Introduction: Despite the launch of indirect, “proximity” talks between Palestinians and Israelis, Palestinian President Mahmoud Abbas continues to resist a resumption of direct negotiations with Israel absent a full settlement freeze. As chairman of the Palestine Liberation Organization (PLO) and president of the Palestinian Authority (PA), Abbas also insists that any new negotiations pick up where previous talks left off in December 2008 and that the parties spell out ahead of time a clear “endgame,” including a timetable for concluding negotiations. While these may seem like unreasonable preconditions, Palestinian reluctance to dive headfirst into yet another round of negotiations is rooted in some genuine, hard-learned lessons drawn from nearly two decades of repeated failures both at the negotiating table and on the ground.

Not only have negotiations failed to bring Palestinians closer to their national aspirations but the peace process itself has presided over (and in some ways facilitated) a deepening of Israel’s occupation and an unprecedented schism within the Palestinian polity. Such failures have cost the Palestinian leadership dearly in terms of both its domestic legitimacy and its international credibility. While it remains committed to a negotiated settlement with Israel based on a two-state solution, the PLO/PA leadership has been forced to rethink previous approaches to the peace process and to negotiations, as much for its own survival as out of a desire for peace.

Haunted by past failures, Palestinian negotiators are now guided, to varying degrees, by six overlapping and sometimes conflicting lessons:

1. Realities on the ground must move in parallel with negotiations at the table.

2. Don’t engage in negotiations for their own sake.

3. Agreements are meaningless without implementation.

4. Incrementalism does not work.

5. Avoid being blamed at all costs.

6. Don’t go it alone.

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Introduction:

In the ebb and flow of Middle East diplomacy, the two interrelated issues of an Israeli-Syrian peace settlement and Washington’s bilateral relationship with Damascus have gone up and down on Washington’s scale of importance. The election of Barack Obama raised expectations that the United States would give the two issues the priority they had not received during the eight years of the George W. Bush administration. Candidate Obama promised to assign a high priority to the resuscitation of the Arab-Israeli peace process, and separately to “engage” with Iran and Syria (as recommended by the Iraq Study Group in 2006).

In May 2009, shortly after assuming office, President Obama sent the assistant secretary of state for Near Eastern affairs, Jeffrey Feltman, and the senior director for the Middle East in the National Security Council, Daniel Shapiro, to Damascus to open a dialogue with Bashar al-Asad’s regime. Several members of Congress also travelled to Syria early in Obama’s first year, including the chairman of the Senate Committee on Foreign Relations, John Kerry, and the chairman of the House Committee on Foreign Affairs, Howard Berman. In addition, when the president appointed George Mitchell as special envoy to the Middle East, Mitchell named as his deputy Fred Hof, a respected expert on Syria and the Israeli-Syrian dispute. Last summer, both Mitchell and Hof visited Damascus and began their give and take with Syria.

And yet, after this apparent auspicious beginning, neither the bilateral relationship between the United States and Syria, nor the effort to revive the Israeli-Syrian negotiation has gained much traction. Damascus must be chagrined by the fact that when the Arab-Israeli peace process is discussed now, it is practically equated with the Israeli-Palestinian track. This paper analyzes the difficulties confronting Washington’s and Jerusalem’s respective Syria policies and offers an approach for dealing with Syria. Many of the recommendations stem from lessons resulting from the past rounds of negotiations, so it is important to understand what occurred.

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Syria is trapped on a crumbling precipice, and however it might fall will entail significant risks for the United States and for the Syrian people.

The brutal regime of Bashar al-Asad is employing its loyal military forces and sectarian thugs to crush the opposition and reassert its tyranny. Even if Bashar fails, Syria may not be out of the woods: an increasingly likely alternative to the current regime is a bloody civil war similar to what we saw in Lebanon, Bosnia, Congo, and most recently in Iraq. The horrors of such a war might even exceed the brutal reassertion of Asad’s control, and would cause spillover into Syria’s neighbors—Turkey, Iraq, Jordan, Lebanon, and Israel—that could be disastrous for them and for American interests in the Middle East.

But the unrest in Syria, which is now entering its second year, also offers some important opportunities, ones that would come from the fall of the regime of Bashar al-Asad, whose family has ruled the country with an iron grip for over forty years. Syria is Iran’s oldest and most important ally in the Arab world, and the Iranian regime has doubled down on Asad, providing him with financial aid and military support to shore up his regime. Asad’s departure would deal a significant blow to Tehran, further isolating it at a time when it has few friends in the region or the world. In addition, Damascus is steadfast in its hostility toward Israel, and Asad’s regime is also a longtime supporter of terrorist groups like Hizballah and Hamas, and has at times aided al-Qa’ida terrorists and former regime elements in Iraq. The regime’s collapse, therefore, could have significant benefits for the United States and its allies in the region.

Actually ousting Asad, however, will not be easy. Although the Obama administration has for months called for Asad to go, every policy option to remove him is flawed, and some could even make the situation worse—seemingly a recipe for inaction. Doing nothing, however, means standing by while Asad murders his own people, and Syria plunges into civil war and risks becoming a failed state. Already the violence is staggering: as of March 2012, at least 8,000 Syrians have died and thousands more have been arrested and tortured in trying to topple the regime. At the same time, Syria is fragmenting. The Syrian opposition remains divided, and the Free Syrian Army is more a brand than a meaningful, unified force. Al- Qa’ida is urging fighters to join the fray in Syria, and sectarian killings and atrocities are growing. Should the violence continue to intensify, Syria’s neighbors may increase their meddling, and instability could spread, further weakening already-fragile neighbors like Iraq and Lebanon.

So to protect U.S. interests, Asad cannot triumph. But a failed Syria, one wracked by civil war, would be just as bad. Thus, U.S. policy must walk this tightrope, trying to remove Asad, but doing so in a way that keeps Syria an intact state capable of policing its borders and ensuring order at home. At the end of the day, however, removing Asad may not be doable at a price the United States is willing to pay. If so, the U.S. government may be forced to choose between living with a brutal but weakened Asad or getting rid of Asad regardless of the consequences.

This memo lays out six options for the United States to consider to achieve Asad’s overthrow, should it choose to do so:

1. Removing the regime via diplomacy;
2. Coercing the regime via sanctions and diplomatic isolation;
3. Arming the Syrian opposition to overthrow the regime;
4. Engaging in a Libya-like air campaign to help an opposition army gain victory;
5. Invading Syria with U.S.-led forces and toppling the regime directly; and
6. Participating in a multilateral, NATO-led effort to oust Asad and rebuild Syria.

The options are complex, and policymakers will probably try to combine several in an attempt to accentuate the positives and minimize the negatives, which will inevitably be difficult and bring out new complications. But by focusing on discrete approaches, this memo helps expose their relative strengths and weaknesses. For each course of action, this memo describes the strategy inherent to the option and what it would entail in practice. It also assesses the option’s advantages and disadvantages.

This memo does not endorse any particular policy option. Rather, it seeks to explain the risks and benefits of possible courses of action at this moment in time. As conditions change, some options may become more practical or desirable and others less so. The authors mostly agree on the advantages and disadvantages of each approach but weigh the relative rewards and costs differently.

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Last September, as part of its annual conference with the United States Central Command, the Saban Center for Middle East Policy at the Brookings Institution conducted a day-long simulation of a confrontation between the United States and Iran arising from a hypothetical scenario in which the Syrian opposition had made significant gains in its civil war and was on the verge of crushing the Assad regime.  

The simulation suggested that, even in the wake of President Rouhani’s ascension to power and the changed atmosphere between Tehran and Washington, there is still a risk of misunderstanding and miscalculation between the two sides.

This new Middle East Memo examines the possible U.S. foreign policy lessons that emerged from this crisis simulation, and stresses the importance of communication, understanding the Saudi-Iran conflict and the difficulty in limited interventions. 

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• Hard Road to Damascus: A Crisis Simulation of U.S.-Iranian Confrontation over Syria

       

Complexity and ambivalence are inherent in Israel’s relationship with its Middle Eastern environment. Israel’s national security agenda is shaped by the hostility of a large part of the Arab and Muslim worlds. During the past 66 years, Israel has been able to crack the wall of Arab hostility, to make peace with two Arab neighbors, and to establish semi-normal relations with several Arab states. But the Arab-Israeli conflict, and its Palestinian core in particular, rages on, and Iran has joined the fray as a powerful and determined adversary.

In Israel, debates over the state’s identity, its place and role in the region, and the more specific issues of the future of the West Bank and Israel’s relationship with the Palestinians, govern the country’s politics and national discourse. The March 2015 Israeli elections are being conducted over a wide range of issues, but they are seen first and foremost as a referendum on these key questions. Politics and policy can hardly be separated. Appearances can be misleading. Currently, the focus of the election campaign seems to be on socio-economic issues. The main challenger of Netanyahu’s current government and potential right-wing coalition is “The Zionist Camp” led by Isaac Herzog and Tzipi Livni. They are strong advocates of reviving a peace process with the Palestinians, but they realize that the Israeli public has drifted to the right. Furthermore, the primaries in the Labor Party produced a left-leaning list of candidates. But whatever the current drift of the campaign, in the elections’ immediate aftermath, whoever forms the next government will have to deal primarily with the Palestinian issue and the national security challenges facing the country.

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• Israel and the Changing Middle East

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

Much public focus is being given to a broader role for hospitals in improving the health of their communities. This focus parallels a growing interest in addressing the social determinants of health as well as health care policy reforms designed to increase the efficiency and quality of care while improving health outcomes.

This interest in the community role of hospitals has drawn attention to the federal legal standards and requirements for nonprofit hospitals seeking federal tax exemption. Tax-exempt hospitals are required to provide community benefits. And while financial assistance to patients unable to pay for care is a basic requirement of tax-exemption, IRS guidelines define the concept of community benefit to include a range of community health improvement efforts.

At the same time, the IRS draws a distinction between community health improvement spending–which it automatically considers a community benefit–and certain “community-building” activities where additional information is required in order to be compliant with IRS rules. In addition, community benefit obligations are included in the Affordable Care Act (ACA).

Specifically, the ACA requires nonprofit hospitals periodically to complete a community health needs assessment (CHNA), which means the hospital must conduct a review of health conditions in its community and develop a plan to address concerns. While these requirements are causing hospitals to look more closely at their role in the community, challenges remain. For instance, complex language in the rules can mean hospitals are unclear what activities and expenditures count as a “community benefit.” Hospitals must take additional steps in order to report community building as community health improvement.

These policies can discourage creative approaches. Moreover, transparency rules and competing hospital priorities can also weaken hospital-community partnerships. To encourage more effective partnerships in community investments by nonprofit hospitals:

• The IRS needs to clarify the relationship between community spending and the requirements of the CHNA. 
• There needs to be greater transparency in the implementation strategy phase of the CHNA. 
• The IRS needs to broaden the definition of community health improvement to encourage innovation and upstream investment by hospitals.

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Fee-for-service payments encourage high-volume services rather than high-quality care. Alternative payment models (APMs) aim to realign financing to support high-value services.

The 2 main components of gastroenterologic care, procedures and chronic care management, call for a range of APMs. The first step for gastroenterologists is to identify the most important conditions and opportunities to improve care and reduce waste that do not require financial support.

We describe examples of delivery reforms and emerging APMs to accomplish these care improvements. A bundled payment for an episode of care, in which a provider is given a lump sum payment to cover the cost of services provided during the defined episode, can support better care for a discrete procedure such as a colonoscopy. Improved management of chronic conditions can be supported through a per-member, per-month (PMPM) payment to offer extended services and care coordination.

For complex chronic conditions such as inflammatory bowel disease, in which the gastroenterologist is the principal care coordinator, the PMPM payment could be given to a gastroenterology medical home. For conditions in which the gastroenterologist acts primarily as a consultant for primary care, such as noncomplex gastroesophageal reflux or hepatitis C, a PMPM payment can support effective care coordination in a medical neighborhood delivery model. Each APM can be supplemented with a shared savings component.

Gastroenterologists must engage with and be early leaders of these redesign discussions to be prepared for a time when APMs may be more prevalent and no longer voluntary.

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Given the lackluster healthcare exchange enrollment numbers, unaffordable coverage, and increasing overall healthcare costs, President Obama is wrong to think the Affordable Care Act (ACA) needs just a few tweaks – its most fundamental aspects need to be rethought. Obama’s essay marks the first time a modern sitting president has had a piece published in the journal.

Much of the progress made under the ACA expanding healthcare coverage to the uninsured has been thanks to increased enrollment in Medicaid -- not the exchanges -- a harbinger of even less progress to come.  Secretary of Health and Human Services Sylvia Burwell sharply adjusted down projections of new exchange enrollees in 2016 to 1.3 million. Furthermore, the Congressional Budget Office (CBO) has estimated that over the next decade, as the population increases, coverage will expand only modestly and the proportion of the uninsured will cease to decline.

Six key areas in the ACA are flawed -- and need to be fixed if healthcare reform is to meet its promise and not have rampant cost problems:

1. Subsidies still leave plans too expensive. Congress must continue income-related subsidies while making coverage affordable to both households and taxpayers, which is “no easy task” because it could drive up costs of the ACA considerably.
2. The Cadillac tax needs to be fixed. While better than nothing, it doesn’t confront the underlying problem of health insurance being tax deductible, which is regressive and inefficient. One suggestion is a modification of the Cadillac tax that makes any excess plan costs above a cap be considered taxable income to the employee, as opposed to an excise tax.
3. Increase federalism in the healthcare system. States should apply for waivers under Section 1332, which takes effect in 2017 and gives states flexibility to meet the law’s goals while retaining its basic protections. The Administration has made a serious mistake in dragging its feet and acting overly restrictively with states who could launch their own bold and far-reaching experiments, as it has itself in encouraging conservative states to expand Medicaid under the ACA.
4. The exchanges need to be the primary vehicle for health insurance – not Medicaid expansion. Equalizing the subsidy structure for exchange plans and the tax treatment of employer-sponsored benefits, more employees would go on the exchanges which gives them greater choice and portability.
5. Replace the Independent Payment Advisory Board with a premium support system for Medicare. Premium support would enforce a long-term budget for Medicare by allowing greater control of the beneficiaries themselves, as opposed to imposing payment and price controls; it would also accelerate innovation in the design and pricing of Medicare services.
6. The ACA should focus more on the “upstream” determinants of health – beyond just medical services. We need to find ways to blend health, housing, transportation, social services and other items to reduce the need for costly medical services, he writes.

If it were a separate economy, the US health system would be equivalent to the first or sixth largest economy in the world. It is both pragmatic and principled to recognize that achieving agreement on how to redesign an economy that large, or to do it successfully in 1 piece of legislation, is beyond the capabilities of the federal government. That is why core parts of the ACA need to be reassessed and revised and why empowering the US system of federalism to adapt and experiment with this law is so important.

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Read "The Future of the Affordable Care Act: Reassessment and Revision."