enforcement officials strictly advise against it, simply because paying the ransom invites future attacks. Once the hackers know that an organization pays the ransom, they will repeat their attacks for more money. The other option is to refuse the payment. While this solution reduces the chances of future attacks, it will impose significant costs on the organization as it may take weeks or even months to remove all the malicious software from the computer systems.

The good news is, although there is not much to do once a system is attacked with ransomware, it is very easy to significantly reduce the chances of being attacked. While even the most secure computer systems could be hacked as there is no security technology that guarantees 100% protection against threats, implementing the most basic security solutions could significantly reduce the chances of experiencing a ransomware attack.


Most such attacks are not targeted, but opportunistic. Hackers look for organizations and businesses that seem more vulnerable than others. The ones that have neglected to set basic security standards in place are more likely to be targeted for ransomware attacks. The process is very similar to burglaries in which the criminals do not target a specific home, but rather cruise neighborhoods to find houses that do not seem to have security systems.

The best defense against ransomware attacks is putting basic security safeguards in place. It will most likely dissuade hackers that are after a quick buck and are not motivated to spend time hacking into a secure system while there are easier targets out there.

The critical services provided by government agencies make them attractive targets for ransomware attacks. In the case of Baltimore, the attack halted home sales and water bill payments. Due to the sensitivity and urgency of services that government agencies provide to the public, cities cannot afford to leave their computer systems suspended for prolonged periods. Hackers are more likely to attack city governments, assuming that cities will be desperate to release their files and pay the demanded ransom.

As I have discussed earlier, compared to private organizations, government agencies usually have less resources to invest in information security technologies. Old and fragmented computer systems exacerbate this problem, since older systems are much more difficult and expensive to maintain than newer ones. Despite these difficulties, all levels of government should invest in upgrading security technologies to reasonable levels, or else many more agencies will soon become victims of ransomware attacks in the future.


Categories: Elder

Red-tape voter suppression: How new, draconian voter registration rules undermine voting rights

Brookings Institute -- Medicare - Tue, 06/11/2019 - 7:00am

In Tennessee, a draconian new law aims to penalize groups engaging in voter registration campaigns. Civil rights advocates have rightly compared the legislation to the racist voter suppression policies of the Jim Crow era and are contesting the law’s constitutionality. Having experienced the effects of similar legislation in the field, we can say with confidence that if the Tennessee law is allowed to stand, it will undermine voter registration efforts and keep eligible voters off the rolls.

In 2018, in Dallas, Texas, and Cleveland, Ohio, our team conducted a randomized controlled trial of a new policy idea: offering voter registration to people when they file their income tax returns at Volunteer Income Tax Assistance (VITA) sites. The experiment was a success: the program doubled voter registration rates among the initially unregistered.

A less encouraging finding was the sheer disparity between our two test states. Each year, millions of Americans register to vote or update their voter registration thanks to the tireless efforts of civil society organizations that run voter registration tables, go door-to-door with voter registration forms, or otherwise remind potential voters to get registered in time to vote. But running a voter registration campaign that would be uncontroversial in other states is extremely difficult in Texas, because Texas has some of the most severe limits on voter registration of any state in the nation. It takes a simple procedure and makes it needlessly bureaucratic and extremely intimidating to both voters and volunteers, while doing absolutely nothing to make voter registration more secure.

When a tax filer came into a Cleveland VITA site, they were met by an intake volunteer and presented with a voter registration form along with their standard IRS paperwork. If an individual wished to register, they would then complete the voter registration form and return it to the intake volunteer, who mailed the registration forms to the county within ten business days. No intimidation, no penalties, no additional burden on VITA intake staff.

Now, here’s how a similar voter registration drive works in Texas:

To collect a voter registration form in Texas, you must be a “Volunteer Deputy Registrar,” or VDR. A VDR must be a U.S. citizen, meaning that legal, longtime residents cannot do voter registration in the state. In immigrant communities, this immensely reduces the pool of people who can assist in a voter registration drive.

Moreover, VDRs must receive special training from the county, and their certification to register voters only applies to residents of the county in which they are trained. Texas has an astonishing 254 counties. A VDR who completed their training in Fort Worth, which resides in Tarrant County, cannot register voters in Dallas, less than 30 minutes away. If a Dallas resident were to be in Fort Worth and come across a voter registration table, the VDR trained in Fort Worth could not accept their voter registration form. If we had been trying to run an experiment in multiple counties, it would have required an immense additional investment in volunteer recruitment and training for every county in which we wished to work—luckily, we happened to work in only one county.

Just taking the VDR class is a hurdle. For our experimental work, we were lucky that Dallas County makes these courses accessible. In other counties, voting rights expert Ari Berman reports, the training to become a VDR “typically occurs once a month, sometimes less.” And one’s status as a VDR expires “on December 31st of every even-numbered year,” meaning VDRs must recertify for every federal election.

Texas voter registration forms require only your name, address, date of birth, and an identification number, either from your Texas ID or the last four digits of your social security number. Check a box that you are a U.S. citizen and will be 18 on or before Election Day, affirm that you are a resident and not precluded from voting because of your criminal history or mental incapacity, sign and date, and you are ready to vote.

Or you would be, but Texas adds additional hoops and hurdles to the registration process. Each time a VDR receives a completed registration form, they must return a signed receipt to the applicant—plus send duplicates to the county. All completed forms must be submitted to the county by hand (not by mail) by 5pm on the fifth day (not the fifth business day) after the date they are received. Each VDR is issued materials including a certificate of appointment, handbook, applications, and a receipt book, all of which must be accounted for and returned no later than the second day after their two-year appointment is terminated. VDRs are also barred from photocopying the information on the voter registration form, even just the names and addresses—adding an extra obstacle for registration campaigns that would want to follow up with newly registered voters to remind them to turn out on Election Day.

An additional challenge is the lack of clarity about these time-consuming and irksome procedures. It took several phone calls, for instance, to get in touch with an official who could answer definitively whether the five-day submission deadline included the day of collection or started the following day. We also had to clarify arcane details like this: while weekend days count towards the five-day deadline, if the fifth day falls on a weekend, a VDR actually has until Monday to submit the voter registration form.

To be clear, these procedures do nothing to assure the security of the registration process. The training explicitly notes that VDRs “may not determine if the applicant is actually qualified to register to vote.” It is red tape, pure and simple. But it is red tape accompanied by bolded warnings like this: “Failure to deliver an application in a timely manner is a criminal offense.” Fearing lawsuits, some national voter registration groups have opted not to work in Texas at all.

What did all this bureaucratic nonsense mean for our experiment? First, the duplicate forms made voter registration too much of a burden to combine with the intake procedure at the tax preparation sites. So instead, we had to bring in additional volunteers to offer voter registration and ensure that they were trained as VDRs.

The hurdles to becoming a VDR make it more difficult to find language-appropriate registrars. This likely reduced the effectiveness of the experiment for Spanish speakers. Nearly half of the Filer Voter participants in Texas signed our Spanish consent form; however, the results of the experiment showed that the program was over three times more effective at registering those who signed in English.

And because the forms had to be delivered by hand to the county, rather than dropped in the mail, we had to develop a carpool system to collect and deliver the forms within the allotted five days. Finally, if we wanted to confirm our findings by repeating the experiment, as all good scientists would, every one of the VDRs who participated in Texas in 2018 would have to be recertified if they wished to collect voter registration forms in 2020.

We knew going into the experiment that Texas was going to be a “hard case” for our registration idea. In fact, a number of voter registration organizations suggested we pilot our program elsewhere. But there is little point testing a policy only in the venues where it is most likely to succeed. So, we invested heavily in our Texas experiment, including hiring local voting procedure experts to guide the project.

In the end, we did successfully register voters in Texas, though at a much lower rate than in Ohio. In Ohio, the Filer Voter program increased registration among the initially unregistered by 9.7 percentage points while in Texas there was only a 3.6 point increase. To be fair, we can’t say how much of the difference is due to the Texas laws; the Dallas population likely also had a higher percentage of non-citizens than Cleveland did. But what is clear is that registering voters in Texas was astronomically more difficult, and no more secure, than in Ohio.

The new law passed in Tennessee does not impose precisely the same requirements on voter registration groups as Texas, but the outlines are similar. For example, organizers in Tennessee who fail to follow the new rules could face extremely stiff penalties: fines of up to $10,000 and close to a year in jail.

It does not actually require new data or direct personal experience to predict the impact of these laws, because voter suppression has a long and terrible history in the United States. There is no reason that the United States should, in the 21st Century, be debating the basic procedures of democracy. But since this debate is occurring, we should be very clear. Based on our experience in Texas, it is obvious that these new rules in Tennessee will intimidate civic organizations and keep eligible voters away from the polls. It is anti-democratic, unjust and of a piece with America’s most shameful political traditions.

Categories: Elder

Do the current Democratic politics spell doom for charter schools?

Brookings Institute -- Medicare - Mon, 06/10/2019 - 3:35pm

In prior posts, I argued that education is likely to play a major role in the Democratic primaries. This is due to several factors, including: the growing importance of education as a national issue, the unions’ continued power, and the possibility that no Democrat will emerge with a majority of votes prior to the convention where institutional power players like unions have an outsized role.


Unfortunately for Democrats, education will play a big role for another reason as well. Charter school policy has become a divisive issue within the party. For the left wing of the party, it is an opportunity to support public education, oppose privatization, and gain support of the powerful teacher unions all at the same time. All the while, all but one of the top-tier presidential candidates has either been neutral or supportive of charter schools in the past. All are now being forced to the left on the issue, opposing charters more and more.

However, as I explain, the positions the candidates are taking are not nearly as hostile to charter schools as it might seem. Even if one of the more skeptical candidates were to win the presidency and adopt their policies, charter schooling is likely to continue its steady expansion.

How did we get here?

To understand where this is going, we have to understand how we got where we are today. Why are charter schools such a hot topic? First, charter schools now represent at least 6% of the publicly funded schooling market, a number that has steadily increased the inception of charter schools almost three decades ago. Second, in some cities, like my hometown of New Orleans, charter schools have either mostly or completely replaced traditional public schools, something no one thought imaginable (or even desirable) when charter schools first started. Third, the Democratic Party has turned to the left with skepticism of private organizations (especially for-profits) and markets generally. Fourth, support for charter schools is starting to cut more along racial lines. Charter schools are therefore cleaving a divide on two dimensions at once: an ideological divide between neoliberals and progressives and a racial divide that is especially problematic in a multiracial party.

The backlash against charter schools began to be evident in the debate over ESSA and the rollback of NCLB and the Barack Obama-era waivers. This general anti-reform sentiment then got into full swing with the 2016 presidential election. Hillary Clinton, once a strong supporter of charter schools, backpedaled in the 2016 Democratic primary with criticism of charter schools (though with no explicit proposals that would have undermined charters). Then came the results of the election. After making occasional statements advocating school choice during his campaign, President Trump appointed Betsy DeVos for secretary of education, perhaps the most significant behind-the-scenes political supporter of charter schools (and vouchers) in the country. It is difficult for Democrats to support any policy that the Trump administration endorses, and DeVos’ appointment widened the already-growing breach among Democrats.

So, how are candidates playing the charter hand they’ve been dealt? Before I answer that question, a few small disclosures: I have had past conversations with two of the candidates (Joe Biden and Elizabeth Warren) about education issues. I also supported and advised the Obama-Biden administration on several issues (though I am not presently advising the campaigns of any declared candidates).

Candidate positions on charter schools

I have analyzed the education policy positions of the top-tier Democratic primary candidates. To avoid cherry picking, I picked the “top tier” based a single source: Nate Silver’s analysis of the polling data as of April 26. The top seven candidates on his list are (in order of polling): Biden, Bernie Sanders, Pete Buttigieg, Warren, Kamala Harris, Beto O’Rourke, and Cory Booker. Apologies if your favorite candidate has been left out, but there are simply too many candidates this year to consider them all at length (and most of my analysis would apply even if we considered all the candidates).

On charter schools, the top-tier candidates break down into five categories:

  • Consistent public supporters of charter schools (None)
  • Supported charter schools in the past but since backed off (Warren, O’Rourke, Booker)
  • No clear position on charter schools (Buttigieg)
  • No clear position before but currently a charter skeptic (Biden)
  • Long-time opponents of charter schools (Sanders, Harris)

Let me start from the beginning and work my way down, noting that this list has changed twice in the past three weeks.

When I started writing this piece three weeks ago, there was, in fact, one steady supporter: Booker. He was not just a supporter, either. Having gone on Oprah with Mark Zuckerberg and Republican Chris Christie to announce a massive overhaul (and charterization) of the Newark, New Jersey schools, charter schools were his signature issue. He even spoke at a conference hosted by DeVos’ organization (before she became secretary). He later tried to address this obvious political problem by opposing DeVos’ nomination.

As I started writing this post, I thought Booker would stick to his guns, and become the only candidate who would speak to and for charter supporters, including the growing charter establishment and wealthy philanthropists who have long supported him. But, then, he came out with this just a few days ago with this in a campaign stump speech: “I’m a guy who believes in public education and, in fact, I look at some of the charter laws … and I find them sickening.” (This comes from a video posted by The Hill on Twitter.) To be clear, this statement is not a complete abandonment of charters, but can you imagine Sanders saying that Medicare laws are “sickening”? I never thought I’d hear this from Booker. It’s not even clear that it was good politics, since he just swerved out of the only lane he had to himself.

Joining Booker is O’Rourke who, as recently as 2016, talked about charter schools as a “proven educational model.” In 2015, O’Rourke also spoke positively about charters. Since 2016, however, it’s been mostly silence and more backpedaling. His spokesperson recently said: “He has made it clear that our focus should be on, and our taxpayer funds should go towards, public school classrooms where the overwhelming majority of American students attend.”

Warren is in the same boat. A longtime Republican, she was a charter supporter until she turned against them in a 2016 referendum in her home state of Massachusetts. Booker, O’Rourke, and Warren are therefore all following Clinton’s 2016 lead.


Buttigieg has said very little about policy so far, though the fact that his husband is a charter school teacher has drawn headlines.

Biden managed to go several decades seemingly saying nothing about charter schools. Then, last week followed in the direction of the others and embraced a ban on for-profit charter schools.

Sanders is partly the impetus for all of this. His recent proposals would ban for-profit charter schools and put a moratorium on their growth. As Biden and Sanders are the two leading candidates in the race, and given the leftward swing in the party, their jujitsu on this issue is telling. Note that Biden’s proposal is narrower and more realistic in banning only federal funding for for-profit charter schools. Harris, meanwhile, has embraced a charter moratorium, but has not apparently talked about for-profits.

Where does that leave us? In some ways this is standard fare: Moderate candidates tack to extreme wings of the party in the primary and (likely) tack back to the middle in the general election. Of course, that logic only holds if a moderate candidate wins. Sanders has nowhere to tack back to.

In the meantime, we can expect the polling on charter schools to get worse. The average voter might not hear a single positive message about charter schools for the next 12 months and, if they do, it will most likely come from President Trump. That spells trouble. … Or does it?

The long-term prognosis is better for charter schools

Charter supporters actually hold a stronger hand than it seems, if we separate the short-term battle of the 2020 Democratic primary battle from the long-term war. Trump/DeVos will eventually be out of office. When Democrats take over again—whether in 2020 or beyond—the odds are that it will not be Sanders, but a candidate with moderate view on the issue. Sanders is really the only candidate who seems genuinely opposed to charter schools and even he is only calling for a moratorium and ban on the small share of charters that are for-profits.

For all the attention and bluster, not a single candidate seems to want to turn back the clock and get rid of charter schools. Even if Sanders won the primary and general election, there would almost certainly be more charter schools in place after he left office than when he started. A federal ban on for-profits would no doubt apply only to federal funding for charter schools, which is small.

Moreover, charter schooling has expanded almost nonstop for decades. Charter supporters have worried about the slowing growth of charter schools, but growth is growth, especially when it is happening as charter schools have been under political attack. This is telling about who’s really winning. It is also why unions are pushing back.

The future also depends on where the evidence goes. I have written about this before. The short of it is that both sides exaggerate their claims. Charter critics are mostly wrong that charter schools are weakening traditional public schools and/or that they are making segregation worse. Likewise, charter supporters are wrong to dismiss the many scandals and mostly wrong that charter schools are allowing families to successfully escape failing schools. Average charter performance is only slightly better than traditional public schools nationally, meaning that when families leave traditional public schools for charters, they are about as likely to end up in a worse school than a better one. It’s a mixed bag. Charter schools have not transformed America’s schools, at least not yet. They do seem to be getting better over time and generating some meaningful improvements, at least in urban areas. If that continues, then this will certainly, and deservedly, help swing more independent voters to the charter cause. If not, then we may need to seriously rethink this.

The next 12 months will be very uncomfortable for charter supporters, to be sure, and this will create a short-term political mess for the party. The reason for that mess is that charter supporters have been gradually winning the war.

Categories: Elder

Africa in the news: New environmental policies on the continent, Zimbabwe’s IMF stabilization program, and Sudan update

Brookings Institute -- Medicare - Sat, 06/08/2019 - 6:00am
Tanzania, Kenya, and UNECA enact environment-positive policies and programs

On Saturday, June 1, Tanzania’s ban on plastic bags went into effect. According to The Citizen, the new law targets the “import, export, manufacturing, sale, storage, supply, and use of plastic carrier bags regardless of their thickness” on the Tanzanian mainland. The law also bans the selling of items wrapped in plastic unless the “nature of such items” specifically require it. The consequences can be severe: The manufacturing or import of the bags have a maximum penalty of 1 billion Tanzanian shillings ($435,000) or up to two years in prison. Even possession of such bags carries a maximum fine of 200,000 Tanzanian shillings or up to seven days in prison. There is also an “on-the-spot” fine of $13, and visitors to the country must surrender any plastic bags in their possession at entry. Tanzania joins neighbors Rwanda and Kenya in the ban on plastic bags.[author-bio]

Similarly, on Thursday, June 5, Kenya’s new ban on single-use plastics in its national parks came into effect. According to The Star, “Kenyans going to the beach or national parks are banned from carrying water bottles, plastic plates, plastic cups as well as plastic spoons and forks.

Meanwhile, on June 5, the United Nations Economic Commission for Africa (UNECA), in conjunction with European clean energy leaders, launched its climate change-focused energy initiative, Renew Africa, which aims to boost investments, especially from the European private sector, in renewable energy on the continent.

Zimbabwe and IMF agree on stabilization program

Last Friday, Zimbabwe’s central bank said it would cease printing money as part of a landmark deal with the International Monetary Fund (IMF), which has agreed to support Zimbabwe’s economic reform agenda through a staff-monitored program (SMP). As part of the agreement, IMF staff will support and offer authorities technical assistance to restore monetary stability. In particular, the SMP will assist Zimbabwe in the implementation of coherent economic and social policies that will guide the nation’s return to macroeconomic stability as well as help gain confidence from and reengage with the international community.[more-blog-posts]

Zimbabwe continues to face deep macroeconomic imbalances from the substantial accumulation of fiscal deficits and external arrears, sustained inflation even in the post-Mugabe era due to over-borrowing from the central bank to pay bills, and currency instability after abandoning its own debilitated currency for a quasi-currency system.

Economic policies under the SMP emphasize the restoration of macroeconomic and financial sector stability by implementing a large fiscal adjustment, eliminating central bank financing of the fiscal deficit, and adopting reforms to allow the effective functioning of market-based foreign exchange and debt markets. Structural reforms include steps to reform and privatize state-owned enterprises, enhance governance in procurement and revenue administration, and improve the business environment.

Talks break down amid deadly attacks on Sudanese protesters

Early this week, dozens of peaceful protesters calling for an immediate transfer of power to a civilian-led authority in Khartoum, Sudan were killed during a Rapid Security Force (RSF) raid of their camp. The RSF, a state-sanctioned paramilitary force, has been patrolling the streets since Monday. Medics aligned with the protest movement have put the total number of casualties since patrols started at more than 100 people, with reports of over 40 bodies pulled from the Nile River by midweek.

The African Union (AU) interceded Thursday, suspending Sudan from participating in organizational bodies until a civilian-led transitional authority is established. Sudan’s suspension is the first since the AU suspended Egypt in 2013 following the military overthrow of Mohamed Morsi. The United States, the United Kingdom, and Norway also issued a joint statement condemning the crackdown on protesters and blaming the Transitional Military Council for ordering the attacks. Saudi Arabia, the United Arab Emirates, and Egypt continued to back the military council led by chair General Abdel Fattah al-Burhan Abdulrahma and deputy chair Mohamed Hamdan Daqlu, leader of the RSF, and support the resumption of talks. Opposition leaders, though, refuse to participate in further negotiations with the transitional government after the RSF’s role in Monday’s attack. Meanwhile, Ethiopian Prime Minister Abiy Ahmed, alongside officials from the regional body IGAD (Intergovernmental Authority on Development), traveled to Khartoum Friday following the AU suspension to mediate between the government and opposition. Opposition leaders, initially resistant to further negotiations with the government, accepted Abiy’s mediation, contingent on the Transitional Military Council meeting a number of conditions. Among the alliance’s list of demands are stipulations that the Transitional Military Council recognize the deadly attack on protesters, allow an international commission to investigate the RSF’s crimes, reopen internet access, release political prisoners, and respect Sudanese citizens’ civil liberties.

Genevieve Jesse contributed to this post.

Categories: Elder

Can technology improve service delivery?

Brookings Institute -- Medicare - Fri, 06/07/2019 - 3:18pm

For the last 15 years, I have been focused on (some may say obsessed with) the delivery of basic services such as health and education. In the last two years, as a member of the Pathways for Prosperity Commission, I’ve been interested in how technology can promote inclusive growth. Imagine my delight therefore when the Commission issued a report on technology and service delivery!

The report, “Positive disruption: health and education in a digital age,” starts with the right questions: What are the reasons why health and education services are failing in many developing countries, and can technology alleviate those problems? The first question is similar to the one asked in the 2004 World Development Report, “Making Services Work for Poor People,” which concluded that the reason was a failure of accountability—of service providers to policymakers, and of policymakers or politicians to citizens (Figure 1).

Figure 1: The framework of accountability relationships

Source: World Development Report 2004

The framework in “Positive disruption” has the same actors (with the addition of intermediate organizations), although the relationships are two-way (Figure 2).

Figure 2: A simplified system framework for health and education

Source: Pathways for Prosperity Commission

Both frameworks lead to the conclusion that interventions that improve only one link in the chain are insufficient to improve service delivery. For instance, a program to introduce time-stamp machines to monitor nurses’ presence (and thereby reduce absenteeism) in Udaipur, India led to the machines’ being vandalized by the nurses and no change in absence rates. “Positive disruption” documents several examples of technologies, such as the One Laptop Per Child initiative in Peru, that had little effect on children’s math and reading scores, partly because it didn’t relieve other constraints in the education system, such as teachers’ knowledge.[author-bio]

But the report goes further to show how technology can play a role in strengthening the system. For instance, Mindspark—digital personalized learning software that facilitates tailoring learning to each student’s level—showed 38 percent improvement in math scores after just four and a half months in a pilot, after-school program in Delhi. Digital technologies can capture and share data to make administrative systems work better. The data can be used to provide incentives for better performance (digital feedback to health workers in Mali led to a 10 percent increase in the number of houses visited); fill knowledge gaps among frontline workers (such as online courses in HIV for Zambian clinicians); and induce better uptake of services by citizens (SMS reminders to Kenyan patients to take their medicines).

“Positive disruption” is appropriately cautious about the limits, and possible unintended consequences, of using digital technology for improving service delivery. The monitoring of teachers and nurses may reduce absenteeism initially, but the effects sometimes dissipate over time, as in the example from Udaipur above, or on teachers in India more generally. And the sharing of data, which makes the administrative systems operate more efficiently, involves a host of privacy issues especially when it comes to individuals’ health data. Unless the appropriate norms and rules of data privacy, protection, and governance are in place, these innovations could backfire or elicit a backlash from the population (or both).

Despite its hopeful, wide-ranging, and balanced treatment, “Positive disruption” missed an opportunity to highlight the role of technology in strengthening another link in the service-delivery chain: that between citizens and politicians. However much we help politicians hold service providers accountable (through digital monitoring, incentives, etc.), if the politician does not find it in his or her interest to improve service delivery, they will not implement the programs. And if people do not vote along service delivery lines, and vote instead along caste, ethnicity, or religious lines for example, then there is no incentive for the politician to hold teachers and doctors accountable for performance. Furthermore, if teachers are part of a patronage system where no-show jobs are part of the currency, then the incentives for reform are even weaker.

One reason why people, especially poor people, don’t vote along service delivery lines is that they may not know enough about the politician’s performance. Digital technology can play a role in getting this information out to poor people. The information has to be accessible and salient. The recent effort in India to produce data on child health by political constituency, and publish it ahead of the elections, is a step in that direction. Sometimes, politicians find it more effective to promise their constituents private goods, including cash, rather than public goods such as health and education, if they vote for them. There is evidence that “vote-buying” leads to poorer health and education outcomes. But even if they have received cash, people have a choice when they enter the voting booth—if it is genuinely a secret ballot. Electronic voting—another technological development—can reinforce the anonymity of the ballot. As Thomas Fujiwara shows, the Brazilian districts that replaced paper ballots with electronic voting had better public health outcomes.

In short, while “Positive disruption” presents a realistic, well-grounded, and yet ambitious vision for harnessing technology to improve service delivery, I think it should be even more ambitious, and explore ways of using digital technology to strengthen the weakest link in the service delivery chain, namely the ability of citizens, especially poor citizens, to hold politicians accountable.[more-blog-posts]

Categories: Elder

How to make concrete progress on the Global Compact on Refugees

Brookings Institute -- Medicare - Fri, 06/07/2019 - 1:20pm

As World Refugee Day approaches on June 20, the number of refugees worldwide will likely surpass last year’s 25.4 million. That governments in the West and elsewhere—under pressure from anti-immigrant populists—are increasingly shutting their doors to refugees and asylum-seekers only exacerbates their plight.[author-bio]

Meanwhile, the international community aspires to do better. The 2018 Global Compact on Refugees (GCR) puts forward a wealth of policy ideas to improve protection for refugees and support for host countries. In many current political environments, the GCR’s broader recommendations may receive pushback; hence, concrete ideas for implementation will matter.

The place to start could be Turkey. Turkey hosts the largest number of refugees in the world and has had a burden-sharing agreement with the European Union since 2016, but the agreement needs to be revisited or restructured to encourage Syrians to achieve greater self-reliance. Recognizing the centrality of the migrant issue for Europe—and Turkey’s key role in stemming flows—the compact’s innovative ideas serve the interests of both sides, as well as of course refugees themselves and the broader international community.

Why the compact matters

More than a million Syrian and other nationals poured into Europe, mostly on foot, in 2015 and 2016. In response, at a United Nations Summit in September 2016 the New York Declaration for Refugees and Migrants called for the creation of a global compact on refugees.

The compact came to fruition last year, calling on U.N. members to develop long-term, sustainable solutions to large movements of refugees by helping to:

  • Ease pressures on host countries,
  • Enhance refugee self-reliance,
  • Expand access to third-country solutions, and
  • Support conditions in countries of origin for return in safety and dignity.

The GCR has elicited praise for once more reiterating that protecting refugees is a global responsibility and for advocating that more should be done to share the burden born by host countries. Yet it has been criticized as being designed to protect rich countries from unwanted refugees and leaving the burden on the developing world, which continues to host the overwhelming majority of the world’s refugees.

The rise of populism and anti-immigration politics in Europe and the United States make the prospects for expanding access to third-country solutions politically challenging, at least in the near term. Early in 2019, the United Nations High Commissioner (UNHCR) noted that “less than 5 percent of global refugee resettlement needs” were met last year. The persistence of violent conflicts in as diverse places as Afghanistan, Congo, Myanmar, Somalia, Syria, and Yemen make the resulting displacement crises ever more protracted. In many of these cases, the safe, dignified, and sustainable return of refugees to their homes will remain elusive.

This makes local solutions, rather than resettlement, the default outcome, and hence improving refugee self-reliance and easing pressure on host countries is paramount. Further strain on host countries will only jeopardize already scarce resources and fragile societal peace— overburdening them could provoke even more political backlash. The GCR calls for national and international stakeholders to “promote economic opportunities, decent work, job creation and entrepreneurship programs for host community members and refugees” to promote social cohesion and enable refugees to build productive and sustainable lives free from charity and precarity.

Enabling refugees’ access to host countries’ labor markets will not be easy. Most of the countries that host large numbers of refugees—like Turkey, Jordan, and Lebanon—have weak economies and high unemployment levels. This forces refugees to seek employment informally, increasing the exploitation and aggravation of refugees’ precarious situations. Resentment towards refugees grows, in particular among unskilled locals who see their wages and employment prospects being eroded.

This is an unsustainable situation for both the refugees and the host community. Yet studies have shown that migrants and refugees can contribute to the economic growth and the welfare of host countries if they are properly incorporated into those countries’ labor markets. For this to be achieved, refugees must be given a chance to participate in the formal economy and therefore pay taxes and contribute to social security funds. The letter and the spirit of the GCR can help to bring this about.

Applying the compact’s lessons to Turkey and Europe

Turkey hosts more than 3.6 million Syrian refugees and nearly 400,000 of other nationalities. Syrians have been under temporary protection since they first began to arrive in April 2011. This arrangement has enabled them to enjoy protection from forced return to Syria and access to basic public services including health care and, more recently, public schools.[related-books]

The UNHCR and the EU, among others in the international community, praise Turkey for hosting such large number of refugees. According to government officials, Turkey has spent more than $37 billion for the refugees, supplemented by funds made available through the Facility for Refugees in Turkey (FRIT), adopted as part of the migration deal reached between Turkey and the EU in 2016 to stem the flow of Syrians into Europe. FRIT, via the Emergency Social Safety Net (ESSN), has provided more than 1.5 million recipients with a modest level of cash assistance to help families meet their basic needs since November 2016, and has supported various projects to improve refugees’ living conditions.

These efforts, however, have fallen well short of enabling refugees to maintain self-reliance. There are no reliable statistics, but the World Bank in 2018 reported that “at least half of the over two million working-age Syrians work informally,” with possibly 200,000 working as seasonal laborers in the agricultural sector, often in particularly difficult conditions. Informality makes them vulnerable to exploitation, especially women and children. Even after extensive efforts, including a Conditional Cash Transfer for Education program, almost 40% of Syrian and other refugee children remain out of school.

Although the Turkish government introduced legislation in 2016 to open its labor market to Syrian refugees, informal labor has persisted. Administrative hurdles and a fear among some Syrians that giving up their informal work status will actually cost them some competitive edge meant that fewer than 39,000 work permits were issued in 2018, a modest increase from 15,700 in 2017. International organizations such the UNHCR, United Nations Development Programme (UNDP), Food and Agricultural Organization (FAO), International Labor Organization (ILO), and International Organization for Migration (IOM) are still working to improve the skill set of refugees and enhance their employability. NGOs such as SGDD-ASAM, United Works and Spark have focused on placing refugees into formal jobs. The Turkish Employment Agency (ISKUR) is also collaborating with the UNDP to expand its labor market services to cover refugees.

Are these efforts having an impact? It is hard to know. Prospects for economic integration of refugees is complicated by:

  • The fact that their educational level is significantly lower than locals;
  • Slow economic growth, which contracted from 11.1% in 2011 when refugees first began to arrive to 2.6 % in 2018, and
  • High unemployment in general in Turkey, with a rate of almost 15% —the highest in a decade.

The World Bank’s Global Economic Prospects report foresees negative growth for Turkey in 2019, worsening the picture for refugees. However, the GCR—with its emphasis on the importance of international community helping “to foster inclusive economic growth for host communities and refugees”—offers a framework to help the EU and Turkey to explore possibilities going beyond the FRIT.[more-blog-posts]

Refugees, labor, and trade

One immediate idea originating from the GCR is exploring “preferential trade arrangements … especially for goods and sectors with high refugee participation in the labor force.”

The EU-Jordan Compact of 2016 allowed Jordanian industrial goods to enter the EU in return for a commitment from Jordan to extend work permits to Syrians refugees. This arrangement would benefit the host community by increasing exports, while improving the overall livelihood of both the host and refugee communities through economic growth. While the agreement has encountered challenges, both parties are so far sticking with it and seeking to learn from these challenges. Similar approaches are being adopted for Bangladesh and Ethiopia, too.

Such preferential trade agreements are particularly suited for Turkey because it already has a customs union with the EU, which has benefitted the Turkish economy and exports greatly since its inception.

Yet, the customs union has fallen behind the times, and both sides have agreed to modernize and upgrade beyond industrial goods, to include agricultural products, services, and public procurements sectors. Impact studies commissioned both by the EU and Turkey demonstrated that such an expansion would offer Turkey significant welfare gains. The poor state of relations between the EU and Turkey has kept both sides from starting negotiations. The impasse is likely to last, and in the interim both sides could pragmatically be addressing some key administrative issues. For instance, improving certain costly transport delays resulting from cumbersome administrative border procedures could enhance opportunities for companies exporting perishable agricultural products; Syrian refugees, in turn, could be employed in Turkey’s agricultural sector, which suffers from a shortage of skilled labor amid falling enrollments in agricultural and veterinary studies. Turkey and the EU could institute scholarship programs for Turkish and the growing number of Syrian youths graduating from Turkish universities to take up advanced studies and apprenticeship opportunities in EU institutions before returning to Turkey. Such a program could be accompanied by commitments from major Turkish agrobusiness companies to offer them long-term careers. This program would enhance employment prospects for Syrians and help prepare the human capital that Turkey will need when the customs union is finally modernized.

Everybody wins?

Each protracted refugee situation has its own particularities, and what may work for the Turkish case may not be applicable elsewhere. However, as a general rule, it is important to explore and encourage policies that can enhance the self-reliance of refugees and resilience of host communities.

Moving forward, both the EU and Turkey have a stake in giving life to the GCR and ensuring that refugees are employed formally and offered decent work. Turkey needs to adopt ideas from the letter and spirit of the GCR, because incorporating close to 4 million refugees into Turkish economy and society while maintaining social peace won’t be easy. Turkey cannot accomplish this on its own, especially at a time when its economy is increasingly troubled.

The EU is Turkey’s most obvious partner. Europe has a stake in sharing responsibility with Turkey—not just because Turkey is already an important economic partner, but because it is central to European stability, something the 2015 migration crisis made clear. Such cooperation would be a win for the EU, for Turkey, and most importantly, for the refugees and their host communities, who have not exhibited the xenophobia and anti-refugee sentiment visible in Europe. And more broadly, these early efforts to operationalize the GCR would demonstrate to the international community that burden-sharing in protecting refugees is indeed possible.

Categories: Elder

Charts of the week: Donuts

Brookings Institute -- Medicare - Fri, 06/07/2019 - 10:58am

Because June 7 is “National Donut Day,” here are some charts from Brookings research that remind us of the tasty fried dough treat. Enjoy!


In their analysis of digitalization in the American workforce, a team from the Metropolitan Policy Program detailed the digital content of hundreds of occupations in the U.S. “Workers of every stripe,” they observed, “from corporate finance officers to sales people to utility workers and nurses—are now spending sizable portions of their workdays using tools that require digital skills.”


While across the country homeownership rates have not shown long-term declines, William Frey noted that the housing bust of the Great Recession occurred just as members of the millennial generation were entering the housing market. “This tamped down their homeownership rate compared with young adults at earlier ages,” he said, adding that “this delay in homeownership may be robbing millennials of a head start toward a traditional means of wealth accumulation.”


Experts documented the deployment of broadband internet services by metropolitan area. “Broadband, especially wireline broadband in American homes,” they wrote, “is the essential infrastructure for unlocking the internet’s economic benefits.” They noted that the largest gap at 25 Mbps speed is in rural areas.

Thanks to the social media team in the Brookings Office of Communications for inspiring this edition of Charts of the Week with this Twitter thread.



Categories: Elder

Charter schools: Good or bad for students in district schools?

Brookings Institute -- Medicare - Fri, 06/07/2019 - 12:01am

As charter school enrollments grow, are school districts so weakened by financial losses that teaching and learning must suffer? Or does competition spur traditional public schools and districts to improve—for the benefit of all?


There are bodies of research and policy advocacy on both questions, but the results are difficult to reconcile.

Studies focusing on charters’ effects on district finances mostly find harm, and infer that school quality must be suffering. Studies focusing on charters’ effects on overall instructional quality often find no effects but find positive effects much more often than harm to students.

Is somebody wrong here? Does charter growth wreck district schools, or does competition lift all boats?

Some facts are generally accepted: When students leave a district for any reason (moving away, enrolling in charter or private schools) the district no longer has to pay to educate them, but some costs remain.

But there is serious disagreement about the consequences. The “inevitable harm” narrative has become a rallying cry in teachers union strikes from California to West Virginia. Los Angeles union leaders sought and won state support for anti-charter caps and regulations.

Studies on district finances focus on “sticky” costs that can’t be adjusted quickly as district enrollment falls—debts, pension obligations, and administrative costs, for example. These are essentially fixed costs in a year when enrollment declines. Other cost drivers (administrative staffing policies, schools too small to support their overhead, etc.) are within the district’s power to fix.

Whatever the remaining costs, they must be paid from the income generated by a smaller number of students, so more of the district’s available funding goes to overhead. Assumptions about what costs are fixed and where cuts can be made are crucial. Studies that take great care in testing assumptions and offsetting savings against costs inevitably find expenses left behind in the first year after district enrollment falls, but vary on how long those persist.

Careful studies estimate that, in the year after a student transfers to a charter school, anywhere from $1,500 to $3,500 of fixed costs must be paid from a shrinking district budget. Some reporting higher numbers assume districts can do little to adjust spending.

Studies of the second question on the effects of charter school enrollment on district school quality look at different evidence: test scores and other student outcomes like attendance and persistence. Though they do not consistently find benefits to students in district schools, they rarely find the harm predicted on the basis of districts’ overall funding and costs.

These studies have appeared from 2005 to the present. Recent ones of New York City and Massachusetts have some of the strongest positive results. New studies of Chicago and Denver—though not focused directly on the effects of charter competition—show improvements in district schools even as charter enrollment grows and some charter schools stand out as high performers. A recent study of schools in Washington, D.C., shows neither harm nor benefit to students in district-run public schools, except for benefits to students whose schools are near high-performing charter schools.

Recent studies also provide some evidence about whether and how district schools improve in the face of charter competition. For example, a 2018 study of New York City shows that district schools increase funding in affected schools. A 2018 study of Massachusetts suggests short-term subsidies to districts can soften the effects of enrollment loss to charter schools. Studies of Denver and Chicago show that enhanced school freedom of action is a factor in the improvement of district schools in a charter-rich environment.

Earlier studies were possibly less positive because they relied on data more than a decade old, and before districts (Chicago and Denver, for example) learned how to improve their schools while charters grew. This is credible in light of evidence that schools facing competition can steadily improve over several years.


RAND’s 2009 study of charter schools in eight cities found few effects in either direction, except for some negative effects in Texas. Two early statewide studies of Ohio and Michigan also documented slight declines in public school test scores. Mixed results are also common in early studies—for example, positive effects on reading scores but negative effects on mathematics, or vice versa. One early study of an unidentified city found negative effects on elementary school students but positive ones for high schoolers.

How can it be that some studies find enrollment shifts to charter schools harm district finances, while others seldom find harm and often find benefits to students? The studies look at different outcomes, so it is possible that districts struggle financially but succeed in insulating students from harm.

This is consistent with new reports on California. One, from the Center on Reinventing Public Education, which I founded, finds no evidence that charter school growth increases the chances school districts will be flagged by the state for fiscal distress. The other, from a University of Southern California researcher, finds districts facing charter school competition tend to have lower fund balances, but do not show higher levels of debt or other, more severe signs of financial stress.

None of these studies examine educational and financial effects of charter schools in the same cities. To sort out financial and achievement effects, we need coordinated studies in particular cities, analyzing the effects of charter growth on district finances and tracing these through school funding and instructional practices to effects on students.

The question of effects of charter growth on district schools and students is important enough to warrant thorough and objective study: a sample of districts impacted by charter schools with careful review of financial challenges, district responses, consequences for school operations, and student results.

But until such studies are done, people with different perspectives will remain in well-established warring camps. Policymakers and voters can’t know whether the competing findings on financial and educational results are either:

1. Both true: Districts are stressed financially by the shifts of resources they must make in order to compete with charter schools, but not helpless. Districts can feel budgetary pain even while their schools are protected and enhanced; or

2. Not both true in all situations: For example, in localities that are above some threshold of debt, fixed costs, charter growth rate, or political stalemate that make it impossible for them to sustain school quality.

The facts can be hard. There is no need to settle for incomplete or cherry-picked evidence. At a time when people who care about children abhor false claims and biased arguments, foundations or government could step up to sponsor the needed research. Until then, voters and policymakers should be skeptical about claims that charter school growth harms district schools.

Categories: Elder

Figures of the week: International trade in services

Brookings Institute -- Medicare - Thu, 06/06/2019 - 4:44pm

On May 28, the United Nations Conference on Trade and Development (UNCTAD) released a report detailing the growth in international trade in services in 2018. The report states that global services exports increased by 7.7 percent between 2017 and 2018, reaching a total of $5.8 trillion. As Figure 1 shows, Africa tied with Asia and Oceania for the highest growth rate in services exports, at 9.4 percent.

Figure 1: Annual growth rate of total services exports by region, 2018 (percentage)

Source: UNCTAD. 2019. “International Trade in Services 2018.”

Despite this impressive growth, the real value of Africa’s services exports remains low, accounting for only slightly over 2 percent of world services exports. As Figure 2 shows, world services trade is still dominated by developed economies in Europe and North America and by developing economies in Asia and Oceania. The composition of trade also differs by world region: The services sector in developed countries is dominated by financial, insurance, business, and intellectual property services, while African services exports are dominated by travel, which accounts for 42 percent of the continent’s total services exports.

Figure 2: Exports of services by region and service category, 2018 (billions of US$)

Source: UNCTAD. 2019. “International Trade in Services 2018.”

Within Africa, the extent and composition of services exports also varies by region, as shown in Figure 3. North Africa leads the continent in value of services exports, at over $50 billion, while Central (Middle) Africa’s services exports total less than $5 billion. Travel accounts for the highest share of services exports in every region except West Africa, where other services—mostly composed of financial, insurance, and business services—play a more prominent role.

Figure 3: Services exports in Africa by region and service category, 2018 (billions of US$)

Source: UNCTAD. 2019. “International Trade in Services 2018.” [author-bio]

The entering into force of the African Continental Free Trade Agreement (AfCFTA) on May 30, 2019 presents a significant opportunity for African countries to continue increasing their trade in services. African Union members have agreed on a January 2020 deadline to submit negotiated market access offers for five priority services sectors: transport, communications, financial services, tourism, and business services. It will be key for countries to pay attention to the importance of services as the AfCFTA negotiations continue, as services will play a leading role in intra-African integration and the future of continental trade.[more-blog-posts]

Categories: Elder

The Economy Is Strong. So Why Do So Many Americans Still Feel at Risk?

Medicare -- New York Times - Tue, 05/21/2019 - 6:00am
The sunny job numbers and steady growth hide the fact that most people think the economy works only for people in power.
Categories: Elder, Medicare

‘Medicare for All’ Could Kill Two Million Jobs, and That’s O.K.

Medicare -- New York Times - Thu, 05/16/2019 - 3:12pm
Reform has a cost. But the point of a health care system is to treat patients, not to buttress the economy.
Categories: Elder, Medicare

Many Americans Will Need Long-Term Care. Most Won’t be Able to Afford It.

Medicare -- New York Times - Fri, 05/10/2019 - 1:20pm
A decade from now, most middle-income seniors will not be able to pay the rising costs of independent or assisted living.
Categories: Elder, Medicare

Many Hospitals Charge Double or Even Triple What Medicare Would Pay

Medicare -- New York Times - Thu, 05/09/2019 - 1:02pm
A study of 25 states provides a rare glimpse of the stark disparities between what private insurers and the federal government paid for inpatient and outpatient care.
Categories: Elder, Medicare

‘Medicare for All’ Gets Much-Awaited Report. Both Sides Can Claim Victory.

Medicare -- New York Times - Wed, 05/01/2019 - 6:29pm
The Congressional Budget Office usually offers detailed estimates, but not in this case.
Categories: Elder, Medicare

Gingerly, Democrats Give ‘Medicare for All’ an Official Moment

Medicare -- New York Times - Tue, 04/30/2019 - 6:20pm
The proposal gets its first congressional hearing. Another one is coming soon.
Categories: Elder, Medicare

Social Security and Medicare Funds Face Insolvency, Report Finds

Medicare -- New York Times - Mon, 04/22/2019 - 3:44pm
The social safety net programs are fraying as baby boomers age, the trustees of Social Security and Medicare said, but a political fix seems far away.
Categories: Elder, Medicare


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